John K. Yue , John H. Kanter , Jason K. Barber , Michael C. Huang , Thomas A. van Essen , Mahmoud M. Elguindy , Brandon Foreman , Frederick K. Korley , Patrick J. Belton , Dana Pisică , Young M. Lee , Ryan S. Kitagawa , Mary J. Vassar , Xiaoying Sun , Gabriela G. Satris , Justin C. Wong , Adam R. Ferguson , J. Russell Huie , Kevin K.W. Wang , Hansen Deng , Ross D. Zafonte
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引用次数: 0
摘要
背景当代治疗创伤性脑损伤（TBI）的手术方法仍不明确。方法前瞻性、观察性的 "创伤性脑损伤研究与临床知识转化研究"（2014-2018；ClinicalTrials.gov #NCT02119182）招募了在创伤后 24 小时内前往创伤中心并接受头部计算机断层扫描的受试者。我们对年龄≥17岁的住院受试者进行了二次数据分析。结果在2032名受试者中（年龄：平均=41.4岁，范围=17-89岁；男性=71%，女性=29%），260人接受了颅骨手术，其中65%为减压开颅术，23%为开颅术，12%为其他手术。接受手术的受试者（与未接受手术的受试者相比）的神经损伤更严重（格拉斯哥昏迷量表中位数 = 6 vs. 15；中线移位≥5 mm：48% vs. 2%；蝶骨脱出：61% vs. 4%；P＜0.05）：61% vs. 4%; p < 0.0001）。颅骨切除术/开颅术的中位时间为1.8小时（四分位间范围=1.1-5.0小时），67%的受试者接受了颅内压监测。73%的减压开颅手术受试者和58%的开颅手术受试者颅内病变类型≥3种。减压开颅术（与开颅术相比）与颅内损伤严重程度（鹿特丹评分中位数 = 4 vs. 3，p < 0.0001）、重症监护住院时间（中位数 = 13 vs. 4 天，p = 0.0002）和六个月的不良预后（62% vs. 30%；p = 0.0001）有关。在一个具有代表性的大型创伤性脑损伤住院患者队列中，手术决策和手术时间与颅内损伤严重程度相关。接受颅脑手术的患者以多灶性创伤为主。这些发现总结了目前美国各创伤中心的创伤性脑损伤手术实践，并为有针对性的亚人群分析奠定了基础。
Clinical profile of patients with acute traumatic brain injury undergoing cranial surgery in the United States: report from the 18-centre TRACK-TBI cohort study
Background
Contemporary surgical practices for traumatic brain injury (TBI) remain unclear. We describe the clinical profile of an 18-centre US TBI cohort with cranial surgery.
Methods
The prospective, observational Transforming Research and Clinical Knowledge in Traumatic Brain Injury Study (2014–2018; ClinicalTrials.gov #NCT02119182) enrolled subjects who presented to trauma centre and received head computed tomography within 24-h (h) post-TBI. We performed a secondary data analysis in subjects aged ≥17-years with hospitalisation. Clinical characteristics, surgery type/timing, hospital and six-month outcomes were reported.
Findings
Of 2032 subjects (age: mean = 41.4-years, range = 17–89-years; male = 71% female = 29%), 260 underwent cranial surgery, comprising 65% decompressive craniectomy, 23% craniotomy, 12% other surgery. Subjects with surgery (vs. without surgery) presented with worse neurological injury (median Glasgow Coma Scale = 6 vs. 15; midline shift ≥5 mm: 48% vs. 2%; cisternal effacement: 61% vs. 4%; p < 0.0001). Median time-to-craniectomy/craniotomy was 1.8 h (interquartile range = 1.1–5.0 h), and 67% underwent intracranial pressure monitoring. Seventy-three percent of subjects with decompressive craniectomy and 58% of subjects with craniotomy had ≥3 intracranial lesion types. Decompressive craniectomy (vs. craniotomy) was associated with intracranial injury severity (median Rotterdam Score = 4 vs. 3, p < 0.0001), intensive care length of stay (median = 13 vs. 4-days, p = 0.0002), and six-month unfavourable outcome (62% vs. 30%; p = 0.0001). Earlier time-to-craniectomy was associated with intracranial injury severity.
Interpretation
In a large representative cohort of patients hospitalised with TBI, surgical decision-making and time-to-surgery aligned with intracranial injury severity. Multifocal TBIs predominated in patients with cranial surgery. These findings summarise current TBI surgical practice across US trauma centres and provide the foundation for analyses in targeted subpopulations.
Funding
National Institute of Neurological Disorders and Stroke; US Department of Defense; Neurosurgery Research and Education Foundation.
期刊介绍：
The Lancet Regional Health – Americas, an open-access journal, contributes to The Lancet's global initiative by focusing on health-care quality and access in the Americas. It aims to advance clinical practice and health policy in the region, promoting better health outcomes. The journal publishes high-quality original research advocating change or shedding light on clinical practice and health policy. It welcomes submissions on various regional health topics, including infectious diseases, non-communicable diseases, child and adolescent health, maternal and reproductive health, emergency care, health policy, and health equity.
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