影响小儿重型颅脑损伤预后的危险因素分析

目的分析各种危险因素对小儿重型颅脑损伤预后的影响。方法用寿命表分析，单变量和多变量分析等统计学方法分析年龄、损伤类型、颅骨骨折、颅内血肿、反射消失、癫痫、脑肿胀／脑水肿、格拉斯哥昏迷计分（GCS）、低血压、低氧血症等因素对预后的影响。结果91例患儿，死亡31例（34．1％），死亡大多发生在伤后1周以内，预后与原发性损伤的严重程度有关，GCS记分是影响预后的最主要因素，GCS记分5～8分者88．9％存活，而GCS小于5分者仅14．3％存活；伤后6个月时的致残率为23．1％。单变量分析发现癫痫大发作（P〈0．0001）、多发性损伤（P=0．0112）、反射消失（P〈0．0001）、外伤后急性弥漫性脑水肿／脑肿胀（P〈0．0001）是影响预后的因素，年龄、颅骨骨折和颅内血肿对预后的影响无统计学意义。用Cox模型进一步分析发现治疗前的反射消失、外伤后急性弥漫性脑水肿／脑肿胀是影响预后的最主要因素（P〈0．0009），年龄、颅骨骨折、颅内血肿对预后无影响。结论原发性反射消失、GCS记分是预测预后的最好指标，脑水肿／脑肿胀是影响预后的最主要因素。所以，为了改善患儿的预后，应将颅脑损伤患儿的治疗重点放在预防和减低脑肿胀／脑水肿上。

Risk factors of severe craniocerebral injuries in children

Objective To analyze the risk factors of severe craniocerebral injury in children.Methods The multiple indexes including age, type and severity of injury, skull fracture, intracranial hematoma, areflexia, epilepsy, cerebral edema, Glasgow Coma Scale (GCS) scores and blood pressure were retrospectively analyzed in 91 children with severe craniocerebral injuries aged below 14 years. And the relationship of these indexes with the short term and long term outcomes was also demonstrated.Results Of 91 children with craniocerebral injury, 31 died ( 34.1% ). The majority of deaths occurred within 7 days after injury. The mortality was related to the severity of primary injury at the accident site and the scores of GCS. Survival rate of children with GCS scores higher than 5 was 88.9% , while it was decreased to 14.3% in children with GCS scores less than 5 ( P < 0.0001 ). Twenty one children ( 23.1% ) had severe neurologic impairments at 6 months after injury. The risk factors for poor outcome, identified by univariate analysis, included epilepsy, multiple injuries, areflexia, and brain swelling or edema. Age, skull fracture and intracranial hemorrhage/hematoma had nothing to do with the prognosis. The results of multivariate regression analysis (Cox model) showed that areflexia and secondary cerebral swelling/edema were the most important risk factors for outcomes ( P < 0.0009 ). Conclusions The GCS system deserves to be one of the most important predictive values for children with severe craniocerebral injury. Prevention of cerebral swelling or edema may contribute to better outcomes in these children.