Mukerji Shivali, Darwin Sophia, Suchdev Kushak, Levine Adam, Xu Lan, Daneshmand Ali, Nozari Ala
Department of Anesthesiology, Boston Medical Center, 750 Albany Street, Boston, MA, 02118, USA.
Department of Neurology, Boston Medical Center, Boston, MA, USA.
Eur J Trauma Emerg Surg. 2022 Dec;48(6):4813-4822. doi: 10.1007/s00068-022-02009-7. Epub 2022 Jun 22.
Penetrating ballistic brain injury (gunshot traumatic brain injury or GTBI) is associated with a high mortality. Admission Glascow Coma Scale (GCS), injury severity score and neurological findings, cardiopulmonary instability, coagulopathy and radiological finding such as bullet trajectory and mass effect are shown to predict survival after GTBI. We aimed to examine the dynamics of the observed coagulopathy and its association with outcome.
In this single-centered retrospective cohort study, we examined 88 patients with GTBI between 2015 and 2021. Variables analyzed include patient age; temperature, hemodynamic and respiratory variables, admission Glasgow Coma Scale (GCS); injury severity score (ISS); head abbreviated injury scale (AIS); Marshall, Rotterdam, SPIN and Baylor scores, and laboratory data including PTT, INR and platelet count. Receiver operating characteristic analysis was conducted to evaluate the performance of the predictive models.
The average age of our sample was 28.5 years and a majority were male subjects (92%). Fifty-four (62%) of the patients survived to discharge. The GCS score, as well as the motor, verbal, and eye-opening sub-scores were higher in survivors (P < 0.001). As was expected, radiologic findings including the Marshall and Rotterdam Scores were also associated with survival (P < 0.001). Although the ISS and Head AIS scores were higher (P < 0.001), extracranial injuries were not more prevalent in non-survivors (P= 0.567). Non-survivors had lower platelet counts and elevated PTT and INR (P < 0.001) on admission. PTT normalized within 24 h but INR continued to increase in non-survivors. SPIN score, which includes INR, was a better predictor for mortality than Rotterdam, Marshall, and Baylor etc. CONCLUSION: Progressively increasing INR after GTBI is associated with poor outcome and may indicate consumption coagulopathy from activation of the extrinsic pathway of coagulation and metabolic derangements that are triggered and sustained by the brain injury. The SPIN score, which incorporates INR as a major survival score component, outperforms other available prediction models for predicting outcome after GTBI.
穿透性弹道脑损伤（枪伤性脑损伤或 GTBI）与高死亡率相关。入院时的格拉斯哥昏迷量表（GCS）、损伤严重程度评分和神经学检查结果、心肺功能不稳定、凝血功能障碍以及诸如子弹轨迹和占位效应等影像学检查结果已被证明可预测 GTBI 后的生存情况。我们旨在研究观察到的凝血功能障碍的动态变化及其与预后的关系。
在这项单中心回顾性队列研究中，我们研究了 2015 年至 2021 年间 88 例 GTBI 患者。分析的变量包括患者年龄；体温、血流动力学和呼吸变量、入院时格拉斯哥昏迷量表（GCS）；损伤严重程度评分（ISS）；头部简明损伤量表（AIS）；马歇尔、鹿特丹、SPIN 和贝勒评分，以及包括活化部分凝血活酶时间（PTT）、国际标准化比值（INR）和血小板计数在内的实验室数据。进行受试者工作特征分析以评估预测模型的性能。
我们样本的平均年龄为 28.5 岁，大多数为男性受试者（92%）。54 例（62%）患者存活至出院。幸存者的 GCS 评分以及运动、言语和睁眼子评分更高（P < 0.001）。正如预期的那样，包括马歇尔和鹿特丹评分在内的影像学检查结果也与生存相关（P < 0.001）。尽管 ISS 和头部 AIS 评分更高（P < 0.001），但非幸存者的颅外损伤并不更普遍（P = 0.567）。非幸存者入院时血小板计数较低，PTT 和 INR 升高（P < 0.001）。PTT 在 24 小时内恢复正常，但非幸存者的 INR 持续升高。包括 INR 的 SPIN 评分比鹿特丹、马歇尔和贝勒等评分更能预测死亡率。结论：GTBI 后 INR 逐渐升高与不良预后相关，可能表明由于凝血外源性途径激活以及脑损伤引发并持续的代谢紊乱导致消耗性凝血功能障碍。将 INR 作为主要生存评分组成部分的 SPIN 评分在预测 GTBI 后的预后方面优于其他可用的预测模型。
