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題 名 | 不同病因導致顱內出血之預後與凝血機能異常之探討=A Study of the Correlation between Coagulopathy and Intracranial Hemorrhage in Regard to Severity and Prognosis |
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作 者 | 李俊儒; | 書刊名 | 中華民國重症醫學雜誌 |
卷 期 | 13:2 2012.12[民101.12] |
頁 次 | 頁64-81 |
分類號 | 416.291 |
關鍵詞 | 凝血病變指數; 顱內出血; 頭部外傷預後; Coagulation score; Intracranial hemorrhage; Prognosis of head injury; |
語 文 | 中文(Chinese) |
中文摘要 | 背景與目的:頭部外傷所導致的顱內出血經常會引起相當程度的凝血功能異常,但是自發性顱內出血是否也有類似情況則較無一致的結論;嚴重的創傷性顱內出血固然產生高度的罹病率( morbidity)與死亡率( mortality),可是當一開始意識狀況清醒的病人(talk and deteriorate syndrome),一旦腦部的狀況惡化,雖然發生比例不高,但是往往會延誤應該進行的治療。因此對於不同病因的顱內出血與凝血病變發生率、凝血病變指數與腦損傷嚴重度及其預後的關係,有進一步研究的必要。 方法:本研究採回溯性 (retrospective)病例對照(case-control study)的分析方式,在中部某區域型教學醫院,從 2007年 1月 1日至 2008年 12月 31日止共 24個月期間內,經電腦斷層影像證明有顱內出血之外科加護病房成年病患,排除先前有神經系統疾病、凝血問題、嚴重系統性疾病、入院 24小時以內死亡者。記錄不同出血病因、年齡、 Glasgow coma scale(GCS)、兩側瞳孔對光的反應、電腦斷層掃描上之中線偏移距離、 Abbreviated injury score(AIS)、創傷機轉、各項凝血異常參數的總分(凝血病變指數, disseminated intravascular coagulation score)以代表凝血病變嚴重度、發病後到抽取血液的時間、有無發生低血壓、有否發生低血氧,與發病一個月以後的 Glasgow Outcome Scale(GOS)。分析方法使用 SPSS 13.0版套裝統計軟體進行參數估計(parameter estimation)與假設檢定(hypothesis test)。 結果:總計有 87個創傷與自發性顱內出血病例被選入本研究,其中外傷性出血 56例,自發性出血 31例。 1.外傷性顱內出血發生凝血異常的機會大於自發性顱內出血( 82.1% vs. 22.6%,p<0.001)。2.外傷性顱內出血發生且併發凝血功能異常的病例,其 GCS分數明顯較差(分數的中位數: 9 vs. 13,p=0.001),CT中線偏移距離較遠(等級的中位數: 5-15mm vs.< 5mm p=0.018),瞳孔對光反射較無反應(等級的中位數 : 一眼瞳孔對光無反應vs.正常, p=0.004),另外也有較高的 AIS分數(分數的中位數: 3 vs. 2, p=0.003)與穿透傷比例( 34.8%,Fisher exact test p=0.048)。3.創傷組包含多處出血且合併蜘蛛膜下腔出血的病例,不僅伴隨有凝血機能異常而且凝血病變指數明顯較高於單一出血位置。 4.接受操作曲線( Receiver operating characteristic curve)決定了凝血病變指數的最佳切點為 4分(sensitivity=72%, specificity=80.6%,likelihood ratio=3.711);以多變項的逐步邏輯回歸( stepwise logistic regression)對分組後的 GOS與在單變項回歸顯著的風險因子進行分析,預後變差( GOS=1,2,3)的獨立的風險因子依序為: (1). 一眼以上的瞳孔對光無縮小反應( odds ratio=82,p=0.03);(2).AIS 大於等於 4分(odds ratio=36.3,p=0.011);(3).凝血異常指數大於等於 4分(odds ratio= 30.8, p=0.021);(4).CT上之中線偏移大於等於 5mm(odds ratio=15.4,p=0.05 )。 (5). 經傳統的神經學檢查與影像學發現判斷屬於較輕微的外傷病患,其 GOS的分數與凝血異常指數的關聯性,明顯高於較嚴重的頭部外傷病患。 結論:凝血病變指數可以有效的評估頭部外傷之嚴重程度,並且對於將來復原情況的預測具有準確度,特別是疾病之初以傳統檢查工具判斷為較輕微的患者。 |
英文摘要 | background and purpose: The correlations between coagulopathy and traumatic intracranial hemorrhage (ICH) have been proposed by numerous studies, but there are discrepancies for spontaneous ICH. No doubt severe traumatic ICH always induces high morbidity and mortality; nevertheless, the patients who have lucid interval (talk and deteriorate syndrome) will mask the entity of injury and delay the imperative treatment. So it is indispensable to study the incidence of coagulopathy for ICH caused by different etiologies and the relationships between coagulation score and ICH in regard to severity and prognosis. method: This is a retrospective case-control study. The adult patients with intracranial hemorrhage (ICH), which had been proved by computer tomography (CT) and admitted to the surgical intensive care unit of one certain hospital in the midland of Taiwan, were enrolled from January, 1 2007 to December, 31 2008. Those patients with previous neurogenic disorder, coagulopathy disorder, serious systemic disease, and died within 24 hours were excluded. The complete histories about etiology, age, Glasgow coma scale (GCS), bilateral pupil light reflex, the extent of midline-shift on CT scan, Abbreviated injury score (AIS), traumatic mechanism, modified disseminated intravascular coagulation score (represent the severity of coagulopathy), the time form disease onset to blood drawn, hypotension, and hypoxemia were all recorded. The analytic methods were to make use of the software (SPSS for windows, version 13.0) for parameter estimation and hypothesis test. result: There were eighty-seven patients with ICH (56 traumatic cases and 31 spontaneous cases) selected into this study. 1. The incidence of coagulopathy was higher in traumatic group (82.1% vs. 22.6% p<0.001). 2. In the traumatic ICH category, the subgroup combined with coagulopathy possessed poor GCS (median: 9 vs. 13,p=0.001), farther extent of midline-shift on CT scan (median of grade: 5-15mm vs. <5mm, p=0.018), bad pupil light reflex (median of grade: one pupil without light reflex vs. normal, p=0.004), higher AIS (median: 3 vs. 2, p=0.003), greater proportion of penetrating injury (34.8%, Fisher exact test p=0.048). 3. In traumatic group, multiple bleeding nidi associated with subarachnoid hemorrhage should not only get high proportion of coagulopathy but also have higher coagulation score. 4. The receiver operating characteristic curve determined the best cut-off point of coagulation score is 4 (sensitivity=72%, specificity=80.6%, likelihood ratio=3.711); multivariate stepwise logistic regression for GOS and significant risk factor of univariate logistic regression disclosed the independent risk in turn: (1). More than one pupil without light (odds ratio=82, p=0.03 ), (2). AIS≧4 (odds ratio=36.3, p=0.011), (3). Modified disseminated intravascular coagulation score ≧4 (odds ratio= 30.8, p=0.021), (4). midline-shift ≧ 5mm on CT scan (odds ratio=15.4, p=0.05). (5). The GOS of mild head injury were more correlative with coagulopathy than severe ones, which were diagnosed by neurological examination and image study. conclusion: Modified disseminated intravascular coagulation score could assess the severity and the outcome of head injury, especially certain patients classified to less critical by traditionally diagnostic tools. |
本系統中英文摘要資訊取自各篇刊載內容。