摘要
目的探讨创伤性颅脑损伤(TBI)后弥漫性脑肿胀患者预后的影响因素,并构建风险预测模型。方法回顾性收集2019年6月至2024年6月宁波市杭州湾医院收治的149例TBI后弥漫性脑肿胀患者资料,根据患者14 d内存活情况分为死亡组(n=78)与存活组(n=71),比较两组临床资料,通过多因素Cox回归分析得到TBI后弥漫性脑肿胀患者预后可能的影响因素,基于多因素Cox回归分析结果构建风险预测模型,并通过列线图将模型可视化;通过受试者工作特征(ROC)曲线、校准曲线及决策曲线分析对模型预测效能进行内部验证。另收集2024年7月至2025年3月医院收治的63例TBI后弥漫性脑肿胀患者资料,绘制ROC曲线,对模型预测效能进行外部验证。结果初步比较死亡组与存活组患者的资料后,将有差异的连续变量指标[入院时格拉斯哥昏迷量表(GCS)评分、血红蛋白、中性粒细胞/淋巴细胞比值(NLR)、C反应蛋白、白蛋白、铁蛋白、泛素羧基末端水解酶L1(UCH-L1)],经ROC曲线得到预测患者死亡风险的最佳阈值,根据最佳阈值对上述指标进行二分类变量分类后,纳入全部资料行多因素Cox回归分析,结果显示,合并蛛网膜下腔出血、治疗中有创监测颅内压、血红蛋白<112.44 g/L、NLR≥9.21、C反应蛋白≥11.34 mg/L、铁蛋白≥279.15 ng/mL、UCH-L1≥33.27 ng/mL均为TBI后弥漫性脑肿胀患者预后的独立危险因素(P<0.05)。基于多因素Cox回归结果构建风险预测模型,绘制ROC曲线显示,模型预测TBI后弥漫性脑肿胀患者死亡的曲线下面积(AUC)为0.982(95%CI 0.969~0.997),区分度好;模型校准曲线趋于理想曲线,一致性好;绘制决策曲线分析,风险阈值在0.00~1.00范围,模型临床净受益率始终大于0,最大净受益率为0.460,模型有较好的临床应用价值。验证集ROC曲线AUC为0.974(95%CI 0.942~1.000),提示已构建的模型具有较好的外部预测效能。结论合并蛛网膜下腔出血、治疗中颅内压监测方式、血红蛋白、NLR、C反应蛋白、铁蛋白、UCH-L1均可能是TBI后弥漫性脑肿胀患者预后的风险因素,据此构建的风险预测模型对患者短期预后风险有较好的预测效能。
Objective To explore the influencing factors of prognosis in the patients with diffuse brain swelling after traumatic brain injury(TBI),and to construct a risk prediction model.Methods The data of 149 patients with diffuse brain swelling after TBI admitted to Ningbo Hangzhou Bay Hospital from June 2019 to June 2024 were retrospectively collected.According to the survival status of the patients within 14 days,they were divided into the death group(n=78)and the survival group(n=71).The clinical data of the two groups were compared.The possible influencing factors of prognosis in the patients with diffuse brain swelling after TBI were obtained by multivariate Cox regression analysis.A risk prediction model was constructed based on the results of multivariate Cox regression analysis,and the model was visualized with nomogram.The predictive efficacy of the model was internally verified through the receiver operating characteristic(ROC)curve,calibration curve and decision curve.In addition,the data of 63 patients with diffuse brain swelling after TBI admitted to the hospital from July 2024 to March 2025 were collected as the validation set.The ROC curve was plotted by using the data from the validation set to externally validate the predictive efficacy of the model.Results After preliminary comparison of data between the death group and the survival group,continuous variable indicators with differences[Glasgow coma scale(GCS)score at admission,hemoglobin,neutrophil/lymphocyte ratio(NLR),C-reactive protein,albumin,ferritin,and ubiquitin carboxyterminal hydrolase L1(UCH-L1)]were used to obtain the optimal threshold for predicting mortality risk of the patients through ROC curve.Based on the optimal threshold,the above indicators were classified into binary variables and included in all data for multivariate Cox regression analysis.The results showed that subarachnoid hemorrhage,invasive monitoring of intracranial pressure during treatment,hemoglobin<112.44 g/L,NLR≥9.21,C-reactive protein≥11.34 mg/L,ferritin≥279.15 ng/mL and UCH-L1≥33.27 ng/mL were independent risk factors for the prognosis of patients with diffuse brain swelling after TBI(P<0.05).A risk prediction model was constructed based on the results of multivariate Cox regression,and the ROC curve showed that the area under curve(AUC)of the model predicting the mortality of patients with diffuse brain swelling after TBI was 0.982(95%CI 0.969-0.997),indicating good discrimination.The model calibration curve tended towards the ideal curve with good consistency.Decision curve was drawn with a risk threshold within the range of 0.00-1.00.The clinical net benefit rate of the model was always greater than 0,and the maximum net benefit rate was 0.460.The model had good clinical application value.The AUC of the validation set was 0.974(95%CI 0.942-1.000),indicating that the established model had good external predictive performance.Conclusions The combination of subarachnoid hemorrhage,intracranial pressure monitoring during treatment,hemoglobin,NLR,C-reactive protein,ferritin,and UCH-L1 may all be risk factors for the prognosis of patients with diffuse brain swelling after TBI.The risk prediction model constructed based on these indexes may have good predictive efficacy for the short-term prognosis risk of patients.
作者
应希轶
刘鹏
Ying Xiyi;Liu Peng(Health Science Center,Ningbo University,Ningbo 315000,China)
出处
《中国急救医学》
2025年第6期482-489,共8页
Chinese Journal of Critical Care Medicine
关键词
创伤性颅脑损伤
弥漫性脑肿胀
预后
风险预测模型
Traumatic brain injury
Diffuse brain swelling
Prognosis
Risk prediction model
