Orlando Alessandro, Panchal Ripul R, Quan Glenda, Backen Timbre, Gordon Jeffrey, Mellor Lane, Dhakal Laxmi, Hamilton David, Palacio Carlos H, Kerby Justin, Acuna Dave, Berg Gina M, Levy Andrew Stewart, Rubin Benjamin, Coresh Josef, Bar-Or David
1Injury Outcomes Network, Englewood, Colorado.
2Department of Neurosurgery, Medical City Plano, Texas.
J Neurosurg. 2024 Oct 11;142(3):839-850. doi: 10.3171/2024.5.JNS232478. Print 2025 Mar 1.
Because there is no reliable method on admission to predict whether a patient will require neurosurgical intervention in the future, the general approach remains to treat each patient with mild traumatic brain injury (mTBI) and subdural hematoma (SDH) as if they will require such an intervention. Consequently, there is a growing population of patients with mTBI and SDH that is overtriaged despite having a low probability of needing neurosurgical intervention. This study aimed to train and validate a predictive rule-out tool for neurosurgical intervention in patients with mTBI and SDH.
This was a retrospective cohort study of all trauma patients admitted to six level I trauma centers in three states. Patients were included if they met the following criteria: admitted between 2016 and 2020, ≥ 18 years of age, ICD-10 diagnosis of isolated SDH, initial head imaging available, initial Glasgow Coma Scale score of 13-15, and arrived within 48 hours of injury. Exclusion criteria included skull fracture, intracranial hemorrhage other than an SDH, and no neurosurgical consultation. Prediction variables included 34 demographic, clinical, and radiographic variables. The study outcome was neurosurgical intervention within 48 hours of hospital admission. Seventy-five percent of the data were used for training, and 25% for testing. Multivariable logistic regression with fivefold cross-validation was used on the training set to identify covariates with the highest specificity while holding sensitivity at 100%. Results were validated on the testing set.
In total, 1000 patients were in the training set and 333 in the testing set. The overall neurosurgical intervention rate was 8.8%. For the fivefold cross-validation process, three variables were selected that maximized specificity while holding sensitivity at 100%: maximum hematoma thickness, initial Glasgow Coma Scale score, and preinjury antithrombotic use (sensitivity 100%, specificity 56%, area under the receiver operating characteristic curve 0.94). With a cutoff probability of neurosurgical intervention set at 1.88%, the final model was validated to predict neurosurgical intervention with a sensitivity of 100% (95% CI 88.4%-100%) and specificity of 55.1% (95% CI 49.3%-60.8%).
In this study, the largest of its kind to date, the authors successfully developed and validated a new tool for ruling out the necessity of neurosurgical intervention in patients with mTBI and isolated SDH. By successfully identifying more than half of patients who are unlikely to require neurosurgery within the first 2 days of admission, this tool can be used to improve treatment efficiency and provide patients and clinicians with valuable prognostic information.
由于入院时没有可靠的方法来预测患者未来是否需要神经外科干预，目前的一般做法是将每例轻度创伤性脑损伤（mTBI）和硬膜下血肿（SDH）患者都当作需要此类干预来进行治疗。因此，尽管mTBI和SDH患者需要神经外科干预的可能性较低，但被过度分诊的患者数量却在不断增加。本研究旨在训练并验证一种针对mTBI和SDH患者神经外科干预的预测排除工具。
这是一项对三个州的六个一级创伤中心收治的所有创伤患者进行的回顾性队列研究。符合以下标准的患者被纳入研究：2016年至2020年入院，年龄≥18岁，ICD-10诊断为单纯性SDH，有初始头部影像学资料，初始格拉斯哥昏迷量表评分为13 - 15分，且在受伤后48小时内入院。排除标准包括颅骨骨折、除SDH外的颅内出血以及未进行神经外科会诊。预测变量包括34个人口统计学、临床和影像学变量。研究结局为入院后48小时内进行神经外科干预。75%的数据用于训练，25%用于测试。在训练集上使用五重交叉验证的多变量逻辑回归来识别特异性最高同时保持敏感性为100%的协变量。结果在测试集上进行验证。
训练集共有1000例患者，测试集有333例患者。总体神经外科干预率为8.8%。在五重交叉验证过程中，选择了三个变量，在保持敏感性为100%的同时使特异性最大化：血肿最大厚度、初始格拉斯哥昏迷量表评分和受伤前使用抗血栓药物（敏感性100%，特异性56%，受试者操作特征曲线下面积0.94）。将神经外科干预的截断概率设定为1.88%，最终模型经验证预测神经外科干预的敏感性为100%（95%CI 88.4% - 100%），特异性为55.1%（95%CI 49.3% - 60.8%）。
在这项迄今为止同类研究中规模最大的研究中，作者成功开发并验证了一种新工具，用于排除mTBI和单纯性SDH患者进行神经外科干预的必要性。通过成功识别出超过一半在入院后前两天内不太可能需要神经外科手术的患者，该工具可用于提高治疗效率，并为患者和临床医生提供有价值的预后信息。
