目的 分析影响重型颅脑创伤(TBI)术前继发瞳孔散大患者预后的相关因素.方法 回顾性分析2019年5月至2023年5月湖州学院附属南太湖医院神经外科收治的173例重型TBI术前继发瞳孔散大患者的临床资料.术后6个月依据格拉斯哥预后分级(GOS)将患者分为预后较佳组(GOS Ⅳ～Ⅴ级)及预后不佳组(GOS Ⅰ～Ⅲ级).比较两组患者的性别、年龄,术前瞳孔散大为单侧或双侧、格拉斯哥昏迷评分(GCS)、环池状态、中线结构移位、瞳孔散大至手术减压时间,手术总时长、手术方式、颅内压(ICP)监测探头类型、初始ICP、术后即刻ICP、围手术期有低血压和(或)低氧血症、多发性损伤的差异.将上述差异有统计学意义的因素纳入多因素logistic回归模型,分析影响重型TBI术前继发瞳孔散大患者预后不佳的独立危险因素.结果 173例患者中,预后较佳组46例(26.6％);预后不佳组127例(73.4％),其中死亡54例(31.2％).单因素分析结果显示,与预后较佳组比较,预后不佳组术前瞳孔双侧散大、术前GCS3～5分、瞳孔散大至手术减压时间≥1h、初始ICP≥40 mm Hg(1 mm Hg=0.133 kPa)、术后即刻ICP≥12 mm Hg、围手术期有低血压和(或)低氧血症的患者所占比率高,差异均有统计学意义(均P＜0.05),其他指标的差异均无统计学意义(均P＞0.05).多因素logistic回归分析显示,术前GCS3～5分(OR=5.13,95％CI:1.89～13.92,P=0.001)、瞳孔散大至手术减压时间≥1 h(OR=3.15,95％CI:1.26～7.87,P=0.014)、术后即刻 ICP≥ 12 mm Hg(OR=4.77,95％CI:1.21～18.84,P=0.026)及围手术期有低血压和(或)低氧血症(OR=3.30,95％CI:1.33～8.18,P=0.010)为影响重型TBI术前继发瞳孔散大患者预后的独立危险因素.结论 重型TBI术前继发瞳孔散大患者的预后受多个因素的影响,其中术前GCS3～5分、瞳孔散大至手术减压时间≥1 h、术后即刻ICP≥12 mm Hg及围手术期有低血压和(或)低氧血症是导致患者预后相对较差的独立危险因素.
Analysis of influencing factors on prognosis in patients with severe craniocerebral trauma with preoperative mydriasis
Objective To analyze the relevant factors affecting the prognosis of patients with severe traumatic brain injury(TBI)with preoperative mydriasis.Methods The clinical data of 173 patients with preoperative secondary mydriasis after severe TBI admitted to the Neurosurgery Department of South Taihu Hospital Affiliated to Huzhou University from May 2019 to May 2023 were retrospectively analyzed.Six months after surgery,patients were divided into a good outcome group(GOS Ⅳ to Ⅴ)and a poor outcome group(GOS Ⅰ to Ⅲ)based on the Glasgow Outcome Scale(GOS).We compared the gender and age of the two groups of patients,whether the preoperative mydriasis was unilateral or bilateral,Glasgow Coma Scale(GCS),circumferential cistern status,midline structural shift,pupil dilation to surgical decompression time,operation time,operation method,ICP probe type,initial intracranial pressure(ICP),immediate postoperative ICP,perioperative hypotension and/or hypoxemia,and multiple injuries.The above factors with statistically significant differences were incorporated into the multivariate logistic regression model to analyze the independent risk factors affecting the poor prognosis of patients with secondary mydriasis before severe TBI surgery.Results Among the 173 patients,46(26.6％)were in the good outcome group;127(73.4％)were in the poor outcome group,of which 54(31.2％)died.The results of univariate analysis showed that compared with the group with better outcome,the group with poor outcome had higher proportions of patients with preoperative bilateral pupil dilation,preoperative GCS of 3 to 5 points,pupil dilation to surgical decompression time ≥ 1 hour,and initial ICP ≥ 40 mm Hg(1 mm Hg=0.133 kPa),immediate postoperative ICP ≥12 mm Hg,and perioperative hypotension and/or hypoxemia,and the differences were statistically significant(all P＜0.05);the differences in other indicators were not statistically significant(all P＞0.05).Multivariate logistic regression analysis showed that preoperative GCS of 3-5 poi nts(OR=5.13,95％CI:1.89-13.92,P=0.001),mydriasis to surgical decompression time ≥ 1 hour(OR=3.15,95％CI:1.26-7.87,P=0.014),immediate postoperative ICP≥12 mm Hg(OR=4.77,95％CI:1.21-18.84,P=0.026)and perioperative hypotension and/or hypoxemia(OR=3.30,95％CI:1.33-8.18,P=0.010)were independent risk factors affecting the prognosis of patients with mydriasis secondary to severe craniocerebral trauma.Conclusions The prognosis of patients with preoperative mydriasis secondary to severe TBI is affected by multiple factors,including preoperative GCS of 3 to 5 points,time interval from mydriasis to surgical decompression ≥1 hour,immediate postoperative ICP ≥12 mm Hg,and perioperative hypotension and/or hypoxemia are important risk factors leading to relatively poor patient prognosis.
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