Marshall评分对创伤性脑损伤早期死亡预测价值高

芝加哥——北美放射学会(RSNA)2012年会上公布的一项获奖研究显示，与鹿特丹CT评分系统相比，Marshal CT评分系统能够更好地预测创伤性脑损伤(TBI)患者的早期死亡。

Marshall评分和鹿特丹评分是两种最常用的放射学评分系统，但两者对CT表现的分类不同。Marshall评分系统包括基底池状态、中线移位＞5 mm及出血肿块，而鹿特丹评分系统包括基底池、中线移位＞5 mm、蛛网膜下腔出血和/或脑室内出血及硬膜外出血，但不包括出血肿块。

在这项研究中，日本仙台市东北大学的放射科医生Daddy Mata Mbemba博士及其同事评估了245例连续就诊的轻至重度TBI患者的初始CT扫描结果和出院状态，旨在探讨Marshall评分和鹿特丹 评分是否与出院时死亡(即早期死亡)相关。纳入根据新奥尔良标准和/或加拿大头部CT准则被建议进行CT检查的轻度(定义为格拉斯哥昏迷量表评分13~15分)病例。患者的平均年龄为49岁(15~93岁)，67%为男性。

出院时，25例患者死亡，220例存活。至死亡的中位时间为3天(1~83天)。Logistic回归分析显示，与早期死亡独立相关的CT表现包括基底池状态[比值比(OR)= 771.5；P＜0.001]、中线移位阳性(OR=56.2；P=0.0011)、出血肿块(OR =12.9；P=0.0065)、以及蛛网膜下腔出血和/或脑室内出血(OR=3.8；P=0.0394)。硬脑膜外出血存在与否并不是显著预测因素。

Mbemba博士表示，Marshall评分和鹿特丹评分系统均包括无基底池和中线移位阳性这2个显著的早期死亡独立预测因素，但只有Marshall评分系统包括出血肿块这一额外的显著预测因素，这可能是Marshall评分系统预测TBI早期死亡的效果优于鹿特丹评分系统的原因。

Mbemba博士及其同事声明无相关经济利益冲突。

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By: PATRICE WENDLING, Clinical Neurology News Digital Network

CHICAGO – The Marshall CT classification system is a better predictor of early death in patients with traumatic brain injury than is the Rotterdam score, an award-winning study found.

As observed in previous reports, higher scores on both computed tomography–based scoring systems were significantly associated with early death among patients with mild to severe traumatic brain injury, or TBI (both P values less than .0001).

In a logistic regression analysis, however, only the Marshall scoring system was significantly associated with early death, defined as death at hospital discharge (P less than .002), Dr. Daddy Mata Mbemba reported at the annual meeting of the Radiological Society of North America.

This is likely because the two strongest independent predictors of early death – the absence of basal cistern and positive midline shift – are included in both CT scoring systems, while the next strongest predictor, hemorrhagic mass, is included in the Marshall score only, he explained.

Marshall and Rotterdam are the two most commonly used radiologic scoring systems, according to Dr. Mbemba, but they group CT findings differently. The Marshall score includes the status of basal cisterns, midline shift greater than 5 mm, and hemorrhagic mass, whereas the Rotterdam score includes basal cisterns, midline shift greater than 5 mm, subarachnoid hemorrhage and/or intraventricular hemorrhage, and epidural hemorrhage, but not hemorrhagic mass, explained Dr. Mbemba, a radiologist at Tohoku University, Sendai City, Japan.

He noted that several studies have suggested that increased intracranial pressure may lead to early death, while vasospasm associated with subarachnoid hemorrhage and/or intraventricular hemorrhage that decrease intracerebral circulation is associated with a worsening clinical outcome.

To assess whether the Marshall or Rotterdam scores are related to death at hospital discharge, investigators in the current study reviewed the initial CT scans and status at hospital discharge of 245 consecutive patients with mild to severe TBI. Mild cases, defined by a Glasgow Coma Scale score of 13-15, were included if a CT examination was recommended according to New Orleans Criteria and/or the Canadian CT Head Rule. Patients’ mean age was 49 years (range, 15-93 years), and 67% were men.

At hospital discharge, 25 patients had died and 220 were alive. The median time to death was 3 days (range, 1-83 days), said Dr. Mbemba, who earned a trainee research award from RSNA for his study.

In a logistic regression analysis, CT findings independently related to early death were basal cistern status (odds ratio, 771.5; P less than .001), positive midline shift (OR, 56.2; P = .0011), hemorrhagic mass (OR, 12.9; P = .0065), and subarachnoid hemorrhage and/or intraventricular hemorrhage (OR 3.8; P = .0394), Dr. Mbemba said. The presence or absence of an epidural hemorrhage was not a significant predictor.

In a recently published study, initial Marshall and Rotterdam scores were significantly associated with mortality after severe TBI, while Glasgow Coma Scale scores on admission were not (Neurosurgery 2012;70:1095-105). No relationship was observed, however, between any of the three scoring systems and ICU intracranial pressure or brain tissue oxygen tension, suggesting that factors associated with outcome, may not always predict a patient’s ICU course, especially intracranial physiology.

Dr. Mbemba and his coauthors reported no relevant financial disclosures.