小结
定义
创伤性脑损伤（traumatic brain injury, TBI）是指头部受到撞击或外力冲击导致正常脑部功能或结构受到破坏。[1]Centers for Disease Control and Prevention, US Department of Health and Human Services. Surveillance report of traumatic brain injury-related emergency department visits, hospitalizations, and deaths - United States, 2014. 2019 [internet publication]. https://www.cdc.gov/traumaticbraininjury/pdf/TBI-Surveillance-Report-508.pdf [2]Scorza KA, Cole W. Current concepts in concussion: Initial evaluation and management. Am Fam Physician. 2019 Apr 1;99(7):426-434. https://www.aafp.org/afp/2019/0401/p426.html http://www.ncbi.nlm.nih.gov/pubmed/30932451?tool=bestpractice.com 钝性创伤、穿透伤和冲击伤都可能导致 TBI。并非所有头部撞击都会导致 TBI。通常根据损伤后格拉斯哥昏迷量表（Glasgow Coma Scale, GCS）评分和/或神经行为缺陷，TBI 可被分为轻度、中度和重度。
“脑震荡”一词常与轻度 TBI 替换使用。美国疾病预防控制中心和世界卫生组织都认为轻度 TBI 是由钝力或机械力导致的不超过 30 分钟的一过性意识模糊、定向障碍或意识丧失；可能伴有一过性神经行为缺陷；并且 GCS 评分不低于 13 分。[3]McCrea HJ, Perrine K, Niogi S, et al. Concussion in sports. Sports Health. 2013 Mar;5(2):160-4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3658375 http://www.ncbi.nlm.nih.gov/pubmed/24427385?tool=bestpractice.com CDC: heads up Opens in new window
分类
TBI可以根据多种方法归类：包括形态、严重程度、部位、损伤机制、机体对损伤的生理反应。
TBI 存在极大的异质性，短期和长期结局受具体颅内损伤、是否伴有颅外损伤、年龄和已有合并症的影响。大多数分类系统都基于早期稳定期的患者症状、临床检查或诊断发现，并未考虑 TBI 的进展和变化。
但是，有研究表示，对于多项可影响结局的变量，可以每过一段时间重复进行风险评估并据此进行分类。[4]Tenovuo O, Diaz-Arrastia R, Goldstein LE, et al. Assessing the severity of traumatic brain injury-Time for a change? J Clin Med. 2021 Jan 4;10(1):. https://www.doi.org/10.3390/jcm10010148 http://www.ncbi.nlm.nih.gov/pubmed/33406786?tool=bestpractice.com
按照临床严重程度分类
GCS 评分被广泛用于 TBI 严重程度以及预后分级。[5]Carney N, Totten AM, O'Reilly C, et al. Guidelines for the management of severe traumatic brain injury, fourth edition. Neurosurgery. 2017 Jan 1;80(1):6-15. https://braintrauma.org/uploads/03/12/Guidelines_for_Management_of_Severe_TBI_4th_Edition.pdf http://www.ncbi.nlm.nih.gov/pubmed/27654000?tool=bestpractice.com [6]Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT head rule for patients with minor head injury. Lancet. 2001;357(9266):1391-6. http://www.ncbi.nlm.nih.gov/pubmed/11356436?tool=bestpractice.com 发生 TBI 后，GCS 评分与计算机体层成像（computed tomography, CT）的阳性检出率呈负相关；如果 GCS 从 15 降至 14，颅内损伤（intracranial injury, ICI）几率和神经外科干预需求会增加一倍。[7]Smits M, Dippel DW, Steyerberg EW, et al. Predicting intracranial traumatic findings on computed tomography in patients with minor head injury: the CHIP prediction rule. Ann Intern Med. 2007 Mar 20;146(6):397-405. http://www.ncbi.nlm.nih.gov/pubmed/17371884?tool=bestpractice.com [8]Ibañez J, Arikan F, Pedraza S, et al. Reliability of clinical guidelines in the detection of patients at risk following mild head injury: results of a prospective study. J Neurosurg. 2004 May;100(5):825-34. http://www.ncbi.nlm.nih.gov/pubmed/15137601?tool=bestpractice.com
轻度 TBI：GCS 评分 13-15 分；死亡率为 0.1%
中度外伤性颅脑损伤：GCS 评分：9-12 分，死亡率为 10%
重度外伤性颅脑损伤：GCS 评分：<9 分，死亡率为 40%
许多临床医生建议，将 GCS 为 13 的患者分类为中度（而非轻度）TBI，因为此类患者出现 ICI 和不良结局的几率更高（相对于 GCS >13 的患者）。[9]Türedi S, Hasanbasoglu A, Gunduz A, et al. Clinical decision instruments for CT scan in minor head trauma. J Emerg Med. 2008 Apr;34(3):253-9. http://www.ncbi.nlm.nih.gov/pubmed/18180129?tool=bestpractice.com [10]Pearson WS, Ovalle F Jr, Faul M, et al. A review of traumatic brain injury trauma center visits meeting physiologic criteria from the american college of surgeons committee on trauma/centers for disease control and prevention field triage guidelines. Prehosp Emerg Care. 2012 Jul-Sep;16(3):323-8. http://www.ncbi.nlm.nih.gov/pubmed/22548387?tool=bestpractice.com [11]Mena JH, Sanchez AI, Rubiano AM, et al. Effect of the modified Glasgow Coma Scale score criteria for mild traumatic brain injury on mortality prediction: comparing classic and modified Glasgow Coma Scale score model scores of 13. J Trauma. 2011 Nov;71(5):1185-92; discussion 1193. http://www.ncbi.nlm.nih.gov/pubmed/22071923?tool=bestpractice.com 澳大利亚的临床指南认识到 GCS 评分下降到 13 分与并发症发生率增加有关，因此将轻度 TBI 患者的 GCS 评分限制到 14 或 15 分。[12]New South Wales Ministry of Health. Closed head injury in adults - initial management. Feb 2012 [internet publication]. http://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2012_013.pdf
妙佑分级系统根据患者的临床和 CT 表现，将 TBI 患者分为肯定、可能性大和可能三种等级。[13]Malec JF, Brown AW, Leibson CL, et al. The Mayo classification system for traumatic brain injury severity. J Neurotrauma. 2007 Sep;24(9):1417-24. http://www.ncbi.nlm.nih.gov/pubmed/17892404?tool=bestpractice.com
根据病因分类
可能由钝性、穿透性或爆炸性伤害导致。
钝性 TBI：发生在表面受到机械力作用，迅速地加速、减速时发生的脑损害。最典型的是发生在机动车相关的损伤中，跌倒、挤压伤或肢体冲突。
穿透性 TBI：发生在异物刺穿颅骨、破坏硬脑膜时，多常见于枪弹伤和刺伤。
冲击性 TBI：常见于炸弹爆炸后和战后，由接触力、惯力、压力过大和声波联合导致。[14]Ling G, Bandak F, Armonda R, et al. Explosive blast neurotrauma. J Neurotrauma. 2009 Jun;26(6):815-25. http://www.ncbi.nlm.nih.gov/pubmed/19397423?tool=bestpractice.com
根据受累区域分类
根据累及区域可以将 TBI 分为弥漫性和局灶性，但这两种类型经常同时存在。
弥漫性颅脑损伤包括：弥漫性轴索损伤 (diffuse axonal injury)、缺氧性脑损伤、弥漫性脑水肿、弥漫性血管损伤。[15]Maas AI, Stocchetti N, Bullock R. Moderate and severe traumatic brain injury in adults. Lancet Neurol. 2008 Aug;7(8):728-41. http://www.ncbi.nlm.nih.gov/pubmed/18635021?tool=bestpractice.com
局灶性损伤包括：一些特定损伤，例如挫伤、颅内血肿、脑梗死、轴突撕裂、颅神经撕脱、颅骨骨折。[15]Maas AI, Stocchetti N, Bullock R. Moderate and severe traumatic brain injury in adults. Lancet Neurol. 2008 Aug;7(8):728-41. http://www.ncbi.nlm.nih.gov/pubmed/18635021?tool=bestpractice.com
按损伤进展情况分类：原发性和继发性
最初的损伤是由于直接的机械力,无论是钝性、穿透或爆炸，可能包括以下内容：
脑震荡
颅骨骨折
挫伤
血肿
蛛网膜下/硬膜下血肿
轴突离断或撕裂。
继发性损伤是指原发性损伤不断演化的病理生理后果。这涉及原发性损伤后多种复杂的神经生物学级联在细胞水平被改变或启动，可能包括以下方面：[15]Maas AI, Stocchetti N, Bullock R. Moderate and severe traumatic brain injury in adults. Lancet Neurol. 2008 Aug;7(8):728-41. http://www.ncbi.nlm.nih.gov/pubmed/18635021?tool=bestpractice.com
脑水肿
颅内压升高
出血
癫痫发作
缺血
感染。
流行病学
TBI 是发生疾病和死亡的重要原因，在美国，每年导致大约 250 万次急诊科就诊，在英国，导致 140 多万次急诊科就诊。[1]Centers for Disease Control and Prevention, US Department of Health and Human Services. Surveillance report of traumatic brain injury-related emergency department visits, hospitalizations, and deaths - United States, 2014. 2019 [internet publication]. https://www.cdc.gov/traumaticbraininjury/pdf/TBI-Surveillance-Report-508.pdf [16]National Institute for Health and Care Excellence. Head injury: assessment and early management. Sep 2019 [internet publication]. http://www.nice.org.uk/Guidance/CG176 TBI 给中低收入国家所带来的残疾和死亡的负担高于高收入国家。[17]Maas AIR, Menon DK, Adelson PD, et al; InTBIR Participants and Investigators. Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research. Lancet Neurol. 2017 Dec;16(12):987-1048. http://www.ncbi.nlm.nih.gov/pubmed/29122524?tool=bestpractice.com
约 90% 的 TBI 患者为轻微颅脑外伤，经过门诊治疗即可回家，无需住院治疗或其他干预。[18]Kay A, Teasdale G. Head injury in the United Kingdom. World J Surg. 2001 Sep;25(9):1210-20. https://www.doi.org/10.1007/s00268-001-0084-6 http://www.ncbi.nlm.nih.gov/pubmed/11571960?tool=bestpractice.com 约 10% 患者的损伤需要住院治疗，死亡率约为 2%。[1]Centers for Disease Control and Prevention, US Department of Health and Human Services. Surveillance report of traumatic brain injury-related emergency department visits, hospitalizations, and deaths - United States, 2014. 2019 [internet publication]. https://www.cdc.gov/traumaticbraininjury/pdf/TBI-Surveillance-Report-508.pdf
TBI 最常发生于婴幼儿（0-4 岁）以及青少年和年轻人（15-24 岁），其次最常发生于老年人（>65 岁）。[1]Centers for Disease Control and Prevention, US Department of Health and Human Services. Surveillance report of traumatic brain injury-related emergency department visits, hospitalizations, and deaths - United States, 2014. 2019 [internet publication]. https://www.cdc.gov/traumaticbraininjury/pdf/TBI-Surveillance-Report-508.pdf 因 TBI 住院/死亡的人以老年人为主。[1]Centers for Disease Control and Prevention, US Department of Health and Human Services. Surveillance report of traumatic brain injury-related emergency department visits, hospitalizations, and deaths - United States, 2014. 2019 [internet publication]. https://www.cdc.gov/traumaticbraininjury/pdf/TBI-Surveillance-Report-508.pdf 在所有年龄组中，男性的 TBI 估计年平均发病率均高于女性。[19]Centers for Disease Control and Prevention. Traumatic brain injury in the United States: Emergency department visits, hospitalizations and deaths 2002-2006 (Blue Book). Mar 2010 [internet publication]. https://www.cdc.gov/traumaticbraininjury/tbi_ed.html
GCS 评分从 15 降至 14 时，神经外科干预（颅骨切开术、颅骨骨折碎片掀起术、颅内压升高监测或脑室造瘘术）需求会增加一倍。[8]Ibañez J, Arikan F, Pedraza S, et al. Reliability of clinical guidelines in the detection of patients at risk following mild head injury: results of a prospective study. J Neurosurg. 2004 May;100(5):825-34. http://www.ncbi.nlm.nih.gov/pubmed/15137601?tool=bestpractice.com
脑震荡和脑震荡后症状
大部分 TBI 患者会发生脑震荡，且在轻度 TBI 患者中通常是唯一表现。中重度 TBI 患者通常存在多种损伤，包括脑震荡症状。
五种主要的脑震荡亚型包括头痛型、认知型、前庭型、心境型和眼球运动型。一项荟萃分析表明，头痛型和认知型是成人和儿童中最常见的亚型。[20]Lumba-Brown A, Teramoto M, Bloom OJ, et al. Concussion guidelines step 2: Evidence for subtype classification. Neurosurgery. 2020 Jan 1;86(1):2-13. https://www.doi.org/10.1093/neuros/nyz332 http://www.ncbi.nlm.nih.gov/pubmed/31432081?tool=bestpractice.com
世界卫生组织对脑震荡后综合征的定义包括颅脑外伤后出现以下 3 种或更多种症状：头痛、头晕、乏力、易激惹、难以集中注意力和执行脑力任务、记忆受损、失眠以及对应激、情绪激动或乙醇的耐受性下降。[21]World Health Organization. The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. 1992 [internet publication]. https://apps.who.int/iris/handle/10665/37958
2017 年，美国 15％ 的高中学生在过去一年内至少报告过一次与运动有关的脑震荡。[22]DePadilla L, Miller GF, Jones SE, et al. Self-reported concussions from playing a sport or being physically active among high school students - United States, 2017. MMWR Morb Mortal Wkly Rep. 2018 Jun 22;67(24):682-5. https://www.cdc.gov/mmwr/volumes/67/wr/mm6724a3.htm?s_cid=mm6724a3_w http://www.ncbi.nlm.nih.gov/pubmed/29927909?tool=bestpractice.com 大约 30% 的儿童和成人在受伤后出现持续超过 30 日的持续性脑震荡后症状。[23]Zemek R, Barrowman N, Freedman SB, et al. Clinical risk score for persistent postconcussion symptoms among children with acute concussion in the ED. JAMA. 2016 Mar 8;315(10):1014-25. http://www.ncbi.nlm.nih.gov/pubmed/26954410?tool=bestpractice.com [24]de Koning ME, Scheenen ME, van der Horn HJ, et al. Non-hospitalized patients with mild traumatic brain injury: the forgotten minority. J Neurotrauma. 2017 Jan 1;34(1):257-61. http://www.ncbi.nlm.nih.gov/pubmed/27029852?tool=bestpractice.com
出血
TBI 患者 CT 最常见的一种发现是创伤性蛛网膜下腔出血（traumatic subarachnoid haemorrhage, SAH），在中/重度 TBI 患者中占 30%-40%，在轻度 TBI 患者中占 5%。[6]Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT head rule for patients with minor head injury. Lancet. 2001;357(9266):1391-6. http://www.ncbi.nlm.nih.gov/pubmed/11356436?tool=bestpractice.com [25]Steyerberg EW, Mushkudiani N, Perel P, et al. Predicting outcome after traumatic brain injury: development and international validation of prognostic scores based on admission characteristics. PLoS Med. 2008 Aug 5;5(8):e165. http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.0050165 http://www.ncbi.nlm.nih.gov/pubmed/18684008?tool=bestpractice.com [26]Roberts I, Yates D, Sandercock P, et al; CRASH trial collaborators. Effect of intravenous corticosteroids on death within 14 days in 10008 adults with clinically significant head injury (MRC CRASH trial): randomised placebo-controlled trial. Lancet. 2004 Oct 9-15;364(9442):1321-8. http://www.ncbi.nlm.nih.gov/pubmed/15474134?tool=bestpractice.com 蛛网膜下腔出血常合并其他损伤。SAH 与中度或重度 TBI 患者的临床结局更差有关，但目前尚不清楚 SAH 是不是损伤严重程度的标志，也不清楚临床结局更差是否因之后的血管痉挛导致。[27]Kramer DR, Winer JL, Pease BA, et al. Cerebral vasospasm in traumatic brain injury. Neurol Res Int. 2013;2013:415813. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3703898 http://www.ncbi.nlm.nih.gov/pubmed/23862062?tool=bestpractice.com
硬膜下血肿（subdural haematoma, SDH）是 TBI 最常见的占位性病变类型，见于 20% 左右的中重度 TBI 患者和 30% 左右的致死性 TBI 患者。只有 3% 的轻度 TBI 患者会发生 SDH。导致住院或死亡的 SDH 最常继发于较年轻成人的机动车相关损伤以及年龄较大成人的跌倒。[6]Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT head rule for patients with minor head injury. Lancet. 2001;357(9266):1391-6. http://www.ncbi.nlm.nih.gov/pubmed/11356436?tool=bestpractice.com [28]Bullock MR, Chesnut R, Ghajar J, et al; Surgical Management of Traumatic Brain Injury Author Group. Surgical management of acute subdural hematomas. Neurosurgery. 2006 Mar;58(3 suppl):S16-24. http://www.ncbi.nlm.nih.gov/pubmed/16710968?tool=bestpractice.com
硬膜外血肿（epidural haematoma, EDH）见于 10% 左右的中重度 TBI 患者和约 1% 的轻度 TBI 患者。EDH 的发病率在青少年和年轻人最高，最常见于 20-30 岁人群。大多数 EDH 病例由交通事故、跌倒和袭击引起。[6]Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT head rule for patients with minor head injury. Lancet. 2001;357(9266):1391-6. http://www.ncbi.nlm.nih.gov/pubmed/11356436?tool=bestpractice.com [25]Steyerberg EW, Mushkudiani N, Perel P, et al. Predicting outcome after traumatic brain injury: development and international validation of prognostic scores based on admission characteristics. PLoS Med. 2008 Aug 5;5(8):e165. http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.0050165 http://www.ncbi.nlm.nih.gov/pubmed/18684008?tool=bestpractice.com
脑内血肿发生在 10%-30% 的中重度 TBI 患者和 <1% 的轻度 TBI 患者。[6]Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT head rule for patients with minor head injury. Lancet. 2001;357(9266):1391-6. http://www.ncbi.nlm.nih.gov/pubmed/11356436?tool=bestpractice.com [15]Maas AI, Stocchetti N, Bullock R. Moderate and severe traumatic brain injury in adults. Lancet Neurol. 2008 Aug;7(8):728-41. http://www.ncbi.nlm.nih.gov/pubmed/18635021?tool=bestpractice.com
脑挫伤
见于 20% 至 30% 的中重度 TBI 患者以及 6% 的轻度 TBI 患者。[6]Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT head rule for patients with minor head injury. Lancet. 2001;357(9266):1391-6. http://www.ncbi.nlm.nih.gov/pubmed/11356436?tool=bestpractice.com [26]Roberts I, Yates D, Sandercock P, et al; CRASH trial collaborators. Effect of intravenous corticosteroids on death within 14 days in 10008 adults with clinically significant head injury (MRC CRASH trial): randomised placebo-controlled trial. Lancet. 2004 Oct 9-15;364(9442):1321-8. http://www.ncbi.nlm.nih.gov/pubmed/15474134?tool=bestpractice.com [29]Iaccarino C, Schiavi P, Picetti E, et al. Patients with brain contusions: predictors of outcome and relationship between radiological and clinical evolution. J Neurosurg. 2014 Apr;120(4):908-18. http://www.ncbi.nlm.nih.gov/pubmed/24506250?tool=bestpractice.com
轴索损伤
可能大部分 TBI 患者都会有一定程度的轴索损伤，但轻度轴索损伤通常需通过显微镜检查才能发现，CT 无法发现。
有学者认为所有 TBI 相关死亡和导致持续性植物状态的 TBI 都存在一定程度的弥漫性轴索损伤（diffuse axonal injury, DAI）。DAI 的存在增加了不良结局的可能性。[30]van Eijck MM, Schoonman GG, van der Naalt J, et al. Diffuse axonal injury after traumatic brain injury is a prognostic factor for functional outcome: a systematic review and meta-analysis. Brain Inj. 2018;32(4):395-402. http://www.ncbi.nlm.nih.gov/pubmed/29381396?tool=bestpractice.com 50%-80% 最终被诊断为 DAI 的患者初始 CT 检查结果正常，而磁共振成像检查可显示 70% 的中度至重度 TBI 患者存在轴索损伤的证据。[31]Skandsen T, Kvistad KA, Solheim O, et al. Prevalence and impact of diffuse axonal injury in patients with moderate and severe head injury: a cohort study of early magnetic resonance imaging findings and 1-year outcome. J Neurosurg. 2010 Sep;113(3):556-63. http://www.ncbi.nlm.nih.gov/pubmed/19852541?tool=bestpractice.com
颅骨骨折
见于 5% 的轻度 TBI 患者和高达 50% 的严重 TBI 患者。大多数的颅骨骨折由跌倒、袭击或与交通事故相关损伤引起。最常见的骨折是单纯线性骨折，占所有颅骨骨折的 50% 以上。不到 1% 的轻度 TBI 患者发生颅骨凹陷性骨折。[6]Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT head rule for patients with minor head injury. Lancet. 2001;357(9266):1391-6. http://www.ncbi.nlm.nih.gov/pubmed/11356436?tool=bestpractice.com
穿透伤或冲击伤
穿透伤分为高速或低速，可能是自己造成的、非故意或与暴力相关。头部有单处枪伤的死亡率约为 50%。[32]Cripps MW, Ereso AQ, Sadjadi J, et al. The number of gunshot wounds does not predict injury severity and mortality. Am Surg. 2009 Jan;75(1):44-8. http://www.ncbi.nlm.nih.gov/pubmed/19213396?tool=bestpractice.com
爆炸伤是战区现役军事人员损伤的主要原因，占重型颅脑损伤的 60%。[33]DuBose JJ, Barmparas G, Inaba K, et al. Isolated severe traumatic brain injuries sustained during combat operations: demographics, mortality outcomes, and lessons to be learned from contrasts to civilian counterparts. J Trauma. 2011 Jan;70(1):11-8. http://www.ncbi.nlm.nih.gov/pubmed/21217475?tool=bestpractice.com
鉴别诊断
撰稿人
作者
Micelle J. Haydel, MD
Albert J. Lauro Professor of Medicine/Emergency Medicine
Clinical Professor Medicine/Emergency Medicine
Section of Emergency Medicine
Louisiana State University Health Science Center
New Orleans
LA
利益声明
MJH is an author of a reference cited in this topic.
鸣谢
Dr Micelle J. Haydel would like to gratefully acknowledge Dr Victoria E. Johnson, Dr Marek Ma, Dr Nathan Ranalli, and Dr Douglas H. Smith, previous contributors to this topic.
利益声明
VEJ, MM, NR, and DHS declare that they have no competing interests.
同行评议者
David W. Wright, MD
Director of Research
Department of Emergency Medicine
Emory University
Atlanta
GA
利益声明
DWW declares that he has no competing interests.
David Sharp, MBBS, BA, MRCP, PhD
Senior Lecturer In Neurology
Imperial College
London
UK
利益声明
DS declares that he has no competing interests.
指南
- 美国放射学会 (ACR) 适用性标准：头部外伤
- 国家和国际职业和精英运动中的脑震荡指南
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