Department of Neurosurgery, Guro Hospital, Korea University Medical Center, 148, Gurodong-ro, Guro-ru, Seoul, 08308, Republic of Korea.
Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea.
Neurocrit Care. 2024 Dec;41(3):997-1008. doi: 10.1007/s12028-024-02043-w. Epub 2024 Jul 12.
Hyperosmolar therapy has long been a cornerstone in managing increased intracranial pressure and improving outcomes in severe traumatic brain injury (TBI). This therapy hinges on elevating serum osmolality, creating an osmotic gradient that draws excess water from the brain's cellular and interstitial compartments and effectively reducing cerebral edema. Given this information, we hypothesized that the serum hyperosmolality prior to any treatment could significantly impact the clinical outcomes of patients with severe TBI, potentially mitigating secondary cerebral edema after trauma.
Data were extracted from the Korean Multi-center Traumatic Brain Injury data bank, encompassing 4628 patients with TBI admitted between January 2016 and December 2018. Of these, 507 patients diagnosed with severe TBI (Glasgow Coma Scale score < 9) were selected for comprehensive analysis across four data domains: clinical, laboratory, initial computed tomography scan, and treatment. Serum osmolality was assessed prior to treatment, and the hyperosmolar group was defined by a pretreatment serum osmolality exceeding 320 mOsm/L, whereas favorable outcomes were characterized by a modified Rankin Scale score of ≤ 3 at 6 months after trauma. Multivariate regression with receiver operating characteristic curve analysis and propensity score matching were used to dissect the data set.
Multivariate analysis showed serum osmolality is significantly associated with clinical outcome in patients with severe TBI (p < 0.001). The optimal cutoff value for predicting favorable outcome was 331 mOsm/L, with a sensitivity of 38.9% and a specificity of 87.7%. Notably, the propensity score matching analysis comparing patients with pretreatment serum hyperosmolality with those without indicated a markedly improved functional outcome in the former group (32.5% vs 18.8%, p = 0.025).
The present study has uncovered a significant correlation between the pretreatment serum osmolality and the clinical outcomes of patients with severe TBI. These findings offer a novel perspective, indicating that a serum hyperosmolality prior to any treatment might potentially have a neuroprotective effect in patients with severe TBI.
高渗治疗一直是管理颅内压升高和改善严重创伤性脑损伤（TBI）患者预后的基石。这种治疗方法依赖于提高血清渗透压，形成一个渗透梯度，将多余的水分从脑的细胞和间质间隙中抽出，有效地减少脑水肿。有鉴于此，我们假设在任何治疗之前的血清高渗状态可能会显著影响严重 TBI 患者的临床结果，可能减轻创伤后的继发性脑水肿。
从韩国多中心创伤性脑损伤数据库中提取数据，包括 2016 年 1 月至 2018 年 12 月期间收治的 4628 例 TBI 患者。其中，507 例诊断为严重 TBI（格拉斯哥昏迷评分<9）的患者在四个数据域（临床、实验室、初始 CT 扫描和治疗）进行了全面分析。在治疗前评估血清渗透压，将治疗前血清渗透压超过 320mOsm/L 的患者定义为高渗组，而良好的结局定义为创伤后 6 个月改良 Rankin 量表评分≤3。采用多变量回归、受试者工作特征曲线分析和倾向评分匹配来剖析数据集。
多变量分析显示，血清渗透压与严重 TBI 患者的临床结果显著相关（p<0.001）。预测良好结局的最佳截断值为 331mOsm/L，敏感性为 38.9%，特异性为 87.7%。值得注意的是，比较治疗前血清高渗组与无高渗组患者的倾向评分匹配分析表明，前者的功能结局明显改善（32.5% vs 18.8%，p=0.025）。
本研究揭示了治疗前血清渗透压与严重 TBI 患者临床结局之间存在显著相关性。这些发现提供了一个新的视角，表明严重 TBI 患者在任何治疗之前的血清高渗状态可能具有神经保护作用。
