背景:许多患有严重创伤性脑损伤(TBI)的儿童在住院期间接受磁共振成像(MRI)。关于早期MRI的不同损伤模式如何告知结果的数据不足。
方法:2010-2021年因严重TBI(格拉斯哥昏迷量表[GCS]评分<9)入院的儿童(3-17岁)使用我们网站的创伤登记进行鉴定。我们使用多变量建模来确定出血性弥漫性轴索损伤(DAI)等级和扩散受限区域的数量(皮质下白质,call体,深灰质,和脑干)在受伤后7天内获得的MRI与遵循命令的时间以及住院康复出院时的儿童功能独立性测量(WeeFIM)评分独立相关。我们控制了临床变量年龄,入院前心肺复苏,瞳孔反应性,运动GCS评分,并在前12小时内发烧(>38°C)。
结果:在260名患者中,136人(52%)在受伤后7天内接受了MRI检查,中位时间为3天(四分位距[IQR]2-4)。早期MRI患者的中位年龄为11岁(IQR7-14),8例(6%)患者接受心肺复苏,19例(14%)患者双侧瞳孔无反应,运动GCS评分中位数为1(IQR1-4),82例(60%)患者发烧。46例(34%)患者出现3级DAI,在75例(55%)患者的call体中发现了限制扩散,29例(21%)患者的深灰质,23例(17%)患者的皮质下白质,20例(15%)患者的脑干。在控制临床变量后,扩散受限的区域数量增加,但不是出血性DAI等级,与较长的时间(风险比0.68,95%置信区间0.53-0.89)和较差的WeeFIM评分(估计β-4.67,95%置信区间-8.33至-1.01)独立相关。
结论:早期MRI区域限制弥散与重度TBI患儿的短期预后独立相关。需要多中心队列研究来验证这些发现,并阐明重度TBI儿童早期MRI特征与长期预后的关系。
BACKGROUND: Many children with severe traumatic brain injury (TBI) receive magnetic resonance imaging (MRI) during hospitalization. There are insufficient data on how different patterns of injury on early MRI inform outcomes.
METHODS: Children (3-17 years) admitted in 2010-2021 for severe TBI (Glasgow Coma Scale [GCS] score < 9) were identified using our site\'s trauma registry. We used multivariable modeling to determine whether the hemorrhagic diffuse axonal injury (DAI) grade and the number of regions with restricted diffusion (subcortical white matter, corpus callosum, deep gray matter, and brainstem) on MRI obtained within 7 days of injury were independently associated with time to follow commands and with Functional Independence Measure for Children (WeeFIM) scores at the time of discharge from inpatient rehabilitation. We controlled for the clinical variables age, preadmission cardiopulmonary resuscitation, pupil reactivity, motor GCS score, and fever (> 38 °C) in the first 12 h.
RESULTS: Of 260 patients, 136 (52%) underwent MRI within 7 days of injury at a median of 3 days (interquartile range [IQR] 2-4). Patients with early MRI were a median age of 11 years (IQR 7-14), 8 (6%) patients received cardiopulmonary resuscitation, 19 (14%) patients had bilateral unreactive pupils, the median motor GCS score was 1 (IQR 1-4), and 82 (60%) patients had fever. Grade 3 DAI was present in 46 (34%) patients, and restricted diffusion was noted in the corpus callosum in 75 (55%) patients, deep gray matter in 29 (21%) patients, subcortical white matter in 23 (17%) patients, and the brainstem in 20 (15%) patients. After controlling for clinical variables, an increased number of regions with restricted diffusion, but not hemorrhagic DAI grade, was independently associated with longer time to follow commands (hazard ratio 0.68, 95% confidence interval 0.53-0.89) and worse WeeFIM scores (estimate β - 4.67, 95% confidence interval - 8.33 to - 1.01).
CONCLUSIONS: Regional restricted diffusion on early MRI is independently associated with short-term outcomes in children with severe TBI. Multicenter cohort studies are needed to validate these findings and elucidate the association of early MRI features with long-term outcomes in children with severe TBI.