高齢者重症頭部外傷に対する積極的治療と患者転帰の変遷：頭部外傷データバンク【プロジェクト1998, 2004, 2009】における検討

抄録

Objectives: With the rapid expansion of the elderly population, there has been an increase of the number of elderly traumatic brain injury (TBI) patients in Japan. Despite the recent progresses in the treatment and monitoring for TBI patients, the prognosis of geriatric TBI remains unfavorable. In this study, transition of aggressive treatment and patient outcome in geriatric TBI patients were analyzed with the data from Japan Neurotrauma Data Bank Project 1998, 2004, and 2009. The functional prognostic factors in geriatric TBI were also examined.

Methods: Of 3,194 cases registered in the JNTDB Project 1998 (P1998), 2004 (P2004), and 2009 (P2009), 1,165 geriatric TBI cases (≥65 years old) were enrolled in this study. The clinical features, aggressive treatment defined as surgical procedure and/or intensive temperature treatment and/or ICP monitoring, and outcomes based on Glasgow Outcome Scale on discharge were compared among P1998, P2004, and P2009. Moreover, to clarify the functional prognostic factors in geriatric TBI patients, logistic regression analysis was performed.

Results: The percentage of geriatric TBI population was significantly increased throughout three projects (P1998; 30.5%, P2004; 34.6%, P2009; 43.9%, p<0.0001). Aggressive treatments including surgical management and intentional temperature management were performed in 71.4% of geriat­ric patients in P2009 and this percentage was significantly increased from P1998 and P2004. With these efforts for geriatric TBI care, mortality ratio was significantly decreased (P1998; 62.7%, P2009; 51.1%, p=0.0003). On the other hand, the percentage of severe disability patient was significantly increased. The percentage of dependent survivors were also increased (P1998; 63.2%, P2009; 68.4%). Patient Age ≥75, Injury Severity Score ≥21, GCS ≤8, existence of traumatic subarachnoidal hemorrhage (SAH), and existence of intraventricular hemorrhage (IVH) were clarified as the functional prognostic factors. IVH was the strongest functional prognostic factor in geriatric TBI patients (OR 5.762, 95%CI 1.317 – 25.216).

Conclusion: Our result revealed that the aggressive treatments provided less mortality in geriatric TBI patients. On the other hand, the effort of aggressive treatments did not result in better functional outcome in this population. For the prompt decision making, patient age, initial GCS, and anatomical severity including SAH and IVH should be helpful as the functional prognostic factors.