Aarabi B, Taghipour M, Alibaii E, Kamgarpour A
University of Nebraska Medical Center, Omaha 68198-2035, USA.
Neurosurgery. 1998 Mar;42(3):500-7; discussion 507-9. doi: 10.1097/00006123-199803000-00014.
To evaluate variables instrumental in central nervous system infections after military missile head wounds, using uni- and multivariate analysis in 964 patients during the 8-year Iran-Iraq War.
Factors considered in this retrospective study were: the types of projectile, mode of injury, paranasal sinus involvement, number of lobes involved, transventricular injuries, place of exploration (base hospital or Nemazee Hospital), cerebrospinal fluid (CSF) fistulas, Glasgow Coma Scale (GCS) score, retained bone, and retained shell fragments.
During the study period, 105 patients (11%) developed central nervous system infections, including 20 abscesses, 1 case of cerebritis, 2 cases of fungus cerebri, and 82 cases of meningitis. gram-negative organisms, especially Klebsiella pneumoniae, were the most frequent offending organisms. Forty-one percent of the 133 deaths were due to infections, but the death rate from infection was only 4.4%. Univariate analysis showed mode of injury, number of lobes involved, ventricular penetration, paranasal sinus involvement, CSF fistulas, place of exploration, GCS score, and retained bone fragments to have significant bearing on the incidence of central nervous system infections. On the other hand, multivariate regression analysis disclosed the following factors each enhancing infection: CSF fistulas (chi2 = 46.526), transventricular injuries (chi2 = 13.4790), and paranasal petrous sinuses involvement (chi2 = 4.2221). When compared with primary exploration at the Nemazee Hospital, both exploration at a base hospital and no exploration at all were associated with increased chances of infection (chi2 = 4.7629 and 8.3220, respectively). Additionally, when tangential, crossed penetrating, and uncrossed penetrating injuries were compared with through-and-through injuries, the uncrossed penetrating mode was associated with less infection (chi2 = 0.1652, 2.6353, and 5.0817, respectively). Only two patients were readmitted for new evidence of infection 3 and 5 months after missile head wounds, one definitely due to and the other on suspicion of CSF fistulas. One hundred and thirty-seven of 587 patients with retained bone fragments were followed a mean of 42 months with no evidence of delayed infection.
In this study, CSF fistulas and transventricular and paranasal sinus injuries all were associated with increased chances of central nervous system infections after military missile head wounds. Infection rate was lower in penetrating injuries not crossing into another dural compartment. Exploration at the Nemazee Hospital, despite delays in evacuation, had less incidence of infection than surgery at a base hospital within the first 24 hours of injury. Retained bone and metal fragments, a lower GCS score at the time of admission, secondary exploration at the Nemazee Hospital, and number of lobes involved were less important when evaluated in a multivariate regression model.
在为期8年的两伊战争期间，对964例患者进行单因素和多因素分析，以评估军事导弹头部创伤后中枢神经系统感染的相关因素。
本回顾性研究考虑的因素包括：弹丸类型、损伤方式、鼻窦受累情况、受累脑叶数量、经脑室损伤、探查地点（基地医院或纳马齐医院）、脑脊液（CSF）瘘、格拉斯哥昏迷量表（GCS）评分、残留骨片和残留弹片。
在研究期间，105例患者（11%）发生中枢神经系统感染，包括20例脓肿、1例脑炎、2例霉菌性脑炎和82例脑膜炎。革兰氏阴性菌，尤其是肺炎克雷伯菌，是最常见的致病微生物。133例死亡患者中有41%死于感染，但感染死亡率仅为4.4%。单因素分析显示，损伤方式、受累脑叶数量、脑室穿透、鼻窦受累、CSF瘘、探查地点、GCS评分和残留骨片对中枢神经系统感染的发生率有显著影响。另一方面，多因素回归分析显示以下因素均增加感染风险：CSF瘘（χ2 = 46.526）、经脑室损伤（χ2 = 13.4790）和鼻窦受累（χ2 = 4.2221）。与在纳马齐医院进行初次探查相比，在基地医院进行探查和根本不进行探查均与感染几率增加相关（χ2分别为4.7629和8.3220）。此外，将切线伤、交叉穿透伤和非交叉穿透伤与贯通伤进行比较时，非交叉穿透伤的感染几率较低（χ2分别为0.1652、2.6353和5.0817）。仅2例患者在导弹头部创伤后3个月和5个月因新的感染证据再次入院，1例明确因CSF瘘，另1例怀疑因CSF瘘。587例有残留骨片的患者中，137例平均随访42个月，无延迟感染证据。
在本研究中，CSF瘘、经脑室和鼻窦损伤均与军事导弹头部创伤后中枢神经系统感染几率增加相关。未穿入另一硬脑膜腔的穿透伤感染率较低。尽管转运延迟，但在纳马齐医院进行探查的感染发生率低于伤后24小时内在基地医院进行手术。在多因素回归模型中评估时，残留骨片和金属碎片、入院时较低的GCS评分、在纳马齐医院进行二次探查以及受累脑叶数量的重要性较低。
