- 期刊
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
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.
並列摘要
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.
延伸閱讀
- 李俊儒（2010）。顱內出血嚴重程度及其預後和凝血機能異常之探討〔碩士論文，中山醫學大學〕。華藝線上圖書館。https://www.airitilibrary.com/Article/Detail?DocID=U0003-1201201022444900
- Yeh, T. C., Kuo, J. R., & Chio, C. C. (2006). 以術中顱內壓監視早期診斷顱內出血之三病例報告. Formosan Journal of Surgery, 39(1), 28-32. https://doi.org/10.29833/FJS.200602.0005
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- Teng, M. M. H., Liou, A. J. K., Lirng, J. F., Luo, C. B., Chen, S. S., Guo, W. Y., Chiang, J. H., Chang, C. Y., & Yang, C. F. (1998). 電腦斷層血管成像術以發現顱內動脈阻塞疾病：影響品質之各項因子. 中華放射線醫學雜誌, 23(4), 137-141. https://www.airitilibrary.com/Article/Detail?DocID=10188940-199808-23-4-137-141-a
- 何巧琳、李梅琛、簡翠薇（2006）。Rehabilitation of Intracranial Hemorrhage Patient Following Craniotomy。醫護科技學刊，8(3)，237-248。https://doi.org/10.6563/TJHS.2006.8(3).7