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Kim B, Jeong H, Kim J, Kim T, Kim K, Lee H, Ahn S, Jo YH, Lee JH, Hwang JE. Incidence and risk factors of delayed intracranial hemorrhage in the emergency department. Am J Emerg Med 2018; 36:271-276. [DOI: 10.1016/j.ajem.2017.08.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 08/02/2017] [Accepted: 08/03/2017] [Indexed: 11/26/2022] Open
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Rao AJ, Lin AL, Hilliard C, Fu R, Lennox T, Barbosa RR, Rowell SE. Blood Ethanol Levels Are Not Related to Coagulation Changes, as Measured by Thromboelastography, in Traumatic Brain Injury Patients. World Neurosurg 2018; 112:e216-e222. [PMID: 29330077 DOI: 10.1016/j.wneu.2018.01.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Revised: 12/30/2017] [Accepted: 01/04/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Brain injury is a leading cause of death and disability in trauma patients. Ethanol (EtOH) use near the time of injury may contribute to worse outcomes in these patients by exacerbating coagulopathy. There are limited data regarding the effects of EtOH on coagulation and progression of traumatic intracranial hemorrhage (TICH). METHODS We performed a retrospective analysis of a prospective observational study of 168 trauma patients with TBI at an urban level 1 trauma center. Thromboelastography (TEG) was performed on admission and over the subsequent 48 hours. Demographic, physiologic, and outcomes data were collected. Computed tomography imaging of the head performed within the first 48 hours of admission was analyzed for progression of TICH. RESULTS Thirty-six percent of patients (n = 61) had positive blood EtOH on admission (median EtOH level = 198 mg/dL [range, 16-376 mg/dL]). EtOH-positive patients were less severely injured than EtOH-negative patients (P = 0.01). Other admission demographic and physiologic variables were similar between groups. There were no significant differences in TEG values between EtOH-positive and EtOH-negative patients on admission or during the subsequent 48 hours. There were no differences in radiographic progression of hemorrhage, the need for neurosurgical procedure, or mortality between EtOH-positive and EtOH-negative patients. CONCLUSIONS EtOH use near the time of traumatic injury was not associated with alterations in coagulation, as measured by traditional coagulation tests or by TEG, in patients with TICH. Furthermore, a positive blood alcohol at admission was not associated with increased mortality or need for neurosurgical procedure these patients.
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Affiliation(s)
- Abigail J Rao
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Amber Laurie Lin
- School of Public Health & Center for Policy Research-Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Cole Hilliard
- Department of Surgery, Division of Trauma, Critical Care & Acute Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Rongwei Fu
- School of Public Health & Center for Policy Research-Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Tori Lennox
- Department of Surgery, Division of Trauma, Critical Care & Acute Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Ronald R Barbosa
- Trauma Services, Legacy Emanuel Hospital and Health Center, Portland, Oregon, USA
| | - Susan E Rowell
- Department of Surgery, Division of Trauma, Critical Care & Acute Surgery, Oregon Health & Science University, Portland, Oregon, USA.
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Early Fibrinolysis Associated with Hemorrhagic Progression Following Traumatic Brain Injury. Shock 2017; 48:644-650. [DOI: 10.1097/shk.0000000000000912] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Di G, Liu H, Jiang X, Dai Y, Chen S, Wang Z, Liu H. Clinical Predictors of Progressive Hemorrhagic Injury in Children with Mild Traumatic Brain Injury. Front Neurol 2017; 8:560. [PMID: 29250024 PMCID: PMC5718156 DOI: 10.3389/fneur.2017.00560] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 10/05/2017] [Indexed: 11/13/2022] Open
Abstract
Objective Traumatic brain injury (TBI) occurs commonly in children. Repeat computed tomography (CT) follow up of TBI patients is often scheduled to identify progressive hemorrhagic injury (PHI). However, the utility of repeated CT scans, especially in children with mild TBI [Glasgow Coma Scale (GCS) scores of 13–15], has been debated. The purposes of the present study were to identify clinical predictors of PHI in children with mild TBI and to clarify relevant clinical factors via radiological examination. Methods From 2014 to 2016, we retrospectively enrolled children <15 years of age with mild TBI. We recorded age, sex, GCS scores on admission, causes of head injury, timing of initial CT, any loss of consciousness, vomiting and seizure data, and type of TBI. Based on repeat CT findings, patients were dichotomized into either a PHI group or a non-PHI group. Also, clinical data were comparatively reviewed. Multivariate logistic regression analysis was used to identify clinical predictors of PHI. Results Of the 175 enrolled children, 15 (8.6%) experienced PHI. Univariate analysis revealed that GCS score on admission, cause of head injury, vomiting, seizure, and TBI type were associated with PHI. Multivariate logistic regression analysis showed that a GCS score of 13 and epidural hemorrhage (EDH) were independently associated with PHI (hazard ratio = 0.131, P = 0.018; hazard ratio = 6.612, P = 0.027, respectively). Conclusion A GCS score of 13 and EDH were associated with PHI. These factors should be considered when deciding whether to repeat CT on children with mild TBI.
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Affiliation(s)
- Guangfu Di
- Department of Neurosurgery, Yijishan Hospital, Wannan Medical College, Wuhu, China
| | - Hua Liu
- Department of Neurosurgery, The First People's Hospital of Kunshan, Jiangsu University, Suzhou, China
| | - Xiaochun Jiang
- Department of Neurosurgery, Yijishan Hospital, Wannan Medical College, Wuhu, China
| | - Yi Dai
- Department of Neurosurgery, Yijishan Hospital, Wannan Medical College, Wuhu, China
| | - Sansong Chen
- Department of Neurosurgery, Yijishan Hospital, Wannan Medical College, Wuhu, China
| | - Zhichun Wang
- Department of Neurosurgery, Yijishan Hospital, Wannan Medical College, Wuhu, China
| | - Hongyi Liu
- Department of Neurosurgery, The Affiliated Brain Hospital, Nanjing Medical University, Nanjing, China
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55
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Kvint S, Schuster J, Kumar MA. Neurosurgical applications of viscoelastic hemostatic assays. Neurosurg Focus 2017; 43:E9. [DOI: 10.3171/2017.8.focus17447] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Patients taking antithrombotic agents are very common in neurosurgical practice. The perioperative management of these patients can be extremely challenging especially as newer agents, with poorly defined laboratory monitoring and reversal strategies, become more prevalent. This is especially true with emergent cases in which rapid reversal of anticoagulation is required and the patient’s exact medical history is not available. With an aging patient population and the associated increase in diseases such as atrial fibrillation, it is expected that the use of these agents will continue to rise in coming years. Furthermore, thromboembolic complications such as deep venous thrombosis, pulmonary embolism, and myocardial infarction are common complications of major surgery. These trends, in conjunction with a growing understanding of the hemostatic process and its contribution to the pathophysiology of disease, stress the importance of the complete evaluation of a patient’s hemostatic profile in guiding management decisions. Viscoelastic hemostatic assays (VHAs), such as thromboelastography and rotational thromboelastometry, are global assessments of coagulation that account for the cellular and plasma components of coagulation. This FDA-approved technology has been available for decades and has been widely used in cardiac surgery and liver transplantation. Although VHAs were cumbersome in the past, advances in software and design have made them more accurate, reliable, and accessible to the neurosurgeon. VHAs have demonstrated utility in guiding intraoperative blood product transfusion, identifying coagulopathy in trauma, and managing postoperative thromboprophylaxis. The first half of this review aims to evaluate and assess VHAs, while the latter half seeks to appraise the evidence supporting their use in neurosurgical populations.
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Affiliation(s)
| | | | - Monisha A. Kumar
- Departments of 1Neurosurgery and
- 2Neurology, University of Pennsylvania, Philadelphia, Pennsylvania
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Schumacher R, Müri RM, Walder B. Integrated Health Care Management of Moderate to Severe TBI in Older Patients-A Narrative Review. Curr Neurol Neurosci Rep 2017; 17:92. [PMID: 28986740 DOI: 10.1007/s11910-017-0801-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE OF REVIEW Traumatic brain injuries are common, especially within the elderly population, which is typically defined as age 65 and older. This narrative review aims at summarizing and critically evaluating important aspects of their health care management in covering the entire pathway from prehospital care to rehabilitation and beyond. RECENT FINDINGS The number of older patients with traumatic brain injury (TBI) is increasing, and there seem to be differences in all aspects of care along their pathway when compared to younger patients. Despite a higher mortality and a generally less favorable outcome, the current literature shows that older TBI patients have the potential to make significant improvements over time. More research is needed to evaluate the most efficient and integrated clinical pathway from prehospital interventions to rehabilitation as well as the optimal treatment of older TBI patients. Most importantly, they should not be denied access to specific treatments and therapies only based on age.
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Affiliation(s)
- Rahel Schumacher
- Department of Neurology, University Neurorehabilitation, Inselspital, University Hospital Bern, Freiburgstrasse 10, 3010, Bern, Switzerland.
| | - René M Müri
- Department of Neurology, University Neurorehabilitation, Inselspital, University Hospital Bern, Freiburgstrasse 10, 3010, Bern, Switzerland
- Gerontechnology and Rehabilitation Group, University of Bern, Bern, Switzerland
| | - Bernhard Walder
- Division of Anaesthesiology, University Hospitals of Geneva, Geneva, Switzerland
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Rao A, Lin A, Hilliard C, Fu R, Lennox T, Barbosa R, Schreiber M, Rowell S. The Utility of Thromboelastography for Predicting The Risk of Progression of Intracranial Hemorrhage in Traumatic Brain Injury Patients. Neurosurgery 2017; 64:182-187. [PMID: 28899039 DOI: 10.1093/neuros/nyx210] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 03/30/2017] [Indexed: 01/02/2023] Open
Affiliation(s)
- Abigail Rao
- Department of Neurological Surgery, OHSU, Portland, Oregon
| | - Amber Lin
- School of Public Health and Center for Policy Re-search, OHSU, Portland, Oregon
| | - Cole Hilliard
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, OHSU, Portland, Oregon
| | - Rongwei Fu
- School of Public Health and Center for Policy Re-search, OHSU, Portland, Oregon
| | - Tori Lennox
- Division of Cardio-thoracic Surgery, University of Wash-ington, Seattle, Washington
| | - Ronald Barbosa
- Trauma Services, Legacy Emanuel Hospital and Health Services, Portland, Oregon
| | - Martin Schreiber
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, OHSU, Portland, Oregon
| | - Susan Rowell
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, OHSU, Portland, Oregon
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Maegele M, Schöchl H, Menovsky T, Maréchal H, Marklund N, Buki A, Stanworth S. Coagulopathy and haemorrhagic progression in traumatic brain injury: advances in mechanisms, diagnosis, and management. Lancet Neurol 2017; 16:630-647. [PMID: 28721927 DOI: 10.1016/s1474-4422(17)30197-7] [Citation(s) in RCA: 204] [Impact Index Per Article: 29.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 05/08/2017] [Accepted: 05/30/2017] [Indexed: 01/28/2023]
Abstract
Normal haemostasis depends on an intricate balance between mechanisms of bleeding and mechanisms of thrombosis, and this balance can be altered after traumatic brain injury (TBI). Impaired haemostasis could exacerbate the primary insult with risk of initiation or aggravation of bleeding; anticoagulant use at the time of injury can also contribute to bleeding risk after TBI. Many patients with TBI have abnormalities on conventional coagulation tests at admission to the emergency department, and the presence of coagulopathy is associated with increased morbidity and mortality. Further blood testing often reveals a range of changes affecting platelet numbers and function, procoagulant or anticoagulant factors, fibrinolysis, and interactions between the coagulation system and the vascular endothelium, brain tissue, inflammatory mechanisms, and blood flow dynamics. However, the degree to which these coagulation abnormalities affect TBI outcomes and whether they are modifiable risk factors are not known. Although the main challenge for management is to address the risk of hypocoagulopathy with prolonged bleeding and progression of haemorrhagic lesions, the risk of hypercoagulopathy with an increased prothrombotic tendency also warrants consideration.
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Affiliation(s)
- Marc Maegele
- Department for Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Center, University Witten/Herdecke, Cologne, Germany; Institute for Research in Operative Medicine, University Witten/Herdecke, Cologne, Germany.
| | - Herbert Schöchl
- Department for Anaesthesiology and Intensive Care Medicine, AUVA Trauma Academic Teaching Hospital, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Tomas Menovsky
- Department for Neurosurgery, Antwerp University Hospital, University of Antwerp, Edegem, Belgium
| | - Hugues Maréchal
- Department of Anaesthesiology and Intensive Care Medicine, CRH La Citadelle, Liège, Belgium
| | - Niklas Marklund
- Department of Clinical Sciences, Division of Neurosurgery, University Hospital of Southern Sweden, Lund University, Lund, Sweden
| | - Andras Buki
- Department of Neurosurgery, The MTA-PTE Clinical Neuroscience MR Research Group, Janos Szentagothai Research Center, Hungarian Brain Research Program, University of Pécs, Pécs, Hungary
| | - Simon Stanworth
- NHS Blood and Transplant/Oxford University Hospitals NHS Foundation Trust, University of Oxford, John Radcliffe Hospital, Oxford, UK
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Hu GW, Lang HL, Guo H, Wu L, Zhang P, Kuang W, Zhu XG. A risk score based on admission characteristics to predict progressive hemorrhagic injury from traumatic brain injury in children. Eur J Pediatr 2017; 176:689-696. [PMID: 28343321 DOI: 10.1007/s00431-017-2897-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 03/14/2017] [Accepted: 03/21/2017] [Indexed: 10/19/2022]
Abstract
UNLABELLED Traumatic brain injury (TBI) is one of the leading causes of death and disability in children, and progressive hemorrhagic injury (PHI) post TBI is associated with poor outcomes. Therefore, the objective of this study was to develop and validate a prognostic model that uses the information available at admission to determine the likelihood of PHI occurrence after TBI in children. The identified demographic data, cause of injury, clinical predictors on admission, computed tomography scan characteristics, and routine laboratory parameters were collected and used to develop a PHI prognostic model with logistic regression analysis, and the prediction model was validated in 68 children. Eight independent prognostic factors were identified: lower Glasgow coma scale score (3 ~ 8) (6 points), intra-axial bleeding/brain contusion (4 points), midline shift ≥5 mm (9 points), platelets <100 × 109/L (11 points), prothrombin time >14 s (6 points), international normalized ratio >1.25 (7 points), D-dimer ≥5 mg/L (14 points), and glucose ≧10 mmol/L (11 points). We calculated risk scores for each child and defined three risk groups: low risk (0-16 points), intermediate risk (17-36 points), and high risk (37-68 points). In the development cohort, the PHI rates after TBI for the low-, intermediate-, and high-risk groups were 10.1, 47.9, and 84.2%, respectively. In the validation cohort, the corresponding PHI rates were 10.9, 47.5, and 85.4%, respectively. The C-statistic for the point system was 0.873 (p = 0.586 by the Hosmer-Lemeshow test) in the development cohort and 0.877 (p = 0.524 by the Hosmer-Lemeshow test) in the validation cohort. CONCLUSION Using admission predictors, we developed a relatively simple risk score that accurately predicted the risk of PHI after TBI in children. What is Known: • TBI is one of the leading causes of death and disability in children, and PHI post TBI is associated with poor outcomes. •Prediction of patients at low risk of PHI could help reduce treatment costs, whereas identification of patients at high risk of PHI could direct early medical intervention to improve outcomes. What is New: • This study firstly developed a risk score system by assessing the admission information that could provide an earlier prediction of the occurrence of PHI after acute TBI in children.
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Affiliation(s)
- Guo-Wen Hu
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Hai-Li Lang
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Hua Guo
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Lei Wu
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Pei Zhang
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Wei Kuang
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Xin-Gen Zhu
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China.
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Khan M, O'Keeffe T, Jehan F, Kulvatunyou N, Kattaa A, Gries L, Tang A, Joseph B. The impact of Glasgow Coma Scale-age prognosis score on geriatric traumatic brain injury outcomes. J Surg Res 2017; 216:109-114. [PMID: 28807194 DOI: 10.1016/j.jss.2017.04.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 04/10/2017] [Accepted: 04/27/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND As the population ages, increasing number of geriatric patients sustain traumatic brain injury (TBI). Communication of accurate prognostic information is crucial for making informed decisions on behalf of such patients. Therefore, the aim of our study was to develop a simple and clinically applicable tool that accurately predicts the prognosis in geriatric TBI patients. METHODS We performed a 1-y (2011) retrospective analysis of isolated geriatric TBI patients (age ≥65 y, head abbreviated injury score [AIS] ≥ 3, and other body AIS < 3) in the National Trauma Data Bank. We calculated a Glasgow Coma Scale (GCS)-age prognosis (GAP) score (age/GCS score) for all patients. Outcome measures were in-hospital adverse outcomes (mortality and Rehab/skilled nursing facility discharge disposition). Regression analysis and receiver operator characteristic curve analysis were performed to determine the discriminatory power of GAP score. RESULTS A total of 8750 geriatric patients with TBI were included. Mean age was 77.8 ± 7.1 y, the median (interquartile range) GCS was 15 (13-15), and the median (interquartile range) head AIS was 4 (3-4). The overall in-hospital mortality rate was 12.7%, and 34.2% of the patients were discharged home. As the GAP score increased, the mortality rate increased and discharge to-home decreased. Receiver operator characteristic curve analysis revealed excellent discriminatory power for mortality (area under the curve: 0.826). Above a GAP score of 12, the mortality rate was >50% and more than 45% of the patients were discharged to Rehab/skilled nursing facility. CONCLUSIONS For geriatric patients with TBI, a simple GAP score reliably predicts outcomes. A score above 12 results in a drastic increase in mortality and an adverse discharge disposition. This simple tool may help clinicians provide accurate prognostic information to patients' families.
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Affiliation(s)
- Muhammad Khan
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Terence O'Keeffe
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Faisal Jehan
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Narong Kulvatunyou
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Abdullah Kattaa
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Lynn Gries
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Andrew Tang
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Bellal Joseph
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona.
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Wan X, Fan T, Wang S, Zhang S, Liu S, Yang H, Shu K, Lei T. Progressive hemorrhagic injury in patients with traumatic intracerebral hemorrhage: characteristics, risk factors and impact on management. Acta Neurochir (Wien) 2017; 159:227-235. [PMID: 27943076 DOI: 10.1007/s00701-016-3043-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 11/24/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Progressive hemorrhagic injury (PHI) is a common occurrence in clinical practice; however, how PHI affects clinical management remains unclear. We attempt to evaluate the characteristics and risk factors of PHI and also investigate how PHI influences clinical management in traumatic intracerebral hemorrhage (TICH) patients. METHODS This retrospective study included a cohort of 181 patients with TICH who initially underwent conservative treatment and they were dichotomized into a PHI group and a non-PHI group. Clinical data were reviewed for comparison. Multivariate logistic regression analysis was applied to identify predictors of PHI and delayed operation. RESULTS Overall, 68 patients (37.6%) experienced PHI and 27 (14.9%) patients required delayed surgery. In the PHI group, 17 patients needed late operation; in the non-PHI group, 10 patients received decompressive craniectomy. Compared to patients with non-PHI, the PHI group was more likely to require late operation (P = 0.005, 25.0 vs 8.8%), which took place within 48 h (P = 0.01, 70.6 vs 30%). Multivariate logistic regression identified past medical history of hypertension (odds ratio [OR] = 4.56; 95% confidence interval [CI] = 2.04-10.45), elevated international normalized ratio (INR) (OR = 20.93; 95% CI 7.72-71.73) and linear bone fracture (OR = 2.11; 95% CI = 1.15-3.91) as independent risk factors for PHI. Hematoma volume of initial CT scan >5 mL (OR = 3.80; 95% CI = 1.79-8.44), linear bone fracture (OR = 3.21; 95% CI = 1.47-7.53) and PHI (OR = 3.49; 95% CI = 1.63-7.77) were found to be independently associated with delayed operation. CONCLUSIONS Past medical history of hypertension, elevated INR and linear bone fracture were predictors for PHI. Additionally, the latter was strongly predictive of delayed operation in the studied cohort.
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Affiliation(s)
- Xueyan Wan
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Ting Fan
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Sheng Wang
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China.
| | - Suojun Zhang
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Shengwen Liu
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Hongkuan Yang
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Kai Shu
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Ting Lei
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
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Vanderwerf JD, Kumar MA. Management of neurologic complications of coagulopathies. HANDBOOK OF CLINICAL NEUROLOGY 2017; 141:743-764. [PMID: 28190445 DOI: 10.1016/b978-0-444-63599-0.00040-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Coagulopathy is common in intensive care units (ICUs). Many physiologic derangements lead to dysfunctional hemostasis; these may be either congenital or acquired. The most devastating outcome of coagulopathy in the critically ill is major bleeding, defined by transfusion requirement, hemodynamic instability, or intracranial hemorrhage. ICU coagulopathy often poses complex management dilemmas, as bleeding risk must be tempered with thrombotic potential. Coagulopathy associated with intracranial hemorrhage bears directly on prognosis and outcome. There is a paucity of high-quality evidence for the management of coagulopathies in neurocritical care; however, data derived from studies of patients with intraparenchymal hemorrhage may inform treatment decisions. Coagulopathy is often broadly defined as any derangement of hemostasis resulting in either excessive bleeding or clotting, although most typically it is defined as impaired clot formation. Abnormalities in coagulation testing without overt clinical bleeding may also be considered evidence of coagulopathy. This chapter will focus on acquired conditions, such as organ failure, pharmacologic therapies, and platelet dysfunction that are associated with defective clot formation and result in, or exacerbate, intracranial hemorrhage, specifically spontaneous intraparenchymal hemorrhage and traumatic brain injury.
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Affiliation(s)
- J D Vanderwerf
- Department of Neurology, Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - M A Kumar
- Departments of Neurology, Neurosurgery, Anesthesiology and Critical Care, Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
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Chang R, Folkerson LE, Sloan D, Tomasek JS, Kitagawa RS, Choi HA, Wade CE, Holcomb JB. Early plasma transfusion is associated with improved survival after isolated traumatic brain injury in patients with multifocal intracranial hemorrhage. Surgery 2016; 161:538-545. [PMID: 27776795 DOI: 10.1016/j.surg.2016.08.023] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 08/15/2016] [Accepted: 08/15/2016] [Indexed: 01/26/2023]
Abstract
BACKGROUND Plasma-based resuscitation improves outcomes in trauma patients with hemorrhagic shock, while large-animal and limited clinical data suggest that it also improves outcomes and is neuroprotective in the setting of combined hemorrhage and traumatic brain injury. However, the choice of initial resuscitation fluid, including the role of plasma, is unclear for patients after isolated traumatic brain injury. METHODS We reviewed adult trauma patients admitted from January 2011 to July 2015 with isolated traumatic brain injury. "Early plasma" was defined as transfusion of plasma within 4 hours. Purposeful multiple logistic regression modeling was performed to analyze the relationship of early plasma and inhospital survival. After testing for interaction, subgroup analysis was performed based on the pattern of brain injury on initial head computed tomography: epidural hematoma, intraparenchymal contusion, subarachnoid hemorrhage, subdural hematoma, or multifocal intracranial hemorrhage. RESULTS Of the 633 isolated traumatic brain injury patients included, 178 (28%) who received early plasma were injured more severely coagulopathic, hypoperfused, and hypotensive on admission. Survival was similar in the early plasma versus no early plasma groups (78% vs 84%, P = .08). After adjustment for covariates, early plasma was not associated with improved survival (odds ratio 1.18, 95% confidence interval 0.71-1.96). On subgroup analysis, multifocal intracranial hemorrhage was the largest subgroup with 242 patients. Of these, 61 (25%) received plasma within 4 hours. Within-group logistic regression analysis with adjustment for covariates found that early plasma was associated with improved survival (odds ratio 3.34, 95% confidence interval 1.20-9.35). CONCLUSION Although early plasma transfusion was not associated with improved in-hospital survival for all isolated traumatic brain injury patients, early plasma was associated with increased in-hospital survival in those with multifocal intracranial hemorrhage.
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Affiliation(s)
- Ronald Chang
- Center for Translational Injury Research, University of Texas Health Science Center, Houston, TX; Department of Surgery, University of Texas Health Science Center, Houston, TX.
| | - Lindley E Folkerson
- Center for Translational Injury Research, University of Texas Health Science Center, Houston, TX; Department of Surgery, University of Texas Health Science Center, Houston, TX
| | - Duncan Sloan
- Center for Translational Injury Research, University of Texas Health Science Center, Houston, TX; Department of Surgery, University of Texas Health Science Center, Houston, TX
| | - Jeffrey S Tomasek
- Center for Translational Injury Research, University of Texas Health Science Center, Houston, TX; Department of Surgery, University of Texas Health Science Center, Houston, TX
| | - Ryan S Kitagawa
- Department of Neurosurgery, University of Texas Health Science Center, Houston, TX
| | - H Alex Choi
- Department of Neurosurgery, University of Texas Health Science Center, Houston, TX
| | - Charles E Wade
- Center for Translational Injury Research, University of Texas Health Science Center, Houston, TX; Department of Surgery, University of Texas Health Science Center, Houston, TX
| | - John B Holcomb
- Center for Translational Injury Research, University of Texas Health Science Center, Houston, TX; Department of Surgery, University of Texas Health Science Center, Houston, TX
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Abstract
PURPOSE OF REVIEW The landscape of trauma is changing due to an aging population. Geriatric patients represent an increasing number and proportion of trauma admissions and deaths. This review explores recent literature on geriatric trauma, including triage criteria, assessment of frailty, fall-related injury, treatment of head injury complicated by coagulopathy, goals of care, and the need for ongoing education of all surgeons in the care of the elderly. RECENT FINDINGS Early identification of high-risk geriatric patients is imperative to initiate early resuscitative efforts. Geriatric patients are typically undertriaged because of their baseline frailty being underappreciated; however, centers that see more geriatric patients do better. Rapid reversal of anticoagulation is important in preventing progression of brain injury. Anticipation of difficult disposition necessitates early involvement of physical therapy for rehabilitation and case management for appropriate placement. SUMMARY Optimal care of geriatric trauma patients will be based on the well established tenets of trauma resuscitation and injury repair, but with distinct elements that address the physiological and anatomical challenges presented by geriatric patients.
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Yuan Q, Sun YR, Wu X, Yu J, Li ZQ, Du ZY, Wu XH, Zhou LF, Hu J. Coagulopathy in Traumatic Brain Injury and Its Correlation with Progressive Hemorrhagic Injury: A Systematic Review and Meta-Analysis. J Neurotrauma 2016; 33:1279-91. [PMID: 26850305 DOI: 10.1089/neu.2015.4205] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
- Qiang Yuan
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, PR China
| | - Yi-rui Sun
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, PR China
| | - Xing Wu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, PR China
| | - Jian Yu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, PR China
| | - Zhi-qi Li
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, PR China
| | - Zhuo-ying Du
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, PR China
| | - Xue-hai Wu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, PR China
| | - Liang-fu Zhou
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, PR China
| | - Jin Hu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, PR China
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