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Levy M, Arfi Levy E, Marianayagam NJ, Frolov V, Maimon S, Salomon O. Distinctive patterns of sequential platelet counts following blunt traumatic brain injury predict outcomes. Brain Inj 2024; 38:818-826. [PMID: 38679938 DOI: 10.1080/02699052.2024.2347571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 04/22/2024] [Indexed: 05/01/2024]
Abstract
OBJECTIVE To determine the role of platelet counts in the context of the decision to treat patients with non-compounded, non-surgically-treated blunt traumatic brain injury (NCNS-bTBI) with anticoagulants/antiaggregants. METHODS A retrospective analysis of 141 anticoagulants/antiaggregants-naïve patients with NCNS-bTBI. Changes in PT-INR and prolonged aPTT were examined and correlated with Marshall and Rotterdam scores, clinical and neuroradiological outcomes. RESULTS Three groups of platelet counts were identified. Group 1 (83% of patients) had normal platelet counts (150,000-450,000 platelets/mm3) from admission to discharge. Group 2 (13%) developed transient thrombocytopenia (<150,000 platelets/mm3) 2-3 days post-trauma. Group 3 (4%) developed extreme thrombocytosis > 1,000,000/mm3 platelets 6-9 days post-trauma. Neither acute coagulopathy of trauma nor progressive hemorrhagic insults followed NCNS-bTBI. Moreover, while patients with thrombocytosis/extreme thrombocytosis presented with a worse Glasgow coma score (GCS) on admission (8.8 ± 2.9 vs. 13 ± 2, p < 0.01) and had longer hospitalization (13.5 ± 10.4 vs. 4.5 ± 2.1 days), their improvement at discharge was the highest (delta GCS, 4 ± 2.8 vs. 1.2 ± 2.1, p = 0.05). Traumatic subarachnoid hemorrhage was associated with isolated thrombocytosis and 'best improvement.' No thromboembolic or hemorrhagic complications occurred. CONCLUSION NCNS-bTBI, thrombocytosis was correlated with better outcomes and was not associated with an increased risk for developing thromboembolism or hemorrhage, precluding the immediate need for any additional antiaggregates.
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Affiliation(s)
- Mikael Levy
- Department of Neurosurgery, Rabin Medical Center, Tel Aviv, Israel
- Functional Neurosurgery Unit, Assuta Medical Centers, Tel Aviv, Israel
| | - Esther Arfi Levy
- Department of Pediatric Cardiac Surgery, Schneider Medical Center, Petach Tikva, Israel
| | | | - Vladimir Frolov
- Interventional Neuroradiology Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Shimon Maimon
- Interventional Neuroradiology Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Ophira Salomon
- Thrombosis and Hemostasis Unit, Sheba Medical Center, Ramat Gan, Israel
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Hein RD, Blancke JA, Schaller SJ. [Anaesthesiological Management of Traumatic Brain Injury]. Anasthesiol Intensivmed Notfallmed Schmerzther 2024; 59:420-437. [PMID: 39074788 DOI: 10.1055/a-2075-9299] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2024]
Abstract
Traumatic brain injury (TBI) is the main cause of death in people < 45 years in industrial countries. Minimising secondary injury to the injured brain is the primary goal throughout the entire treatment. Anaesthesiologic procedures aim at the reconstitution of cerebral perfusion and homeostasis. Both TBI itself as well as accompanying injuries show effects on cardiac and pulmonary function. Time management plays a crucial role in ensuring a safe anaesthesiologic environment while minimizing unnecessary procedures. Furthermore, growing medical drug pre-treatment demands for further knowledge e.g., in antagonization of anticoagulation.
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Zoghi S, Ansari A, Azad TD, Niakan A, Kouhpayeh SA, Taheri R, Khalili H. Early hypocoagulable state in traumatic brain injury patients: incidence, predisposing factors, and outcomes in a retrospective cohort study. Neurosurg Rev 2024; 47:297. [PMID: 38922506 DOI: 10.1007/s10143-024-02523-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 04/12/2024] [Accepted: 06/15/2024] [Indexed: 06/27/2024]
Abstract
Coagulopathy development in traumatic brain injury (TBI) is among the significant complications that can negatively affect the clinical course and outcome of TBI patients. Timely identification of this complication is of utmost importance in the acute clinical setting. We reviewed TBI patients admitted to our trauma center from 2015 to 2021. Demographic data, mechanism of injury, findings on admission, imaging studies, procedures during hospitalization, and functional outcomes were gathered. INR with a cutoff of 1.3, platelet count less than 100 × 10⁹/L, or partial thromboplastin time greater than 40s were utilized as the markers of coagulopathy. A total of 4002 patients were included. Coagulopathy occurred in 38.1% of the patients. Age of the patients (Odds Ratio (OR) = 0.993, 95% Confidence Interval (CI) = 0.986-0.999, p = 0.028), systolic blood pressure (OR = 0.993, 95% CI = 0.989-0.998, p = 0.005), fibrinogen level (OR = 0.998, 95% CI = 0.996-0.999, p < 0.001), and hemoglobin level (OR = 0.886, 95% CI = 0.839-0.936, p < 0.001) were independently associated with coagulopathy. Furthermore, coagulopathy was independently associated with higher mortality rates and longer ICU stays. Coagulopathy had the most substantial effect on mortality of TBI patients (OR = 2.6, 95% CI = 2.1-3.3, p < 0.001), compared to other admission clinical characteristics independently associated with mortality such as fixed pupillary light reflex (OR = 1.8, 95% CI = 1.5-2.4, p < 0.001), GCS (OR = 0.91, 95% CI = 0.88-0.94, p < 0.001), and hemoglobin level (OR = 0.93, 95% CI = 0.88-0.98, p = 0.004). Early coagulopathy in TBI patients can lead to higher mortality rates. Future studies are needed to prove that early detection and correction of coagulopathy and modifiable risk factors may help improve outcomes of TBI patients.
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Affiliation(s)
- Sina Zoghi
- Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ali Ansari
- Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Tej D Azad
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amin Niakan
- Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Reza Taheri
- Shiraz Neuroscience Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
- School of Medicine, Fasa University of Medical Sciences, Fasa, Iran.
| | - Hosseinali Khalili
- Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
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Bhanja D, Hallan DR, Staub J, Rizk E, Zacko JC. Early Celecoxib use in Patients with Traumatic Brain Injury. Neurocrit Care 2024; 40:886-897. [PMID: 37704936 DOI: 10.1007/s12028-023-01827-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 08/01/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Traumatic brain injury (TBI) can cause rapid brain inflammation. There is debate over the safety and efficacy of anti-inflammatory agents in its treatment. With a particular focus on cyclooxygenase 2 (COX2) selective inhibition, we sought to determine the impact of celecoxib versus no celecoxib treatment on outcomes in patients with TBI and compare these with outcomes associated with nonselective COX inhibition (ibuprofen) and corticosteroid (dexamethasone) treatment. METHODS This retrospective cohort study used TriNetX, a large publicly available global health research network, to gather clinical data extracted from the electronic medical records. Using International Classification of Diseases, Tenth Revision and pharmacy codes, we identified patients with TBI who were and were not treated with celecoxib, ibuprofen, and dexamethasone. Analysis was performed on propensity-matched and unmatched cohorts, which were matched on demographics, comorbidities, and neurological injuries. Our primary end point was 1-year survival. Secondary end points were ventilator and tracheostomy dependence, gastrostomy tube placement, seizures, and craniotomy. RESULTS After propensity score matching, a total of 1443 patients were identified in both the celecoxib and no celecoxib cohorts. Ninety-two (6.4%) patients in the celecoxib cohort died within 1 year following TBI versus 145 (10.0%) in the no celecoxib cohort (odds ratio 0.61; 95% confidence interval 0.46-0.80; p = 0.0003). The 1-year survival rate was 96.1% in the celecoxib cohort versus 93.1% in the no celecoxib cohort (p < 0.0001). At the end of the 1-year period, celecoxib was associated with significantly lower gastrostomy tube dependence (p = 0.017), seizure activity (p = 0.027), and myocardial infarction (p = 0.021) compared with the control cohort. Ibuprofen was also associated with higher 1-year survival probability and lower rates of post-TBI complications. Dexamethasone was broadly associated with higher morbidity but was associated with higher 1-year survival probability compared with the no dexamethasone cohort. CONCLUSIONS Early celecoxib and ibuprofen use within 5 days post TBI was associated with higher 1-year survival probabilities and fewer complications. With emerging yet controversial preclinical evidence to suggest that COX inhibition improves TBI outcomes, this population-level study offers suggestive support for these drugs' clinical benefit, which should be pursued in prospective clinical studies.
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Affiliation(s)
- Debarati Bhanja
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, 17033, USA
| | - David R Hallan
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, 17033, USA.
| | - Jacob Staub
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, 17033, USA
| | - Elias Rizk
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, 17033, USA
| | - Joseph Christopher Zacko
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, 17033, USA
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Eghzawi A, Alsabbah A, Gharaibeh S, Alwan I, Gharaibeh A, Goyal AV. Mortality Predictors for Adult Patients with Mild-to-Moderate Traumatic Brain Injury: A Literature Review. Neurol Int 2024; 16:406-418. [PMID: 38668127 PMCID: PMC11053597 DOI: 10.3390/neurolint16020030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 03/30/2024] [Accepted: 04/03/2024] [Indexed: 04/29/2024] Open
Abstract
Traumatic brain injuries (TBIs) represent a significant public health concern, with mild-to-moderate cases comprising a substantial portion of incidents. Understanding the predictors of mortality among adult patients with mild-to-moderate TBIs is crucial for optimizing clinical management and improving outcomes. This literature review examines the existing research to identify and analyze the mortality predictors in this patient population. Through a comprehensive review of peer-reviewed articles and clinical studies, key prognostic factors, such as age, Glasgow Coma Scale (GCS) score, the presence of intracranial hemorrhage, pupillary reactivity, and coexisting medical conditions, are explored. Additionally, this review investigates the role of advanced imaging modalities, biomarkers, and scoring systems in predicting mortality following a mild-to-moderate TBI. By synthesizing the findings from diverse studies, this review aims to provide clinicians and researchers with valuable insights into the factors influencing mortality outcomes in adult patients with a mild-to-moderate TBI, thus facilitating more informed decision making and targeted interventions in clinical practice.
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Affiliation(s)
- Ansam Eghzawi
- Insight Research Institute, Flint, MI 48507, USA; (A.E.); (A.A.); (S.G.); (I.A.)
- Center for Cognition and Neuroethics, University of Michigan-Flint, Flint, MI 48502, USA
- Department of Research, Insight Hospital and Medical Center, Chicago, IL 60616 USA
| | - Alameen Alsabbah
- Insight Research Institute, Flint, MI 48507, USA; (A.E.); (A.A.); (S.G.); (I.A.)
| | - Shatha Gharaibeh
- Insight Research Institute, Flint, MI 48507, USA; (A.E.); (A.A.); (S.G.); (I.A.)
- Center for Cognition and Neuroethics, University of Michigan-Flint, Flint, MI 48502, USA
| | - Iktimal Alwan
- Insight Research Institute, Flint, MI 48507, USA; (A.E.); (A.A.); (S.G.); (I.A.)
- Department of Research, Insight Hospital and Medical Center, Chicago, IL 60616 USA
| | - Abeer Gharaibeh
- Insight Research Institute, Flint, MI 48507, USA; (A.E.); (A.A.); (S.G.); (I.A.)
- Department of Research, Insight Hospital and Medical Center, Chicago, IL 60616 USA
| | - Anita V. Goyal
- Department of Emergency Medicine, Insight Hospital and Medical Center, Chicago, IL 60616, USA
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Li F, Li L, Peng R, Liu C, Liu X, Liu Y, Wang C, Xu J, Zhang Q, Yang G, Li Y, Chen F, Li S, Cui W, Liu L, Xu X, Zhang S, Zhao Z, Zhang J. Brain-derived extracellular vesicles mediate systemic coagulopathy and inflammation after traumatic brain injury. Int Immunopharmacol 2024; 130:111674. [PMID: 38387190 DOI: 10.1016/j.intimp.2024.111674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 02/05/2024] [Accepted: 02/07/2024] [Indexed: 02/24/2024]
Abstract
Traumatic brain injury (TBI) can induce systemic coagulopathy and inflammation, thereby increasing the risk of mortality and disability. However, the mechanism causing systemic coagulopathy and inflammation following TBI remains unclear. In prior research, we discovered that brain-derived extracellular vesicles (BDEVs), originating from the injured brain, can activate the coagulation cascade and inflammatory cells. In this study, we primarily investigated how BDEVs affect systemic coagulopathy and inflammation in peripheral circulation. The results of cytokines and coagulation function indicated that BDEVs can lead to systemic coagulopathy and inflammation by influencing inflammatory factors and chemokines within 24 h. Furthermore, according to flow cytometry and blood cell counter results, we found that BDEVs induced changes in the blood count such as a reduced number of platelets and leukocytes and an increased percentage of neutrophils, macrophages, activated platelets, circulating platelet-EVs, and leukocyte-derived EVs. We also discovered that eliminating circulating BDEVs with lactadherin helped improve coagulopathy and inflammation, relieved blood cell dysfunction, and decreased the circulating platelet-EVs and leukocyte-derived EVs. Our research provides a novel viewpoint and potential mechanism of TBI-associated secondary damage.
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Affiliation(s)
- Fanjian Li
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China; Tianjin Neurological Institute, Tianjin, China; Graduate School, Tianjin Medical University, Tianjin, China; Key Laboratory of Post-trauma Neuro-repair and Regeneration in Central Nervous System, Ministry of Education, Tianjin, China; Tianjin Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin, China
| | - Lei Li
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China; Tianjin Neurological Institute, Tianjin, China; Graduate School, Tianjin Medical University, Tianjin, China; Key Laboratory of Post-trauma Neuro-repair and Regeneration in Central Nervous System, Ministry of Education, Tianjin, China; Tianjin Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin, China
| | - Ruilong Peng
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China; Tianjin Neurological Institute, Tianjin, China; Graduate School, Tianjin Medical University, Tianjin, China; Key Laboratory of Post-trauma Neuro-repair and Regeneration in Central Nervous System, Ministry of Education, Tianjin, China; Tianjin Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin, China
| | - Chuan Liu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China; Tianjin Neurological Institute, Tianjin, China; Graduate School, Tianjin Medical University, Tianjin, China; Key Laboratory of Post-trauma Neuro-repair and Regeneration in Central Nervous System, Ministry of Education, Tianjin, China; Tianjin Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin, China
| | - Xiao Liu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China; Tianjin Neurological Institute, Tianjin, China; Key Laboratory of Post-trauma Neuro-repair and Regeneration in Central Nervous System, Ministry of Education, Tianjin, China; Tianjin Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin, China
| | - Yafan Liu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China; Tianjin Neurological Institute, Tianjin, China; Graduate School, Tianjin Medical University, Tianjin, China; Key Laboratory of Post-trauma Neuro-repair and Regeneration in Central Nervous System, Ministry of Education, Tianjin, China; Tianjin Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin, China
| | - Cong Wang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China; Tianjin Neurological Institute, Tianjin, China; Graduate School, Tianjin Medical University, Tianjin, China; Key Laboratory of Post-trauma Neuro-repair and Regeneration in Central Nervous System, Ministry of Education, Tianjin, China; Tianjin Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin, China
| | - Jianye Xu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China; Tianjin Neurological Institute, Tianjin, China; Graduate School, Tianjin Medical University, Tianjin, China; Key Laboratory of Post-trauma Neuro-repair and Regeneration in Central Nervous System, Ministry of Education, Tianjin, China; Tianjin Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin, China
| | - Qiaoling Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China; Tianjin Neurological Institute, Tianjin, China; Graduate School, Tianjin Medical University, Tianjin, China; Key Laboratory of Post-trauma Neuro-repair and Regeneration in Central Nervous System, Ministry of Education, Tianjin, China; Tianjin Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin, China
| | - Guili Yang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China; Tianjin Neurological Institute, Tianjin, China; Graduate School, Tianjin Medical University, Tianjin, China; Key Laboratory of Post-trauma Neuro-repair and Regeneration in Central Nervous System, Ministry of Education, Tianjin, China; Tianjin Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin, China
| | - Ying Li
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China; Tianjin Neurological Institute, Tianjin, China; Key Laboratory of Post-trauma Neuro-repair and Regeneration in Central Nervous System, Ministry of Education, Tianjin, China; Tianjin Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin, China
| | - FangLian Chen
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China; Tianjin Neurological Institute, Tianjin, China; Key Laboratory of Post-trauma Neuro-repair and Regeneration in Central Nervous System, Ministry of Education, Tianjin, China; Tianjin Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin, China
| | - Shenghui Li
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China; Tianjin Neurological Institute, Tianjin, China; Key Laboratory of Post-trauma Neuro-repair and Regeneration in Central Nervous System, Ministry of Education, Tianjin, China; Tianjin Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin, China
| | - Weiyun Cui
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China; Tianjin Neurological Institute, Tianjin, China; Key Laboratory of Post-trauma Neuro-repair and Regeneration in Central Nervous System, Ministry of Education, Tianjin, China; Tianjin Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin, China
| | - Li Liu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China; Tianjin Neurological Institute, Tianjin, China; Key Laboratory of Post-trauma Neuro-repair and Regeneration in Central Nervous System, Ministry of Education, Tianjin, China; Tianjin Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin, China
| | - Xin Xu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Beijing, China.
| | - Shu Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China; Tianjin Neurological Institute, Tianjin, China; Key Laboratory of Post-trauma Neuro-repair and Regeneration in Central Nervous System, Ministry of Education, Tianjin, China; Tianjin Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin, China.
| | - Zilong Zhao
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China; Tianjin Neurological Institute, Tianjin, China; Key Laboratory of Post-trauma Neuro-repair and Regeneration in Central Nervous System, Ministry of Education, Tianjin, China; Tianjin Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin, China.
| | - Jianning Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China; Tianjin Neurological Institute, Tianjin, China; Key Laboratory of Post-trauma Neuro-repair and Regeneration in Central Nervous System, Ministry of Education, Tianjin, China; Tianjin Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin, China.
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Song JX, Wu JX, Zhong H, Chen W, Zheng JC. Therapeutic efficacy of tranexamic acid on traumatic brain injury: a systematic review and meta-analysis. Scand J Trauma Resusc Emerg Med 2024; 32:18. [PMID: 38454455 PMCID: PMC10921791 DOI: 10.1186/s13049-024-01188-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 02/25/2024] [Indexed: 03/09/2024] Open
Abstract
OBJECTIVE Tranexamic acid (TXA) demonstrates therapeutic efficacy in the management of traumatic brain injury (TBI). The objective of this systematic review and meta-analysis was to evaluate the safety and effectiveness of TXA in patients with TBI. METHODS The databases, namely PubMed, Embase, Web of Science, and Cochrane Library databases, were systematically searched to retrieve randomized controlled trials (RCTs) investigating the efficacy of TXA for TBI from January 2000 to November 2023. RESULTS The present meta-analysis incorporates ten RCTs. Compared to the placebo group, administration of TXA in patients with TBI resulted in a significant reduction in mortality (P = 0.05), hemorrhage growth (P = 0.03), and volume of hemorrhage growth (P = 0.003). However, no significant impact was observed on neurosurgery outcomes (P = 0.25), seizure occurrence (P = 0.78), or pulmonary embolism incidence (P = 0.52). CONCLUSION The administration of TXA is significantly associated with reduced mortality and hemorrhage growth in patients suffering from TBI, while the need of neurosurgery, seizures, and incidence of pulmonary embolism remains comparable to that observed with placebo.
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Affiliation(s)
- Jia-Xing Song
- Department of Emergency, The Second Hospital of Jiaxing: The Second Affiliated Hospital of Jiaxing University, Jiaxing, 314000, Zhejiang Province, China
| | - Jian-Xiang Wu
- Department of Emergency, The Second Hospital of Jiaxing: The Second Affiliated Hospital of Jiaxing University, Jiaxing, 314000, Zhejiang Province, China
| | - Hai Zhong
- Department of Emergency, The Second Hospital of Jiaxing: The Second Affiliated Hospital of Jiaxing University, Jiaxing, 314000, Zhejiang Province, China
| | - Wei Chen
- Department of Emergency, The Second Hospital of Jiaxing: The Second Affiliated Hospital of Jiaxing University, Jiaxing, 314000, Zhejiang Province, China
| | - Jian-Chun Zheng
- Department of Emergency, The Second Hospital of Jiaxing: The Second Affiliated Hospital of Jiaxing University, Jiaxing, 314000, Zhejiang Province, China.
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Hirano T, Yamada K, Terayama T, Iwasaki Y, Yamamoto R, Shinohara K. Concomitant severe traumatic brain injury is not associated with increased red blood cell transfusion volumes in patients with pelvic fractures: A retrospective observational study. Injury 2024; 55:111296. [PMID: 38184413 DOI: 10.1016/j.injury.2023.111296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 11/15/2023] [Accepted: 12/17/2023] [Indexed: 01/08/2024]
Abstract
INTRODUCTION Traumatic brain injury (TBI)-associated coagulopathy significantly influences survival outcomes in patients with multiple injuries. Severe TBI can potentially affect systemic hemostasis due to coagulopathy; however, there is limited evidence regarding whether the risk of hemorrhage increases in patients with pelvic fractures complicated with TBI. Therefore, through multivariable analysis, we aimed to examine the association between severe TBI and increased blood transfusion requirements in patients with pelvic fractures. MATERIALS AND METHODS This retrospective observational study was conducted at a tertiary care facility in Japan. Patients aged 16 years or older with pelvic fractures who were admitted to our intensive care unit between April 2014 and December 2021 were included in the analysis. The patients were categorized into no to mild and severe TBI groups according to whether the Head Abbreviated Injury Scale (AIS) score was 3 or higher. The primary outcome was the number of red blood cell (RBC) units transfused within 24 h after arrival at the hospital. The primary outcome was analyzed using univariable and multivariable linear regression analyses. The covariates used for the multivariable linear regression analysis were age, sex, antithrombotic therapy, mechanism of injury, Pelvic AIS score, and extravasation on contrast-enhanced computed tomography on admission. RESULTS We identified 315 eligible patients (221 and 94 in the no to mild and severe TBI groups, respectively). In the univariable analysis, the RBC transfusion volume within 24 h after arrival was significantly higher in the severe TBI group than in the no to mild TBI group (2.53-unit increase; 95 % confidence interval [CI]: 0.46-4.61). However, in the multivariable analysis, no statistically significant association was detected between severe TBI and the RBC transfusion volume within 24 h after arrival at the hospital (0.87-unit increase; 95 % CI: -1.11-2.85). CONCLUSIONS Concomitant severe TBI was not associated with increased RBC transfusion volumes in patients with pelvic fractures on multivariable analysis.
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Affiliation(s)
- Takaki Hirano
- Department of Anesthesiology and Emergency Medicine, Ohta Nishinouchi Hospital, 2-5-20 Nishinouchi, Koriyama, Fukushima, Japan; Department of Radiology, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-Ku, Tokyo, Japan.
| | - Kohei Yamada
- Department of Traumatology and Critical Care Medicine, National Defense Medical College Hospital, 3-2 Namiki, Tokorozawa, Saitama, Japan
| | - Takero Terayama
- Department of Emergency, Self-Defense Forces Central Hospital, 1-2-24 Ikejiri, Setagaya-Ku, Tokyo Japan
| | - Yudai Iwasaki
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, Japan
| | - Ryohei Yamamoto
- Center for Innovative Research for Communities and Clinical Excellence (CIRC2LE), Fukushima Medical University, 1 Hikarigaoka, Fukushima, Fukushima, Japan; Department of Healthcare Epidemiology, School of Public Health, Graduate School of Medicine, Kyoto University, Yoshida-honmachi, Kyoto Sakyo-ku, Kyoto, Japan
| | - Kazuaki Shinohara
- Department of Anesthesiology and Emergency Medicine, Ohta Nishinouchi Hospital, 2-5-20 Nishinouchi, Koriyama, Fukushima, Japan
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Zipperle J, Schmitt FCF, Schöchl H. Point-of-care, goal-directed management of bleeding in trauma patients. Curr Opin Crit Care 2023; 29:702-712. [PMID: 37861185 DOI: 10.1097/mcc.0000000000001107] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to consider the clinical value of point-of-care (POC) testing in coagulopathic trauma patients with traumatic brain injury (TBI) and trauma-induced coagulopathy (TIC). RECENT FINDINGS Patients suffering from severe TBI or TIC are at risk of developing pronounced haemostatic disorders. Standard coagulation tests (SCTs) are insufficient to reflect the complexity of these coagulopathies. Recent evidence has shown that viscoelastic tests (VETs) identify haemostatic disorders more rapidly and in more detail than SCTs. Moreover, VET results can guide coagulation therapy, allowing individualised treatment, which decreases transfusion requirements. However, the impact of VET on mortality remains uncertain. In contrast to VETs, the clinical impact of POC platelet function testing is still unproven. SUMMARY POC SCTs are not able to characterise the complexity of trauma-associated coagulopathy. VETs provide a rapid estimation of underlying haemostatic disorders, thereby providing guidance for haemostatic therapy, which impacts allogenic blood transfusion requirements. The value of POC platelet function testing to identify platelet dysfunction and guide platelet transfusion is still uncertain.
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Affiliation(s)
- Johannes Zipperle
- Ludwig Boltzmann Institute for Traumatology, the Research Centre in Cooperation with AUVA, Vienna
| | - Felix C F Schmitt
- Department of Anaesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Herbert Schöchl
- Ludwig Boltzmann Institute for Traumatology, the Research Centre in Cooperation with AUVA, Vienna
- Paracelsus Medical University, Salzburg, Austria
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10
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Zhao ZA, Yan L, Wen J, Satyanarayanan SK, Yu F, Lu J, Liu YU, Su H. Cellular and molecular mechanisms in vascular repair after traumatic brain injury: a narrative review. BURNS & TRAUMA 2023; 11:tkad033. [PMID: 37675267 PMCID: PMC10478165 DOI: 10.1093/burnst/tkad033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 02/01/2023] [Accepted: 05/26/2023] [Indexed: 09/08/2023]
Abstract
Traumatic brain injury (TBI) disrupts normal brain function and is associated with high morbidity and fatality rates. TBI is characterized as mild, moderate or severe depending on its severity. The damage may be transient and limited to the dura matter, with only subtle changes in cerebral parenchyma, or life-threatening with obvious focal contusions, hematomas and edema. Blood vessels are often injured in TBI. Even in mild TBI, dysfunctional cerebral vascular repair may result in prolonged symptoms and poor outcomes. Various distinct types of cells participate in vascular repair after TBI. A better understanding of the cellular response and function in vascular repair can facilitate the development of new therapeutic strategies. In this review, we analyzed the mechanism of cerebrovascular impairment and the repercussions following various forms of TBI. We then discussed the role of distinct cell types in the repair of meningeal and parenchyma vasculature following TBI, including endothelial cells, endothelial progenitor cells, pericytes, glial cells (astrocytes and microglia), neurons, myeloid cells (macrophages and monocytes) and meningeal lymphatic endothelial cells. Finally, possible treatment techniques targeting these unique cell types for vascular repair after TBI are discussed.
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Affiliation(s)
- Zi-Ai Zhao
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Avenida da Universidade, Taipa, Macau 999078, China
- Department of Neurology, General Hospital of Northern Theater Command, 83# Wen-Hua Road, Shenyang 110840, China
| | - Lingli Yan
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Avenida da Universidade, Taipa, Macau 999078, China
| | - Jing Wen
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Avenida da Universidade, Taipa, Macau 999078, China
| | - Senthil Kumaran Satyanarayanan
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Avenida da Universidade, Taipa, Macau 999078, China
| | - Feng Yu
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Avenida da Universidade, Taipa, Macau 999078, China
| | - Jiahong Lu
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Avenida da Universidade, Taipa, Macau 999078, China
| | - Yong U Liu
- Laboratory of Neuroimmunology in Health and Disease Institute, Guangzhou First People’s Hospital School of Medicine, South China University of Technology, Guangzhou Higher Education Mega Center, Panyu District, Guangzhou 511400, China
| | - Huanxing Su
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Avenida da Universidade, Taipa, Macau 999078, China
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11
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Dong X, Dong JF, Zhang J. Roles and therapeutic potential of different extracellular vesicle subtypes on traumatic brain injury. Cell Commun Signal 2023; 21:211. [PMID: 37596642 PMCID: PMC10436659 DOI: 10.1186/s12964-023-01165-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 05/13/2023] [Indexed: 08/20/2023] Open
Abstract
Traumatic brain injury (TBI) is a leading cause of injury-related disability and death around the world, but the clinical stratification, diagnosis, and treatment of complex TBI are limited. Due to their unique properties, extracellular vesicles (EVs) are emerging candidates for being biomarkers of traumatic brain injury as well as serving as potential therapeutic targets. However, the effects of different extracellular vesicle subtypes on the pathophysiology of traumatic brain injury are very different, or potentially even opposite. Before extracellular vesicles can be used as targets for TBI therapy, it is necessary to classify different extracellular vesicle subtypes according to their functions to clarify different strategies for EV-based TBI therapy. The purpose of this review is to discuss contradictory effects of different EV subtypes on TBI, and to propose treatment ideas based on different EV subtypes to maximize their benefits for the recovery of TBI patients. Video Abstract.
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Affiliation(s)
- Xinlong Dong
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 119, Nansihuan West Road, Fengtai District, Beijing, China.
- Beijing Key Laboratory of Central Nervous System Injury, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.
| | - Jing-Fei Dong
- Bloodworks Research Institute, Seattle, WA, USA
- Division of Hematology, Department of Medicine, School of Medicine, University of Washington, Seattle, WA, USA
| | - Jianning Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
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12
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Nagai A, Karibe H, Narisawa A, Kameyama M, Ishikawa S, Iwabuchi N, Tominaga T. Cerebral infarction following administration of andexanet alfa for anticoagulant reversal in a patient with traumatic acute subdural hematoma. Surg Neurol Int 2023; 14:286. [PMID: 37680936 PMCID: PMC10481803 DOI: 10.25259/sni_358_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 07/25/2023] [Indexed: 09/09/2023] Open
Abstract
Background Anticoagulants prevent thrombosis in patients with atrial fibrillation (AF) and venous thromboembolism but increase the risk of hemorrhagic complications. If severe bleeding occurs with anticoagulant use, discontinuation and rapid reversal are essential. However, the optimal timing for resuming anticoagulants after using reversal agents remains unclear. Here, we report early cerebral infarction following the use of andexanet alfa (AA), a specific reversal agent for factor Xa inhibitors, in a patient with traumatic acute subdural hematoma (ASDH). The possible causes of thromboembolic complication and the optimal timing for anticoagulant resumption are discussed. Case Description An 84-year-old woman receiving rivaroxaban for AF presented with impaired consciousness after a head injury. Computed tomography (CT) revealed right ASDH. The patient was administered AA and underwent craniotomy. Although the hematoma was entirely removed, she developed multiple cerebral infarctions 10 h after the surgery. These infarctions were considered cardiogenic cerebral embolisms and rivaroxaban was therefore resumed on the same day. This case indicates the possibility of early cerebral infarction after using a specific reversal agent for factor Xa inhibitors. Conclusion Most studies suggest that the safest time for resuming anticoagulants after using reversal agents is between 7 and 12 days. The present case showed that embolic complications may develop much earlier than expected. Early readministration of anticoagulant may allow for adequate prevention of the acute thrombotic syndromes.
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Affiliation(s)
- Arata Nagai
- Department of Neurosurgery, Sendai City Hospital, Sendai, Miyagi, Japan
| | - Hiroshi Karibe
- Department of Neurosurgery, Sendai City Hospital, Sendai, Miyagi, Japan
| | - Ayumi Narisawa
- Department of Neurosurgery, Sendai City Hospital, Sendai, Miyagi, Japan
| | - Motonobu Kameyama
- Department of Neurosurgery, Sendai City Hospital, Sendai, Miyagi, Japan
| | - Shuichi Ishikawa
- Department of Neurosurgery, Isinomaki Red Cross Hospital, Ishinomaki, Japan
| | - Naoya Iwabuchi
- Department of Neurosurgery, Isinomaki Red Cross Hospital, Ishinomaki, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
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13
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Peng S, Lv K. The role of fibrinogen in traumatic brain injury: from molecular pathological mechanisms to clinical management. Eur J Trauma Emerg Surg 2023; 49:1665-1672. [PMID: 35972516 DOI: 10.1007/s00068-022-02084-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 08/08/2022] [Indexed: 11/28/2022]
Abstract
Fibrinogen is the substrate of plasma coagulation. It plays an important role in the formation of reticular network, which is crucial to the strength and stability of blood clots. In addition to directly participating in coagulation, fibrinogen also participates in the destruction of blood-brain barrier and neuroinflammation. This article reviews the pathophysiological changes of fibrinogen after traumatic brain injury. Considerable efforts have been made to understand the mechanisms by which fibrinogen damages the central nervous system. Combined with the latest research hotspots, potentially promising treatment strategies at the molecular level were discussed. We believe that understanding the role of fibrinogen-mediated damage in nerve and blood-brain barrier function will enable timely intervention in patients with nerve damage, and guide the development of novel targeted therapeutics.
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Affiliation(s)
- Shixin Peng
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Yuzhong District, Chongqing, 400016, China
| | - Ke Lv
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Yuzhong District, Chongqing, 400016, China.
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14
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Rimaitis M, Cechanovičiūtė V, Bilskienė D, Balčiūnienė N, Vilcinis R, Rimaitis K, Macas A. Dynamic Changes of Hemostasis in Patients with Traumatic Brain Injury Undergoing Craniotomy: Association with in-Hospital Mortality. Neurocrit Care 2023; 38:714-725. [PMID: 36471184 DOI: 10.1007/s12028-022-01639-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 10/31/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) induces complex systemic hemostatic alterations associated with secondary brain damage and death. We specifically investigated perioperative changes of hemostasis in patients with isolated TBI undergoing major neurosurgery and searched for their influence on outcome. METHODS Serial analysis (four time points, T0-T3) of conventional coagulation assay and rotational thromboelastometry data acquired during 72 h from admission of 68 patients who underwent craniotomy to remove hematoma and/or to decompress the brain was performed. The primary outcome was in-hospital mortality. Secondary outcomes were the prevalence of hypocoagulation and increased clotting activity, coagulation parameters between survivors and nonsurvivors, and cutoff values of coagulation parameters predictive of mortality. RESULTS Overall mortality was 22%. The prevalence of hypocoagulation according to rotational thromboelastometry decreased from 35.8% (T0) to 15.9% (T3). Lower fibrinogen levels, hyperfibrinolysis and fibrinolysis shutdown in the early period (T0-T1) following TBI were associated with higher mortality. Optimal cutoff values were identified: fibrin polymerization thromboelastometry (FIBTEM) clot amplitude at 10 min after clotting time ≤ 13 mm at T0 and FIBTEM clot amplitude at 10 min after clotting time ≤ 16.5 mm at T1 increased the odds of death by 6.0 (95% confidence interval [CI] 1.54-23.13, p = 0.010) and 9.7 (95% CI 2.06-45.36, p = 0.004), respectively. FIBTEM maximum clot firmness ≤ 14.5 mm at T0 and FIBTEM maximum clot firmness ≤ 18.5 mm at T1 increased the odds of death by 6.3 (95% CI 1.56-25.69, p = 0.010) and 9.1 (95% CI 1.88-44.39, p = 0.006). Fibrinogen < 3 g/L on postoperative day 1 (T1) was associated with a 9.5-fold increase of in-hospital mortality (95% CI 1.72-52.98, p = 0.01). Increased clotting activity was not associated with mortality. CONCLUSIONS Rotational thromboelastometry adds important information for identifying patients with TBI at increased risk of death. Early fibrinogen-related coagulation disorders are associated with mortality of patients with TBI undergoing major neurosurgical procedures. Maintenance of higher fibrinogen levels might be necessary for neurosurgical patients with acute TBI.
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Affiliation(s)
- Marius Rimaitis
- Lithuanian University of Health Sciences, Mickeviciaus Str. 9, 44307, Kaunas, Lithuania.
- Clinic of Anesthesiology, Lithuanian University of Health Sciences, Kaunas, Lithuania.
| | - Vaiva Cechanovičiūtė
- Lithuanian University of Health Sciences, Mickeviciaus Str. 9, 44307, Kaunas, Lithuania
| | - Diana Bilskienė
- Lithuanian University of Health Sciences, Mickeviciaus Str. 9, 44307, Kaunas, Lithuania
- Clinic of Anesthesiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Neringa Balčiūnienė
- Lithuanian University of Health Sciences, Mickeviciaus Str. 9, 44307, Kaunas, Lithuania
- Clinic of Neurosurgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Rimantas Vilcinis
- Lithuanian University of Health Sciences, Mickeviciaus Str. 9, 44307, Kaunas, Lithuania
- Clinic of Neurosurgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Kęstutis Rimaitis
- Lithuanian University of Health Sciences, Mickeviciaus Str. 9, 44307, Kaunas, Lithuania
- Clinic of Anesthesiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Andrius Macas
- Lithuanian University of Health Sciences, Mickeviciaus Str. 9, 44307, Kaunas, Lithuania
- Clinic of Anesthesiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
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15
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Kockelmann F, Maegele M. Acute Haemostatic Depletion and Failure in Patients with Traumatic Brain Injury (TBI): Pathophysiological and Clinical Considerations. J Clin Med 2023; 12:jcm12082809. [PMID: 37109145 PMCID: PMC10143480 DOI: 10.3390/jcm12082809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 03/30/2023] [Accepted: 04/07/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Because of the aging population, the number of low falls in elderly people with pre-existing anticoagulation is rising, often leading to traumatic brain injury (TBI) with a social and economic burden. Hemostatic disorders and disbalances seem to play a pivotal role in bleeding progression. Interrelationships between anticoagulatoric medication, coagulopathy, and bleeding progression seem to be a promising aim of therapy. METHODS We conducted a selective search of the literature in databases like Medline (Pubmed), Cochrane Library and current European treatment recommendations using relevant terms or their combination. RESULTS Patients with isolated TBI are at risk for developing coagulopathy in the clinical course. Pre-injury intake of anticoagulants is leading to a significant increase in coagulopathy, so every third patient with TBI in this population suffers from coagulopathy, leading to hemorrhagic progression and delayed traumatic intracranial hemorrhage. In an assessment of coagulopathy, viscoelastic tests such as TEG or ROTEM seem to be more beneficial than conventional coagulation assays alone, especially because of their timely and more specific gain of information about coagulopathy. Furthermore, results of point-of-care diagnostic make rapid "goal-directed therapy" possible with promising results in subgroups of patients with TBI. CONCLUSIONS The use of innovative technologies such as viscoelastic tests in the assessment of hemostatic disorders and implementation of treatment algorithms seem to be beneficial in patients with TBI, but further studies are needed to evaluate their impact on secondary brain injury and mortality.
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Affiliation(s)
- Fabian Kockelmann
- Department of Surgery, Klinikum Dortmund, University Hospital of the University Witten/Herdecke, Beurhausstr. 40, D-44137 Dortmund, Germany
- Institute for Research in Operative Medicine (IFOM), University Witten/Herdecke, Campus Cologne-Merheim, Ostmerheimerstr. 200, D-51109 Köln, Germany
| | - Marc Maegele
- Institute for Research in Operative Medicine (IFOM), University Witten/Herdecke, Campus Cologne-Merheim, Ostmerheimerstr. 200, D-51109 Köln, Germany
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center (CMMC), University Witten/Herdecke, Campus Cologne-Merheim, Ostmerheimerstr. 200, D-51109 Köln, Germany
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16
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Seim RF, Willis ML, Wallet SM, Maile R, Coleman LG. EXTRACELLULAR VESICLES AS REGULATORS OF IMMUNE FUNCTION IN TRAUMATIC INJURIES AND SEPSIS. Shock 2023; 59:180-189. [PMID: 36516458 PMCID: PMC9940835 DOI: 10.1097/shk.0000000000002023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 09/20/2022] [Accepted: 10/20/2022] [Indexed: 12/15/2022]
Abstract
ABSTRACT Despite advancements in critical care and resuscitation, traumatic injuries are one of the leading causes of death around the world and can bring about long-term disabilities in survivors. One of the primary causes of death for trauma patients are secondary phase complications that can develop weeks or months after the initial insult. These secondary complications typically occur because of systemic immune dysfunction that develops in response to injury, which can lead to immunosuppression, coagulopathy, multiple organ failure, unregulated inflammation, and potentially sepsis in patients. Recently, extracellular vesicles (EVs) have been identified as mediators of these processes because their levels are increased in circulation after traumatic injury and they encapsulate cargo that can aggravate these secondary complications. In this review, we will discuss the role of EVs in the posttrauma pathologies that arise after burn injuries, trauma to the central nervous system, and infection. In addition, we will examine the use of EVs as biomarkers for predicting late-stage trauma outcomes and as therapeutics for reversing the pathological processes that develop after trauma. Overall, EVs have emerged as critical mediators of trauma-associated pathology and their use as a therapeutic agent represents an exciting new field of biomedicine.
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Affiliation(s)
- Roland F. Seim
- Curriculum in Toxicology and Environmental Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Department of Surgery, North Carolina Jaycee Burn Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Micah L. Willis
- Curriculum in Toxicology and Environmental Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Department of Surgery, North Carolina Jaycee Burn Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Shannon M. Wallet
- Department of Oral Biology, College of Dentistry, University of Florida, Gainesville, Florida
| | - Robert Maile
- Department of Surgery, University of Florida, Gainesville, Florida
| | - Leon G. Coleman
- Department of Pharmacology, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, North Carolina
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17
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Tsuneoka H, Tosaka M, Nakata S, Ishii N, Osawa S, Shimauchi-Ohtaki H, Honda F, Yoshimoto Y. Emergent surgical evacuation of traumatic intracranial hematoma in patients with preoperative thrombocytopenia: surgical risk and early outcome. Acta Neurol Belg 2023; 123:161-171. [PMID: 34426955 DOI: 10.1007/s13760-021-01786-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 08/16/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Surgical evacuation of intracranial hematoma, including epidural, subdural, intracerebral, and intraventricular hematoma, is recommended in patients with traumatic brain injury (TBI) for prevention of cerebral herniation and possible saving of life. However, preoperative coagulopathy is a major concern for emergent surgery on patients with severe TBI. METHODS We reviewed 65 consecutive patients with severe TBI who underwent emergency craniotomy for intracranial hematomas. RESULTS Univariate analysis showed preoperative pupil abnormality, absence of pupil light reflex, respiratory failure, preoperative thrombocytopenia (< 100 × 109/L), increased activated partial thromboplastin time (> 36 s), low fibrinogen (< 150 mg/dL), platelet transfusion, red cell concentrate transfusion, and presence of brain contusion and traumatic subarachnoid hemorrhage (SAH) on computed tomography were correlated with poor outcome (death or vegetative state). Multivariate analysis revealed that pupil abnormality (p = 0.001; odds ratio [OR] 0.064, 95% confidence interval [CI] 0.012-0.344), preoperative thrombocytopenia (p = 0.016; OR 0.101, 95% CI 0.016-0.656), and traumatic SAH (p = 0.021; OR 0.211, 95% CI 0.057-0.791) were significant factors. Investigation of the 14 patients with preoperative thrombocytopenia found the emergency surgery was successful, with no postoperative bleeding during hospitalization. However, half of the patients died, and almost a quarter remained in the vegetative state mainly associated with severe cerebral edema. CONCLUSIONS Emergent craniotomy for patients with severe TBI who have preoperative thrombocytopenia is often successful, but the prognosis is often poor. Emergency medical care teams and neurosurgeons should be aware of this discrepancy between successful surgery and poor prognosis in these patients. Further study may be needed on the cerebral edema regulator function of platelets.
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Affiliation(s)
- Haruka Tsuneoka
- Department of Neurosurgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Masahiko Tosaka
- Department of Neurosurgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan.
| | - Satoshi Nakata
- Department of Neurosurgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Nobukazu Ishii
- Department of Neurosurgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Sho Osawa
- Department of Neurosurgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Hiroya Shimauchi-Ohtaki
- Department of Neurosurgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Fumiaki Honda
- Department of Neurosurgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Yuhei Yoshimoto
- Department of Neurosurgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
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18
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Salasky VR, Chang WTW. Neurotrauma Update. Emerg Med Clin North Am 2023; 41:19-33. [DOI: 10.1016/j.emc.2022.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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19
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Li Z, Feng Y, Wang P, Han S, Zhang K, Zhang C, Lu S, Lv C, Zhu F, Bie L. Evaluation of the prognosis of acute subdural hematoma according to the density differences between gray and white matter. Front Neurol 2023; 13:1024018. [PMID: 36686517 PMCID: PMC9853902 DOI: 10.3389/fneur.2022.1024018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 11/21/2022] [Indexed: 01/07/2023] Open
Abstract
Objective Acute subdural hematoma (ASDH) is a common neurological emergency, and its appearance on head-computed tomographic (CT) imaging helps guide clinical treatment. To provide a basis for clinical decision-making, we analyzed that the density difference between the gray and white matter of the CT image is associated with the prognosis of patients with ASDH. Methods We analyzed the data of 194 patients who had ASDH as a result of closed traumatic brain injury (TBI) between 2018 and 2021. The patients were subdivided into surgical and non-surgical groups, and the non-surgical group was further subdivided into "diffused [hematoma]" and "non-diffused" groups. The control group's CT scans were normal. The 3D Slicer software was used to quantitatively analyze the density of gray and white matter depicted in the CT images. Results Imaging evaluation showed that the median difference in density between the gray and white matter on the injured side was 4.12 HU (IQR, 3.91-4.22 HU; p < 0.001) and on the non-injured side was 4.07 HU (IQR, 3.90-4.19 HU; p < 0.001), and the hematoma needs to be surgically removed. The median density difference value of the gray and white matter on the injured side was 3.74 HU (IQR, 3.53-4.01 HU; p < 0.001) and on the non-injured side was 3.71 HU (IQR, 3.69-3.73 HU; p < 0.001), and the hematoma could diffuse in a short time. Conclusion Quantitative analysis of the density differences in the gray and white matter of the CT images can be used to evaluate the clinical prognosis of patients with ASDH.
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Affiliation(s)
- Zean Li
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Yan Feng
- Department of Radiology of the First Clinical Hospital, Jilin University, Changchun, China
| | - Pengju Wang
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Shuai Han
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Kang Zhang
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Chunyun Zhang
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Shouyong Lu
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Chuanxiang Lv
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Fulei Zhu
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Li Bie
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China,*Correspondence: Li Bie
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Dong JF, Zhang F, Zhang J. Detecting traumatic brain injury-induced coagulopathy: What we are testing and what we are not. J Trauma Acute Care Surg 2023; 94:S50-S55. [PMID: 35838367 PMCID: PMC9805481 DOI: 10.1097/ta.0000000000003748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
ABSTRACT Coagulopathy after traumatic brain injury (TBI) is common and has been closely associated with poor clinical outcomes for the affected patients. Traumatic brain injury-induced coagulopathy (TBI-IC) is consumptive in nature and evolves rapidly from an injury-induced hypercoagulable state. Traumatic brain injury-induced coagulopathy defined by laboratory tests is significantly more frequent than clinical coagulopathy, which often manifests as secondary, recurrent, or delayed intracranial or intracerebral hemorrhage. This disparity between laboratory and clinical coagulopathies has hindered progress in understanding the pathogenesis of TBI-IC and developing more accurate and predictive tests for this severe TBI complication. In this review, we discuss laboratory tests used in clinical and research studies to define TBI-IC, with specific emphasis on what the tests detect and what they do not. We also offer perspective on developing more accurate and predictive tests for this severe TBI complication.
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Affiliation(s)
- Jing-fei Dong
- Bloodworks Research Institute, Seattle, WA, USA
- Division of Hematology, Department of Medicine, University of Washington, School of Medicine, Seattle, WA, USA
| | - Fangyi Zhang
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, WA, USA
| | - Jianning Zhang
- Tianjin Institute of Neurology, Tianjin, China
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
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21
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Nakae R, Murai Y, Wada T, Fujiki Y, Kanaya T, Takayama Y, Suzuki G, Naoe Y, Yokota H, Yokobori S. Hyperfibrinolysis and fibrinolysis shutdown in patients with traumatic brain injury. Sci Rep 2022; 12:19107. [PMID: 36352256 PMCID: PMC9646769 DOI: 10.1038/s41598-022-23912-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 11/07/2022] [Indexed: 11/11/2022] Open
Abstract
Traumatic brain injury (TBI) is associated with coagulation/fibrinolysis disorders. We retrospectively evaluated 61 TBI cases transported to hospital within 1 h post-injury. Levels of thrombin-antithrombin III complex (TAT), D-dimer, and plasminogen activator inhibitor-1 (PAI-1) were measured on arrival and 3 h, 6 h, 12 h, 1 day, 3 days and 7 days after injury. Multivariate logistic regression analysis was performed to identify prognostic factors for coagulation and fibrinolysis. Plasma TAT levels peaked at admission and decreased until 1 day after injury. Plasma D-dimer levels increased, peaking up to 3 h after injury, and decreasing up to 3 days after injury. Plasma PAI-1 levels increased up to 3 h after injury, the upward trend continuing until 6 h after injury, followed by a decrease until 3 days after injury. TAT, D-dimer, and PAI-1 were elevated in the acute phase of TBI in cases with poor outcome. Multivariate logistic regression analysis showed that D-dimer elevation from admission to 3 h after injury and PAI-1 elevation from 6 h to 1 day after injury were significant negative prognostic indicators. Post-TBI hypercoagulation, fibrinolysis, and fibrinolysis shutdown were activated consecutively. Hyperfibrinolysis immediately after injury and subsequent fibrinolysis shutdown were associated with poor outcome.
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Affiliation(s)
- Ryuta Nakae
- grid.416279.f0000 0004 0616 2203Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, 1-1-5, Sendagi, Bunkyo-Ku, Tokyo, 113-8603 Japan
| | - Yasuo Murai
- grid.416279.f0000 0004 0616 2203Department of Neurological Surgery, Nippon Medical School Hospital, 1-1-5, Sendagi, Bunkyo-Ku, Tokyo, 113-8603 Japan
| | - Takeshi Wada
- grid.39158.360000 0001 2173 7691Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Hokkaido University, N17W5, Kita-Ku, Sapporo-Shi, Hokkaido 060-8638 Japan
| | - Yu Fujiki
- Emergency and Critical Care Center, Kawaguchi Municipal Medical Center, 180, Nishiaraijuku, Kawaguchi-Shi, Saitama 333-0833 Japan
| | - Takahiro Kanaya
- grid.416279.f0000 0004 0616 2203Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, 1-1-5, Sendagi, Bunkyo-Ku, Tokyo, 113-8603 Japan
| | - Yasuhiro Takayama
- grid.416279.f0000 0004 0616 2203Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, 1-1-5, Sendagi, Bunkyo-Ku, Tokyo, 113-8603 Japan
| | - Go Suzuki
- Emergency and Critical Care Center, Kawaguchi Municipal Medical Center, 180, Nishiaraijuku, Kawaguchi-Shi, Saitama 333-0833 Japan
| | - Yasutaka Naoe
- Emergency and Critical Care Center, Kawaguchi Municipal Medical Center, 180, Nishiaraijuku, Kawaguchi-Shi, Saitama 333-0833 Japan
| | - Hiroyuki Yokota
- grid.412200.50000 0001 2228 003XGraduate School of Medical and Health Science, Nippon Sport Science University, 1221-1 Kamoshida-Cho, Aoba-Ku, Yokohama-Shi, Kanagawa 227-0033 Japan
| | - Shoji Yokobori
- grid.416279.f0000 0004 0616 2203Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, 1-1-5, Sendagi, Bunkyo-Ku, Tokyo, 113-8603 Japan
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22
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NAKAE R, MURAI Y, TAKAYAMA Y, NAMATAME K, MATSUMOTO Y, KANAYA T, FUJIKI Y, ONDA H, SUZUKI G, KANEKO J, ARAKI T, NAOE Y, SATO H, UNEMOTO K, MORITA A, YOKOTA H, YOKOBORI S. Neurointensive Care of Traumatic Brain Injury Patients Based on Coagulation and Fibrinolytic Parameter Monitoring. Neurol Med Chir (Tokyo) 2022; 62:535-541. [PMID: 36223950 PMCID: PMC9831625 DOI: 10.2176/jns-nmc.2022-0226] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Coagulopathy, a common complication of traumatic brain injury (TBI), is characterized by a hypercoagulable state developing immediately after injury, with hyperfibrinolysis and bleeding tendency peaking 3 h after injury, followed by fibrinolysis shutdown. Reflecting this timeframe, the coagulation factor fibrinogen is first consumed and then degraded after TBI, its concentration rapidly decreasing by 3 h post-TBI. The fibrinolytic marker D-dimer reaches its maximum concentration at the same time. Hyperfibrinolysis in the acute phase of TBI is associated with poor prognosis via hematoma expansion. In the acute phase, the coagulation and fibrinolysis parameters must be monitored to determine the treatment strategy. The combination of D-dimer plasma level at admission and the level of consciousness upon arrival at the hospital can be used to predict the patients who will "talk and deteriorate." Fibrinogen and D-dimer levels should determine case selection and the amount of fresh frozen plasma required for transfusion. Surgery around 3 h after injury, when fibrinolysis and bleeding diathesis peak, should be avoided if possible. In recent years, attempts have been made to estimate the time of injury from the time course of coagulation and fibrinolysis parameter levels, which has been particularly useful in some cases of pediatric abusive head trauma patients.
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Affiliation(s)
- Ryuta NAKAE
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Yasuo MURAI
- Department of Neurological Surgery, Nippon Medical School Hospital, Tokyo, Japan
| | - Yasuhiro TAKAYAMA
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Kaoru NAMATAME
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Yoshiyuki MATSUMOTO
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Takahiro KANAYA
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Yu FUJIKI
- Emergency and Critical Care Center, Kawaguchi Municipal Medical Center, Kawaguchi, Saitama, Japan
| | - Hidetaka ONDA
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Go SUZUKI
- Emergency and Critical Care Center, Kawaguchi Municipal Medical Center, Kawaguchi, Saitama, Japan
| | - Junya KANEKO
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Takashi ARAKI
- Department of Traumatology, Saitama Children's Medical Center, Saitama, Saitama, Japan
| | - Yasutaka NAOE
- Emergency and Critical Care Center, Kawaguchi Municipal Medical Center, Kawaguchi, Saitama, Japan
| | - Hidetaka SATO
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Kyoko UNEMOTO
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Akio MORITA
- Department of Neurological Surgery, Nippon Medical School Hospital, Tokyo, Japan
| | - Hiroyuki YOKOTA
- Graduate School of Medical and Health Science, Nippon Sport Science University, Yokohama, Kanagawa, Japan
| | - Shoji YOKOBORI
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
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Maroufi SF, Sohrabi H, Dabbagh Ohadi MA, Mohammadi E, Habibi Z. Neurosurgery in 21st-Century Wars in the Middle East: Narrative Review of Literature. World Neurosurg 2022; 166:184-190. [PMID: 35944854 DOI: 10.1016/j.wneu.2022.07.134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/26/2022] [Accepted: 07/27/2022] [Indexed: 12/15/2022]
Abstract
Military neurosurgery has played a crucial role in the development of neurosurgery over time. Much of this progress is due to war-related experiences. Owing to the number and severity of war injuries and the limitations caused by war, surgeons have had to examine different methods and design special protocols for patient management. Given that in recent decades most wars have taken place in the Middle East, many lessons can be learned by reviewing the experiences of neurosurgeons in these wars. Wars in Iraq, Syria, Afghanistan, Lebanon, and Yemen have been the largest and longest conflicts in the Middle East since the beginning of the 21st century, and a number of studies reported the experiences of surgeons in these wars. In this study, we reviewed the experience of military surgeons in managing war neurosurgical injuries in these areas within the last 2 decades.
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Affiliation(s)
- Seyed Farzad Maroufi
- Department of Pediatric Neurosurgery, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Hanye Sohrabi
- Department of Pediatric Neurosurgery, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Amin Dabbagh Ohadi
- Department of Pediatric Neurosurgery, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Esmaeil Mohammadi
- Department of Pediatric Neurosurgery, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Zohreh Habibi
- Department of Pediatric Neurosurgery, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran.
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Abstract
BACKGROUND Improvised explosive devices have resulted in a unique polytrauma injury pattern termed dismounted complex blast injury (DCBI), which is frequent in the modern military theater. Dismounted complex blast injury is characterized by extremity amputations, junctional vascular injury, and blast traumatic brain injury (bTBI). We developed a combat casualty relevant DCBI swine model, which combines hemorrhagic shock (HS) and tissue injury (TI) with a bTBI, to study interventions in this unique and devastating military injury pattern. METHODS A 50-kg male Yorkshire swine were randomized to the DCBI or SHAM group (instrumentation only). Those in the DCBI group were subjected to HS, TI, and bTBI. The blast injury was applied using a 55-psi shock tube wave. Tissue injury was created with bilateral open femur fractures. Hemorrhagic shock was induced by bleeding from femoral arteries to target pressure. A resuscitation protocol modified from the Tactical Combat Casualty Care guidelines simulated battlefield resuscitation for 240 minutes. RESULTS Eight swine underwent the DCBI model and five were allocated to the SHAM group. In the DCBI model the mean base excess achieved at the end of the HS shock was -8.57 ± 5.13 mmol·L -1 . A significant coagulopathy was detected in the DCBI model as measured by prothrombin time (15.8 seconds DCBI vs. 12.86 seconds SHAM; p = 0.02) and thromboelastography maximum amplitude (68.5 mm DCBI vs. 78.3 mm in SHAM; p = 0.0003). For the DCBI models, intracranial pressure (ICP) increased by a mean of 13 mm Hg, reaching a final ICP of 24 ± 7.7 mm Hg. CONCLUSION We created a reproducible large animal model to study the combined effects of severe HS, TI, and bTBI on coagulation and ICP in the setting of DCBI, with significant translational applications for the care of military warfighters. Within the 4-hour observational period, the swine developed a consistent coagulopathy with a concurrent brain injury evidenced by increasing ICP.
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Development and Verification of Prognostic Prediction Models for Patients with Brain Trauma Based on Coagulation Function Indexes. J Immunol Res 2022; 2022:3876805. [PMID: 35928635 PMCID: PMC9345690 DOI: 10.1155/2022/3876805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 06/27/2022] [Accepted: 07/09/2022] [Indexed: 11/17/2022] Open
Abstract
Objective To assess the effect of adding coagulation indices to the currently existing prognostic prediction models of traumatic brain injury (TBI) in the prediction of outcome. Methods A total of 210 TBI patients from 2017 to 2019 and 131 TBI patients in 2020 were selected for development and internal verification of the new model. The primary outcomes include death at 14 days and Glasgow Outcome Score (GOS) at 6 months. The performance of each model is evaluated by means of discrimination (area under the curve (AUC)), calibration (Hosmer-Lemeshow (H-L) goodness-of-fit test), and precision (Brier score). Results The IMPACT Core model showed better prediction ability than the CRASH Basic model. Adding one coagulation index at a time to the IMPACT Core model, the new combined models IMPACT Core+FIB and IMPACT Core+APTT are optimal for the 6-month unfavorable outcome and 6-month mortality, respectively (AUC, 0.830 and 0.878). The new models were built based on the regression coefficients of the models. Internal verification indicated that for the prediction of 6-month unfavorable outcome and 6-month mortality, both the IMPACT Core+FIB model and the IMPACT Core+APTT model show better discrimination (AUC, 0.823 vs. 0.818 and 0.853 vs. 0.837), better calibration (HL, p = 0.114 and p = 0.317) and higher precision (Brier score, 0.148 vs. 0.141 and 0.147 vs. 0.164), respectively, than the original models. Conclusion Our research shows that the combination of the traumatic brain injury prognostic models and coagulation indices can improve the 6-month outcome prediction of patients with TBI.
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Vlachos N, Lampros MG, Lianos GD, Voulgaris S, Alexiou GA. Blood biomarkers for predicting coagulopathy occurrence in patients with traumatic brain injury: a systematic review. Biomark Med 2022; 16:935-945. [PMID: 35833883 DOI: 10.2217/bmm-2022-0294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Purpose: The occurrence of coagulopathy in patients with traumatic brain injury (TBI) is related to severe complications. The authors performed the first systematic review to investigate whether biomarkers can predict the occurrence of hypocoagulopathy or progressive hemorrhagic injury in patients with TBI. Methods: The authors included studies that performed a receiver operating characteristics analysis for the biomarker and provided a clear value along with the respective sensitivity and specificity. Additionally, they attempted to classify each biomarker, taking into account its physiological role. Results: Twelve studies were included. All biomarkers were protein molecules, except in one study that examined the prognostic role of glucose. Copeptin had the highest sensitivity, and S100A12 had the highest specificity in predicting coagulopathy, while IL-33 had the highest sensitivity and GALECTIN-3 had the highest specificity in predicting progressive hemorrhagic injury. Conclusion: The study of the role of biomarkers in predicting the occurrence of coagulopathy in patients with TBI remains in its infancy.
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Affiliation(s)
- Nikolaos Vlachos
- Department of Neurosurgery, University Hospital of Ioannina, Ioannina, 45500, Greece
| | - Marios G Lampros
- Department of Neurosurgery, University Hospital of Ioannina, Ioannina, 45500, Greece
| | - Georgios D Lianos
- Department of Surgery, University of Ioannina, Ioannina, 45500, Greece
| | - Spyridon Voulgaris
- Department of Neurosurgery, University Hospital of Ioannina, Ioannina, 45500, Greece
| | - George A Alexiou
- Department of Neurosurgery, University Hospital of Ioannina, Ioannina, 45500, Greece
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27
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Posti JP, Ruuskanen JO, Sipilä JOT, Luoto TM, Rautava P, Kytö V. Effect of Oral Anticoagulation and Adenosine Diphosphate Inhibitor Therapies on Short-term Outcome of Traumatic Brain Injury. Neurology 2022; 99:e1122-e1130. [PMID: 35764401 DOI: 10.1212/wnl.0000000000200834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 04/22/2022] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Usage of oral anticoagulants (OAC) or adenosine diphosphate inhibitors (ADPi) is known to increase the risk of bleeding. We aimed to investigate the impact of OAC and ADPi therapies on short-term outcomes after traumatic brain injury (TBI). METHODS All adult patients hospitalized for TBI in Finland during 2005-2018 were retrospectively studied using a combination of national registries. Usage of pharmacy-purchased OACs and ADPis at the time of TBI was analyzed with the pill-counting method (Social Insurance Institution of Finland). The primary outcome was 30-day case-fatality (Finnish Cause of Death Registry). The secondary outcomes were acute neurosurgical operation (ANO) and admission duration (Finnish Care Register for Health Care). Baseline characteristics were adjusted with multivariable regression including age, sex, comorbidities, skull or facial fracture, OAC/ADPi treatment, initial admission location, and the year of TBI admission. RESULTS The study population included 57,056 persons (mean age 66 years) of whom 0.9% used direct oral anticoagulants (DOAC), 7.1% Vitamin K antagonists (VKA), and 2.3% ADPis. Patients with VKAs had higher case-fatality than patients without OAC (15.4% vs. 7.1%; adjHR 1.35, CI 1.23-1.48; p<0.0001). Case-fatality was lower with DOACs (8.4%) than with VKAs (adjHR 0.62, CI 0.44-0.87; p=0.005) and was not different from patients without OACs (adjHR 0.93, CI 0.69-1.26; p=0.634). VKA usage was associated with higher neurosurgical operation rate compared to non-OAC patients (9.1% vs. 8.3%; adjOR 1.33, CI 1.17-1.52; p<0.0001). There was no difference in operation rate between DOAC and VKA. ADPi was not associated with case-fatality or operation rate in the adjusted analyses. VKAs and DOACs were not associated with longer admission length compared with the non-OAC group, whereas the admissions were longer in the ADPi group compared with the non-ADPi group. CONCLUSION Preinjury use of VKA is associated with increases in short-term mortality and in need for ANOs after TBI. DOACs are associated with lower fatality than VKAs after TBI. ADPis were not independently associated with the outcomes studied. These results point to relative safety of DOACs or ADPis in patients at risk of head trauma and encourage to choose DOACs when oral anticoagulation is required. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that among adults with TBI, mortality was significantly increased in those using VKAs but not in those using DOACs or ADPis.
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Affiliation(s)
- Jussi P Posti
- Neurocenter, Department of Neurosurgery and Turku Brain Injury Center, Turku University Hospital and University of Turku, Finland
| | - Jori O Ruuskanen
- Neurocenter, Department of Neurology, Turku University Hospital and University of Turku, Finland
| | - Jussi O T Sipilä
- Clinical neurosciences, University of Turku, Turku, Finland; Department of Neurology, Siun sote, North Karelia Central Hospital, Joensuu, Finland
| | - Teemu M Luoto
- Department of Neurosurgery, Tampere University Hospital and Tampere University, Tampere, Finland
| | - Päivi Rautava
- Clinical Research Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Ville Kytö
- Heart Centre and Center for Population Health Research, Turku University Hospital and University of Turku, Turku, Finland.,Research Center of Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland.,Administrative Center, Hospital District of Southwest Finland, Turku, Finland.,Department of Public Health, Faculty of Medicine, University of Helsinki, Helsinki, Finland
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28
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Shulkosky MM, Han EJ, Wahl WL, Hecht JP. Effects of Early Chemoprophylaxis in Traumatic Brain Injury and Risk of Venous Thromboembolism. Am Surg 2022:31348221102604. [PMID: 35575013 DOI: 10.1177/00031348221102604] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The optimal timing to initiate venous thromboembolism (VTE) prophylaxis in patients with a traumatic brain injury (TBI) is still unknown. We designed a study to determine the effect that timing of initiation of VTE prophylaxis has on VTE rates in TBI patients. METHODS Patient records were obtained from 32 level 1 and 2 trauma centers in the Michigan Trauma Quality Improvement Program from 2008 to 2018. Overall, 5589 patients with a TBI were included and split into cohorts based on VTE prophylaxis initiation time. Outcomes included rate of VTE, mortality, and serious in-hospital complications. RESULTS There were nine patients (1.3%) in the <24 hour group with a VTE as compared to 36 (2.6%) in the 24-48 hour group, 51 (4.1%) in the 48-72 hour group, and 181 (8.1%) in the >72 hour group (P < .001). The adjusted odds of VTE were significantly greater in patients initiated within 48-72 hours (AOR 2.861, 95% CI 1.271-6.439) and >72 hours (AOR 3.963, 95% CI 1.824-8.612) compared to <24 hours. Patients that received VTE prophylaxis within 24 hours had similar rates of serious in-hospital complication as patients initiated within 24-48 hours (AOR .956, 95% CI .637-1.434) and 48-72 hour (AOR 1.132, 95% CI .757-1.692) but less than the >72 hour group (AOR 1.662, 95% CI 1.154-2.393) groups. DISCUSSION Patients initiated on VTE prophylaxis within 48 hours of presentation had lower incidence of VTE without a significant increase in serious complications.
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Affiliation(s)
- Megan M Shulkosky
- Department of Pharmacy, 2569Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Emily J Han
- Department of Pharmacy, 21614University of Michigan, Ann Arbor, MI, USA
| | - Wendy L Wahl
- Department of Surgery, 12306The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jason P Hecht
- Department of Pharmacy, 159837St. Joseph Mercy Hospital, Ann Arbor, MI, USA
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29
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Current Clinical Trials in Traumatic Brain Injury. Brain Sci 2022; 12:brainsci12050527. [PMID: 35624914 PMCID: PMC9138587 DOI: 10.3390/brainsci12050527] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/13/2022] [Accepted: 04/19/2022] [Indexed: 12/10/2022] Open
Abstract
Traumatic brain injury (TBI) is one of the leading causes of morbidity, disability and mortality across all age groups globally. Currently, only palliative treatments exist, but these are suboptimal and do little to combat the progressive damage to the brain that occurs after a TBI. However, multiple experimental treatments are currently available that target the primary and secondary biochemical and cellular changes that occur after a TBI. Some of these drugs have progressed to clinical trials and are currently being evaluated for their therapeutic benefits in TBI patients. The aim of this study was to identify which drugs are currently being evaluated in clinical trials for TBI. A search of ClinicalTrials.gov was performed on 3 December 2021 and all clinical trials that mentioned “TBI” OR “traumatic brain injury” AND “drug” were searched, revealing 362 registered trials. Of the trials, 46 were excluded due to the drug not being mentioned, leaving 138 that were completed and 116 that were withdrawn. Although the studies included 267,298 TBI patients, the average number of patients per study was 865 with a range of 5–200,000. Of the completed studies, 125 different drugs were tested in TBI patients but only 7 drugs were used in more than three studies, including amantadine, botulinum toxin A and tranexamic acid (TXA). However, previous clinical studies using these seven drugs showed variable results. The current study concludes that clinical trials in TBI have to be carefully conducted so as to reduce variability across studies, since the severity of TBI and timing of therapeutic interventions were key aspects of trial success.
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XGBoost machine learning algorism performed better than regression models in predicting mortality of moderate to severe traumatic brain injury. World Neurosurg 2022; 163:e617-e622. [PMID: 35430400 DOI: 10.1016/j.wneu.2022.04.044] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 04/08/2022] [Accepted: 04/09/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Traumatic brain injury (TBI) brings severe mortality and morbidity risk to patients. Predicting outcome of these patients is necessary for physicians to make suitable treatments to improve prognosis. The aim of this study is to develop a mortality prediction approach using the XGBoost (extreme gradient boosting) in moderate to severe TBI. METHODS 368 patients hospitalized in West China hospital for TBI with GCS below 13 were identified. To construct XGBoost prediction approach, patients were divided into training set and test set with ratio of 7:3. Logistic regression prediction model was also constructed and compared with XGBoost model. Area under the receiver operating characteristic curve (AUC), accuracy, sensitivity and specificity were calculated to compare the prognostic value between XGBoost and logistic regression. RESULTS 205 patients suffered poor outcome with mortality of 55.7%. Non-survivors had lower Glasgow Coma Scale (GCS) (5 vs 7, p<0.001) and higher Injury Severit Score (ISS) than survivors (25 vs 16, p<0.001). Platelet (p<0.001), albumin (p<0.001), hemoglobin (p<0.001) were significantly lower in non-survivors while glucose (p<0.001) and prothrombin time (PT) (p<0.001)was significantly higher in non-survivors. Among the XGBoost approach, GCS, PT and glucose had the most significant feature importance. The AUC (0.955 vs 0.805) and accuracy (0.955 vs 0.70) of XGBoost were both higher than logistic regression. CONCLUSION Predicting mortality of moderate to severe TBI patients using XGBoost algorism is more effective and precise than logistic regression. The XGBoost prediction approach is beneficial for physicians to evaluate TBI patients at high risk of poor outcome.
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31
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TRAUMATIC BRAIN INJURY PROVOKES LOW FIBRINOLYTIC ACTIVITY IN SEVERELY INJURED PATIENTS. J Trauma Acute Care Surg 2022; 93:8-12. [PMID: 35170585 DOI: 10.1097/ta.0000000000003559] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) in combination with shock has been associated with hypocoagulability. However, recent data suggest that TBI itself can promote a systemic procoagulant state via the release of brain-derived extracellular vesicles. The objective of our study was to identify if TBI was associated with differences in thrombelastography (TEG) indices when controlling for other variables associated with coagulopathy following trauma. We hypothesized that TBI is independently associated with a less coagulopathic state. METHODS Prospective study including all highest-level trauma activations at an urban level 1 trauma center, from 2014-2020. TBI was defined as AIS Head ≥3. Blood samples were drawn at ED admission. Linear regression was used to assess the role of independent predictors on TIC. Models adjusted for ISS, shock (defined as ED SBP < 70, or ED SBP < 90 and ED HR > 108, or first hospital base deficit ≥10), and prehospital GCS. RESULTS Of the 1,023 patients included, 291 (28%) suffered a TBI. TBI patients more often were female (26% vs. 19%, p = 0.01), had blunt trauma (83% vs. 43%, p < 0.0001), shock (33% vs. 25%, p = 0.009), and higher median ISS (29 vs. 10, p < 0.0001). Fibrinolysis shutdown (25% vs. 18%) was more common in the TBI group (p < 0.0001). When controlled for the confounding effects of ISS and shock, the presence of TBI independently decreases LY30 (Beta estimate: - 0.16 ± 0.06, p = 0.004). This effect of TBI on LY30 persisted when controlling for sex and mechanism of injury in addition to ISS and shock (Beta estimate: -0.13 ± 0.06, p = 0.022). CONCLUSIONS TBI is associated with lower LY30 independent of shock, tissue injury, sex, and mechanism of injury. These findings suggest a propensity toward a less coagulopathic state in patients with TBI, possibly due to fibrinolysis shutdown. Tranexamic acid has been reported to improve outcomes following TBI. Our data suggest the mechanism may be independent of changes in fibrinolysis. LEVEL OF EVIDENCE Level III, Prognostic and Epidemiological.
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32
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Labbadia R, Diomedi Camassei F, Antonucci L, Guzzo I, Onetti Muda A, Spada M, Dello Strologo L. Reversible glomerular damage in disseminated intravascular coagulation. Pediatr Transplant 2022; 26:e14147. [PMID: 34585476 DOI: 10.1111/petr.14147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/01/2021] [Accepted: 09/03/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Brain death secondary to traumatic brain injury is one of the main sources of organs for transplantation but it can be associated with disseminated intravascular coagulation, which has been considered a relative contraindication for kidney donation. METHODS We describe two successful pediatric cases of kidney transplantation from a single donor with disseminated intravascular coagulation. RESULTS A 17-year-old male donor died from head injury and both kidneys were offered to our center. Within 24 h, donor's Hb and platelets dropped to 8.3 g/dl and 32 000/mcl, respectively, serum creatinine reached 2.01 mg/dl, and urinalysis showed proteinuria (300 mg/dl). Pre-implant biopsy showed massive occlusion of glomerular capillaries by fibrin thrombi containing fragmented red blood cells and inflammatory cells, and acute tubular damage. Arterioles and small arteries were spared. A diagnosis of DIC was made. The kidneys were transplanted in a 16-year-old girl and a 13-year-old boy. Slow recovery of graft function was observed in both recipients. On post-operative day 3, platelets dropped to a minimum value of 66 000 and 86 000/mcl, respectively. Diuresis was always present. On day 4, platelets started to rise. Six months later, both recipients attained normal renal function. A six-month protocol biopsy showed no microthrombi or other signs of disseminated intravascular coagulation. CONCLUSIONS Despite the limited data available in literature, the outcome of these two cases is positive. Thus, pre-implant kidney biopsy, even if it reveals massive thrombotic occlusion of glomerular capillaries compatible with diagnosis of disseminated intravascular coagulation, should not be considered an absolute contraindication to transplantation.
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Affiliation(s)
- Raffaella Labbadia
- Renal Transplant Unit, Bambino Gesù Children's Research Hospital IRCCS, Rome, Italy
| | | | - Luca Antonucci
- Renal Transplant Unit, Bambino Gesù Children's Research Hospital IRCCS, Rome, Italy
| | - Isabella Guzzo
- Renal Transplant Unit, Bambino Gesù Children's Research Hospital IRCCS, Rome, Italy
| | | | - Marco Spada
- Hepatobiliopancreatic Surgery, Liver and Kidney Transplantation, Bambino Gesù Children's Research Hospital IRCCS, Rome, Italy
| | - Luca Dello Strologo
- Renal Transplant Unit, Bambino Gesù Children's Research Hospital IRCCS, Rome, Italy
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Chen T, Chen S, Wu Y, Chen Y, Wang L, Liu J. A predictive model for postoperative progressive haemorrhagic injury in traumatic brain injuries. BMC Neurol 2022; 22:16. [PMID: 34996389 PMCID: PMC8740436 DOI: 10.1186/s12883-021-02541-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 12/13/2021] [Indexed: 12/01/2022] Open
Abstract
Background Progressive haemorrhagic injury after surgery in patients with traumatic brain injury often results in poor patient outcomes. This study aimed to develop and validate a practical predictive tool that can reliably estimate the risk of postoperative progressive haemorrhagic injury (PHI) in patients with traumatic brain injury (TBI). Methods Data from 645 patients who underwent surgery for TBI between March 2018 and December 2020 were collected. The outcome was postoperative intracranial PHI, which was assessed on postoperative computed tomography. The least absolute shrinkage and selection operator (LASSO) regression model, univariate analysis, and Delphi method were applied to select the most relevant prognostic predictors. We combined conventional coagulation test (CCT) data, thromboelastography (TEG) variables, and several predictors to develop a predictive model using binary logistic regression and then presented the results as a nomogram. The predictive performance of the model was assessed with calibration and discrimination. Internal validation was assessed. Results The signature, which consisted of 11 selected features, was significantly associated with intracranial PHI (p < 0.05, for both primary and validation cohorts). Predictors in the prediction nomogram included age, S-pressure, D-pressure, pulse, temperature, reaction time, PLT, prothrombin time, activated partial thromboplastin time, FIB, and kinetics values. The model showed good discrimination, with an area under the curve of 0.8694 (95% CI, 0.8083–0.9304), and good calibration. Conclusion This model is based on a nomogram incorporating CCT and TEG variables, which can be conveniently derived at hospital admission. It allows determination of this individual risk for postoperative intracranial PHI and will facilitate a timely intervention to improve outcomes.
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Affiliation(s)
- Tiange Chen
- Department of Neurosurgery, Xiangya Hospital, Central South University, No.87 Xiangya Road, Changsha, Hunan, 410008, People's Republic of China
| | - Siming Chen
- Department of Neurosurgery, Xiangya Hospital, Central South University, No.87 Xiangya Road, Changsha, Hunan, 410008, People's Republic of China
| | - Yun Wu
- Department of Neurosurgery, Xiangya Hospital, Central South University, No.87 Xiangya Road, Changsha, Hunan, 410008, People's Republic of China
| | - Yilei Chen
- Department of Neurosurgery, Xiangya Hospital, Central South University, No.87 Xiangya Road, Changsha, Hunan, 410008, People's Republic of China
| | - Lei Wang
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Jinfang Liu
- Department of Neurosurgery, Xiangya Hospital, Central South University, No.87 Xiangya Road, Changsha, Hunan, 410008, People's Republic of China.
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NAKAE R, MURAI Y, MORITA A, YOKOBORI S. Coagulopathy and Traumatic Brain Injury: Overview of New Diagnostic and Therapeutic Strategies. Neurol Med Chir (Tokyo) 2022; 62:261-269. [PMID: 35466118 PMCID: PMC9259082 DOI: 10.2176/jns-nmc.2022-0018] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Coagulopathy is a common sequela of traumatic brain injury. Consumptive coagulopathy and secondary hyperfibrinolysis are associated with hypercoagulability. In addition, fibrinolytic pathways are hyperactivated as a result of vascular endothelial cell damage in the injured brain. Coagulation and fibrinolytic parameters change dynamically to reflect these pathologies. Fibrinogen is consumed and degraded after injury, with fibrinogen concentrations at their lowest 3-6 h after injury. Hypercoagulability causes increased fibrinolytic activity, and plasma levels of D-dimer increase immediately after traumatic brain injury, reaching a maximum at 3 h. Owing to disseminated intravascular coagulation in the presence of fibrinolysis, the bleeding tendency is highest within the first 3 h after injury, and often a condition called “talk and deteriorate” occurs. In neurointensive care, it is necessary to measure coagulation and fibrinolytic parameters such as fibrinogen and D-dimer routinely to predict and prevent the development of coagulopathy and its negative outcomes. Currently, the only evidence-based treatment for traumatic brain injury with coagulopathy is tranexamic acid in the subset of patients with mild-to-moderate traumatic brain injury. Coagulation and fibrinolytic parameters should be closely monitored, and treatment should be considered on a patient-by-patient basis.
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Affiliation(s)
- Ryuta NAKAE
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital
| | - Yasuo MURAI
- Department of Neurological Surgery, Nippon Medical School Hospital
| | - Akio MORITA
- Department of Neurological Surgery, Nippon Medical School Hospital
| | - Shoji YOKOBORI
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital
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Chen Y, Tian J, Chi B, Zhang S, Wei L, Wang S. Factors Associated with the Development of Coagulopathy after Open Traumatic Brain Injury. J Clin Med 2021; 11:jcm11010185. [PMID: 35011926 PMCID: PMC8745860 DOI: 10.3390/jcm11010185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 12/23/2021] [Accepted: 12/24/2021] [Indexed: 11/25/2022] Open
Abstract
Background: The incidence of coagulopathy after open traumatic brain injury (TBI) is high. Coagulopathy can aggravate intracranial hemorrhage and further increase morbidity and mortality. The purpose of this study was to determine the clinical characteristics of coagulopathy after open TBI and its relationship with the prognosis. Methods: This study retrospectively evaluated patients with isolated open TBI from December 2018 to December 2020. Coagulopathy was defined as international normalized ratio (INR) > 1.2, activated thromboplastin time (APTT) > 35 s, or platelet count <100,000/μL. We compared the relationship between the clinical, radiological, and laboratory parameters of patients with and without coagulopathy, and the outcome at discharge. Logistic regression analysis was used to evaluate the risk factors associated with coagulopathy. We then compared the effects of treatment with and without TXA in open TBI patients with coagulopathy. Results: A total of 132 patients were included in the study; 46 patients developed coagulopathy. Patients with coagulopathy had significantly lower platelet levels (170.5 × 109/L vs. 216.5 × 109/L, p < 0.001), and significantly higher INR (1.14 vs. 1.02, p < 0.001) and APTT (30.5 s vs. 24.5 s, p < 0.001) compared to those with no coagulopathy. A Low Glasgow Coma Scale (GCS) score, high neutrophil/lymphocyte ratio (NLR), low platelet/lymphocyte ratio (PLR), and hyperglycemia at admission were significantly associated with the occurrence of coagulopathy. Conclusions: Coagulopathy often occurs after open TBI. Patients with a low GCS score, high NLR, low PLR, and hyperglycemia at admission are at greater risk of coagulopathy, and therefore of poor prognosis. The efficacy of TXA in open TBI patients with coagulopathy is unclear. In addition, these findings demonstrate that PLR may be a novel indicator for predicting coagulopathy.
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36
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Yang F, Peng C, Peng L, Wang J, Li Y, Li W. A Machine Learning Approach for the Prediction of Traumatic Brain Injury Induced Coagulopathy. Front Med (Lausanne) 2021; 8:792689. [PMID: 34957161 PMCID: PMC8703138 DOI: 10.3389/fmed.2021.792689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 11/08/2021] [Indexed: 12/03/2022] Open
Abstract
Background: Traumatic brain injury-induced coagulopathy (TBI-IC), is a disease with poor prognosis and increased mortality rate. Objectives: Our study aimed to identify predictors as well as develop machine learning (ML) models to predict the risk of coagulopathy in this population. Methods: ML models were developed and validated based on two public databases named Medical Information Mart for Intensive Care (MIMIC)-IV and the eICU Collaborative Research Database (eICU-CRD). Candidate predictors, including demographics, family history, comorbidities, vital signs, laboratory findings, injury type, therapy strategy and scoring system were included. Models were compared on area under the curve (AUC), accuracy, sensitivity, specificity, positive and negative predictive values, and decision curve analysis (DCA) curve. Results: Of 999 patients in MIMIC-IV included in the final cohort, a total of 493 (49.35%) patients developed coagulopathy following TBI. Recursive feature elimination (RFE) selected 15 variables, including international normalized ratio (INR), prothrombin time (PT), sepsis related organ failure assessment (SOFA), activated partial thromboplastin time (APTT), platelet (PLT), hematocrit (HCT), red blood cell (RBC), hemoglobin (HGB), blood urea nitrogen (BUN), red blood cell volume distribution width (RDW), creatinine (CRE), congestive heart failure, myocardial infarction, sodium, and blood transfusion. The external validation in eICU-CRD demonstrated that adapting boosting (Ada) model had the highest AUC of 0.924 (95% CI: 0.902–0.943). Furthermore, in the DCA curve, the Ada model and the extreme Gradient Boosting (XGB) model had relatively higher net benefits (ie, the correct classification of coagulopathy considering a trade-off between false- negatives and false-positives)—over other models across a range of threshold probability values. Conclusions: The ML models, as indicated by our study, can be used to predict the incidence of TBI-IC in the intensive care unit (ICU).
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Affiliation(s)
- Fan Yang
- Department of Plastic Surgery and Burns, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Chi Peng
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Liwei Peng
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Jian Wang
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Yuejun Li
- Department of Plastic Surgery and Burns, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Weixin Li
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
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Dong X, Liu W, Shen Y, Houck K, Yang M, Zhou Y, Zhao Z, Wu X, Blevins T, Koehne AL, Wun TC, Fu X, Li M, Zhang J, Dong JF. Anticoagulation targeting membrane-bound anionic phospholipids improves outcomes of traumatic brain injury in mice. Blood 2021; 138:2714-2726. [PMID: 34610086 PMCID: PMC8703367 DOI: 10.1182/blood.2021011310] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 09/20/2021] [Indexed: 12/25/2022] Open
Abstract
Severe traumatic brain injury (TBI) often causes an acute systemic hypercoagulable state that rapidly develops into consumptive coagulopathy. We have recently demonstrated that TBI-induced coagulopathy (TBI-IC) is initiated and disseminated by brain-derived extracellular vesicles (BDEVs) and propagated by extracellular vesicles (EVs) from endothelial cells and platelets. Here, we present results from a study designed to test the hypothesis that anticoagulation targeting anionic phospholipid-expressing EVs prevents TBI-IC and improves the outcomes of mice subjected to severe TBI. We evaluated the effects of a fusion protein (ANV-6L15) for improving the outcomes of TBI in mouse models combined with in vitro experiments. ANV-6L15 combines the phosphatidylserine (PS)-binding annexin V (ANV) with a peptide anticoagulant modified to preferentially target extrinsic coagulation. We found that ANV-6L15 reduced intracranial hematoma by 70.2%, improved neurological function, and reduced death by 56.8% in mice subjected to fluid percussion injury at 1.9 atm. It protected the TBI mice by preventing vascular leakage, tissue edema, and the TBI-induced hypercoagulable state. We further showed that the extrinsic tenase complex was formed on the surfaces of circulating EVs, with the highest level found on BDEVs. The phospholipidomic analysis detected the highest levels of PS on BDEVs, as compared with EVs from endothelial cells and platelets (79.1, 15.2, and 3.5 nM/mg of protein, respectively). These findings demonstrate that TBI-IC results from a trauma-induced hypercoagulable state and may be treated by anticoagulation targeting on the anionic phospholipid-expressing membrane of EVs from the brain and other cells.
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Affiliation(s)
- Xinlong Dong
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Bloodworks Research Institute, Seattle, WA
| | - Wei Liu
- Institute of Pathology, School of Medical Sciences and Gansu Provincial Key Laboratory of Preclinical Study for New Drug Development, Lanzhou University, Lanzhou, China
| | - Yu Shen
- Bloodworks Research Institute, Seattle, WA
| | | | - Mengchen Yang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Yuan Zhou
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Zilong Zhao
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Xiaoping Wu
- Department of Pathology, University of Washington School of Medicine, Seattle, WA
| | - Teri Blevins
- Department of Comparative Medicine, Fred Hutch Cancer Center, Seattle, WA
| | - Amanda L Koehne
- Department of Comparative Medicine, Fred Hutch Cancer Center, Seattle, WA
| | | | - Xiaoyun Fu
- Bloodworks Research Institute, Seattle, WA
- Division of Hematology, Department of Medicine, University of Washington, School of Medicine, Seattle, WA
| | - Min Li
- Institute of Pathology, School of Medical Sciences and Gansu Provincial Key Laboratory of Preclinical Study for New Drug Development, Lanzhou University, Lanzhou, China
| | - Jianning Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Jing-Fei Dong
- Bloodworks Research Institute, Seattle, WA
- Division of Hematology, Department of Medicine, University of Washington, School of Medicine, Seattle, WA
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Wada T, Shiraishi A, Gando S, Yamakawa K, Fujishima S, Saitoh D, Kushimoto S, Ogura H, Abe T, Mayumi T, Sasaki J, Kotani J, Takeyama N, Tsuruta R, Takuma K, Shiraishi SI, Shiino Y, Nakada TA, Okamoto K, Sakamoto Y, Hagiwara A, Fujimi S, Umemura Y, Otomo Y. Pathophysiology of Coagulopathy Induced by Traumatic Brain Injury Is Identical to That of Disseminated Intravascular Coagulation With Hyperfibrinolysis. Front Med (Lausanne) 2021; 8:767637. [PMID: 34869481 PMCID: PMC8634586 DOI: 10.3389/fmed.2021.767637] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 10/20/2021] [Indexed: 01/07/2023] Open
Abstract
Background: Traumatic brain injury (TBI)-associated coagulopathy is a widely recognized risk factor for secondary brain damage and contributes to poor clinical outcomes. Various theories, including disseminated intravascular coagulation (DIC), have been proposed regarding its pathomechanisms; no consensus has been reached thus far. This study aimed to elucidate the pathophysiology of TBI-induced coagulopathy by comparing coagulofibrinolytic changes in isolated TBI (iTBI) to those in non-TBI, to determine the associated factors, and identify the clinical significance of DIC diagnosis in patients with iTBI. Methods: This secondary multicenter, prospective study assessed patients with severe trauma. iTBI was defined as Abbreviated Injury Scale (AIS) scores ≥4 in the head and neck, and ≤2 in other body parts. Non-TBI was defined as AIS scores ≥4 in single body parts other than the head and neck, and the absence of AIS scores ≥3 in any other trauma-affected parts. Specific biomarkers for thrombin and plasmin generation, anticoagulation, and fibrinolysis inhibition were measured at the presentation to the emergency department (0 h) and 3 h after arrival. Results: We analyzed 34 iTBI and 40 non-TBI patients. Baseline characteristics, transfusion requirements and in-hospital mortality did not significantly differ between groups. The changes in coagulation/fibrinolysis-related biomarkers were similar. Lactate levels in the iTBI group positively correlated with DIC scores (rho = −0.441, p = 0.017), but not with blood pressure (rho = −0.098, p = 0.614). Multiple logistic regression analyses revealed that the injury severity score was an independent predictor of DIC development in patients with iTBI (odds ratio = 1.237, p = 0.018). Patients with iTBI were further subdivided into two groups: DIC (n = 15) and non-DIC (n = 19) groups. Marked thrombin and plasmin generation were observed in all patients with iTBI, especially those with DIC. Patients with iTBI and DIC had higher requirements for massive transfusion and emergency surgery, and higher in-hospital mortality than those without DIC. Furthermore, DIC development significantly correlated with poor hospital survival; DIC scores at 0 h were predictive of in-hospital mortality. Conclusions: Coagulofibrinolytic changes in iTBI and non-TBI patients were identical, and consistent with the pathophysiology of DIC. DIC diagnosis in the early phase of TBI is key in predicting the outcomes of severe TBI.
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Affiliation(s)
- Takeshi Wada
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | | | - Satoshi Gando
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan.,Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
| | - Kazuma Yamakawa
- Department of Emergency Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Seitaro Fujishima
- Center for General Medicine Education, Keio University School of Medicine, Tokyo, Japan
| | - Daizoh Saitoh
- Division of Traumatology, Research Institute, National Defense Medical College, Tokorozawa, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Toshikazu Abe
- Department of Emergency and Critical Care Medicine, Tsukuba Memorial Hospital, Tsukuba, Japan.,Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Joji Kotani
- Division of Disaster and Emergency Medicine, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Naoshi Takeyama
- Advanced Critical Care Center, Aichi Medical University Hospital, Nagakute, Japan
| | - Ryosuke Tsuruta
- Advanced Medical Emergency & Critical Care Center, Yamaguchi University Hospital, Ube, Japan
| | - Kiyotsugu Takuma
- Emergency & Critical Care Center, Kawasaki Municipal Hospital, Kawasaki, Japan
| | | | - Yasukazu Shiino
- Department of Acute Medicine, Kawasaki Medical School, Kurashiki, Japan
| | - Taka-Aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Kohji Okamoto
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Kitakyushu, Japan
| | - Yuichiro Sakamoto
- Emergency and Critical Care Medicine, Saga University Hospital, Saga, Japan
| | - Akiyoshi Hagiwara
- Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan
| | - Satoshi Fujimi
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Sumiyoshi, Japan
| | - Yutaka Umemura
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Sumiyoshi, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
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Maegele M. Coagulopathy and Progression of Intracranial Hemorrhage in Traumatic Brain Injury: Mechanisms, Impact, and Therapeutic Considerations. Neurosurgery 2021; 89:954-966. [PMID: 34676410 DOI: 10.1093/neuros/nyab358] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 07/31/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Traumatic brain injury (TBI) remains one of the most challenging health and socioeconomic problems of our times. Clinical courses may be complicated by hemostatic abnormalities either pre-existing or developing with TBI. OBJECTIVE To review frequencies, patterns, mechanisms, novel approaches to diagnostics, treatment, and outcomes of hemorrhagic progression and coagulopathy after TBI. METHODS Selective review of the literature in the databases Medline (PubMed) and Cochrane Reviews using different combinations of the relevant search terms was conducted. RESULTS Of the patients, 20% with isolated TBI display laboratory coagulopathy upon hospital admission with profound effect on morbidity and mortality. Preinjury use of antithrombotic agents may be associated with higher rates of hemorrhagic progression and delayed traumatic intracranial hemorrhage. Further testing may display various changes affecting platelet function/numbers, pro- and/or anticoagulant factors, and fibrinolysis as well as interactions between brain tissues, vascular endothelium, mechanisms of inflammation, and blood flow dynamics. The nature of hemostatic disruptions after TBI remains elusive but current evidence suggests the presence of both a hyper- and hypocoagulable state with possible overlap and lack of distinction between phases and states. More "global" hemostatic assays, eg, viscoelastic and thrombin generation tests, may provide more detailed and timely information on the overall hemostatic potential thereby allowing early "goal-directed" therapies. CONCLUSION Whether timely and targeted management of hemostatic abnormalities after TBI can protect against secondary brain injury and thereby improve outcomes remains elusive. Innovative technologies for diagnostics and monitoring offer windows of opportunities for precision medicine approaches to managing TBI.
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Affiliation(s)
- Marc Maegele
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Center, University Witten/Herdecke, Cologne, Germany.,Institute for Research in Operative Medicine, University Witten/Herdecke, Cologne, Germany.,Treatment Center for Traumatic Injuries, Third Affiliated Hospital of Southern Medical University, Guangzhou, China
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40
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Zhang CN, Li FJ, Zhao ZL, Zhang JN. The role of extracellular vesicles in traumatic brain injury-induced acute lung injury. Am J Physiol Lung Cell Mol Physiol 2021; 321:L885-L891. [PMID: 34549593 DOI: 10.1152/ajplung.00023.2021] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Acute lung injury (ALI), a common complication after traumatic brain injury (TBI), can evolve into acute respiratory distress syndrome (ARDS) and has a mortality rate of 30%-40%. Secondary ALI after TBI exhibits the following typical pathological features: infiltration of neutrophils into the alveolar and interstitial space, alveolar septal thickening, alveolar edema, and hemorrhage. Extracellular vesicles (EVs) were recently identified as key mediators in TBI-induced ALI. Due to their small size and lipid bilayer, they can pass through the disrupted blood-brain barrier (BBB) into the peripheral circulation and deliver their contents, such as genetic material and proteins, to target cells through processes such as fusion, receptor-mediated interactions, and uptake. Acting as messengers, EVs contribute to mediating brain-lung cross talk after TBI. In this review, we aim to summarize the mechanism of EVs in TBI-induced ALI, which may provide new ideas for clinical treatment.
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Affiliation(s)
- Chao-Nan Zhang
- Department of Neurosurgery, Tianjin Institute of Neurology, grid.412645.0Tianjin Medical University General Hospital, Tianjin, China
| | - Fan-Jian Li
- Department of Neurosurgery, Tianjin Institute of Neurology, grid.412645.0Tianjin Medical University General Hospital, Tianjin, China
| | - Zi-Long Zhao
- Department of Neurosurgery, Tianjin Institute of Neurology, grid.412645.0Tianjin Medical University General Hospital, Tianjin, China
| | - Jian-Ning Zhang
- Department of Neurosurgery, Tianjin Institute of Neurology, grid.412645.0Tianjin Medical University General Hospital, Tianjin, China
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Nakae R, Fujiki Y, Takayama Y, Kanaya T, Igarashi Y, Suzuki G, Naoe Y, Yokobori S. Time course of coagulation and fibrinolytic parameters in pediatric traumatic brain injury. J Neurosurg Pediatr 2021; 28:526-532. [PMID: 34416724 DOI: 10.3171/2021.5.peds21125] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 05/03/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Coagulopathy is a well-recognized risk factor for poor outcomes in patients with traumatic brain injury (TBI). Differences in the time courses of coagulation and fibrinolytic parameters between pediatric and adult patients with TBI have not been defined. METHODS Patients with TBI and an Abbreviated Injury Scale of the head score ≥ 3, in whom the prothrombin time (PT)-international normalized ratio (INR), activated partial thromboplastin time (APTT), fibrinogen concentration, and plasma D-dimer levels were measured on arrival and at 3, 6, and 12 hours after injury, were retrospectively analyzed. Propensity score-matched analyses were performed to adjust baseline characteristics between pediatric patients (aged < 16 years) and adult patients (aged ≥ 16 years). RESULTS A total of 468 patients (46 children and 422 adults) were included. Propensity score matching resulted in a matched cohort of 46 pairs. Higher PT-INR and APTT values at 1 to 12 hours after injury and lower fibrinogen concentrations at 1 to 6 hours after injury were observed in the pediatric group compared with the adult group. Plasma levels of D-dimer were elevated in both groups at 1 to 12 hours after injury, but no significant differences were seen between the groups. Multivariate logistic regression analysis of the initial coagulation and fibrinolytic parameters in the pediatric group revealed no prognostic significance of the coagulation parameter values, but elevation of the fibrinolytic parameter D-dimer was an independent negative prognostic factor. CONCLUSIONS In the acute phase of TBI, pediatric patients were characterized by prolongation of PT-INR and APTT and lower fibrinogen concentrations compared with adult patients, but these did not correlate with outcome. D-dimer was an independent prognostic outcome factor in terms of the Glasgow Outcome Scale in pediatric patients with TBI.
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Affiliation(s)
- Ryuta Nakae
- 11Department of Emergency and Critical Care Medicine, Nippon Medical School, Sendagi, Bunkyo-ku, Tokyo; and
| | - Yu Fujiki
- 2Emergency and Critical Care Center, Kawaguchi Municipal Medical Center, Kawaguchi-shi, Saitama, Japan
| | - Yasuhiro Takayama
- 11Department of Emergency and Critical Care Medicine, Nippon Medical School, Sendagi, Bunkyo-ku, Tokyo; and
| | - Takahiro Kanaya
- 11Department of Emergency and Critical Care Medicine, Nippon Medical School, Sendagi, Bunkyo-ku, Tokyo; and
| | - Yutaka Igarashi
- 11Department of Emergency and Critical Care Medicine, Nippon Medical School, Sendagi, Bunkyo-ku, Tokyo; and
| | - Go Suzuki
- 2Emergency and Critical Care Center, Kawaguchi Municipal Medical Center, Kawaguchi-shi, Saitama, Japan
| | - Yasutaka Naoe
- 2Emergency and Critical Care Center, Kawaguchi Municipal Medical Center, Kawaguchi-shi, Saitama, Japan
| | - Shoji Yokobori
- 11Department of Emergency and Critical Care Medicine, Nippon Medical School, Sendagi, Bunkyo-ku, Tokyo; and
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Bradbury JL, Thomas SG, Sorg NR, Mjaess N, Berquist MR, Brenner TJ, Langford JH, Marsee MK, Moody AN, Bunch CM, Sing SR, Al-Fadhl MD, Salamah Q, Saleh T, Patel NB, Shaikh KA, Smith SM, Langheinrich WS, Fulkerson DH, Sixta S. Viscoelastic Testing and Coagulopathy of Traumatic Brain Injury. J Clin Med 2021; 10:jcm10215039. [PMID: 34768556 PMCID: PMC8584585 DOI: 10.3390/jcm10215039] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 10/24/2021] [Accepted: 10/27/2021] [Indexed: 12/14/2022] Open
Abstract
A unique coagulopathy often manifests following traumatic brain injury, leading the clinician down a difficult decision path on appropriate prophylaxis and therapy. Conventional coagulation assays—such as prothrombin time, partial thromboplastin time, and international normalized ratio—have historically been utilized to assess hemostasis and guide treatment following traumatic brain injury. However, these plasma-based assays alone often lack the sensitivity to diagnose and adequately treat coagulopathy associated with traumatic brain injury. Here, we review the whole blood coagulation assays termed viscoelastic tests and their use in traumatic brain injury. Modified viscoelastic tests with platelet function assays have helped elucidate the underlying pathophysiology and guide clinical decisions in a goal-directed fashion. Platelet dysfunction appears to underlie most coagulopathies in this patient population, particularly at the adenosine diphosphate and/or arachidonic acid receptors. Future research will focus not only on the utility of viscoelastic tests in diagnosing coagulopathy in traumatic brain injury, but also on better defining the use of these tests as evidence-based and/or precision-based tools to improve patient outcomes.
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Affiliation(s)
- Jamie L. Bradbury
- Department of Neurosurgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA;
| | - Scott G. Thomas
- Department of Trauma Surgery, Memorial Hospital, South Bend, IN 46601, USA;
| | - Nikki R. Sorg
- Department of Emergency Medicine, Indiana University School of Medicine—South Bend, South Bend, IN 46617, USA; (N.R.S.); (A.N.M.); (S.R.S.)
| | - Nicolas Mjaess
- Department of Intensive Care Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (N.M.); (M.R.B.); (T.J.B.); (J.H.L.); (M.D.A.-F.); (Q.S.); (T.S.)
| | - Margaret R. Berquist
- Department of Intensive Care Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (N.M.); (M.R.B.); (T.J.B.); (J.H.L.); (M.D.A.-F.); (Q.S.); (T.S.)
| | - Toby J. Brenner
- Department of Intensive Care Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (N.M.); (M.R.B.); (T.J.B.); (J.H.L.); (M.D.A.-F.); (Q.S.); (T.S.)
| | - Jack H. Langford
- Department of Intensive Care Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (N.M.); (M.R.B.); (T.J.B.); (J.H.L.); (M.D.A.-F.); (Q.S.); (T.S.)
| | - Mathew K. Marsee
- Department of Otolaryngology, Portsmouth Naval Medical Center, Portsmouth, VA 23708, USA;
| | - Ashton N. Moody
- Department of Emergency Medicine, Indiana University School of Medicine—South Bend, South Bend, IN 46617, USA; (N.R.S.); (A.N.M.); (S.R.S.)
| | - Connor M. Bunch
- Department of Emergency Medicine, Indiana University School of Medicine—South Bend, South Bend, IN 46617, USA; (N.R.S.); (A.N.M.); (S.R.S.)
- Correspondence:
| | - Sandeep R. Sing
- Department of Emergency Medicine, Indiana University School of Medicine—South Bend, South Bend, IN 46617, USA; (N.R.S.); (A.N.M.); (S.R.S.)
| | - Mahmoud D. Al-Fadhl
- Department of Intensive Care Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (N.M.); (M.R.B.); (T.J.B.); (J.H.L.); (M.D.A.-F.); (Q.S.); (T.S.)
| | - Qussai Salamah
- Department of Intensive Care Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (N.M.); (M.R.B.); (T.J.B.); (J.H.L.); (M.D.A.-F.); (Q.S.); (T.S.)
| | - Tarek Saleh
- Department of Intensive Care Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (N.M.); (M.R.B.); (T.J.B.); (J.H.L.); (M.D.A.-F.); (Q.S.); (T.S.)
| | - Neal B. Patel
- Department of Neurosurgery, Memorial Hospital, South Bend, IN 46601, USA; (N.B.P.); (K.A.S.); (S.M.S.); (W.S.L.); (D.H.F.)
- Department of Neurosurgery, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Kashif A. Shaikh
- Department of Neurosurgery, Memorial Hospital, South Bend, IN 46601, USA; (N.B.P.); (K.A.S.); (S.M.S.); (W.S.L.); (D.H.F.)
- Department of Neurosurgery, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Stephen M. Smith
- Department of Neurosurgery, Memorial Hospital, South Bend, IN 46601, USA; (N.B.P.); (K.A.S.); (S.M.S.); (W.S.L.); (D.H.F.)
- Department of Neurosurgery, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Walter S. Langheinrich
- Department of Neurosurgery, Memorial Hospital, South Bend, IN 46601, USA; (N.B.P.); (K.A.S.); (S.M.S.); (W.S.L.); (D.H.F.)
- Department of Neurosurgery, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Daniel H. Fulkerson
- Department of Neurosurgery, Memorial Hospital, South Bend, IN 46601, USA; (N.B.P.); (K.A.S.); (S.M.S.); (W.S.L.); (D.H.F.)
- Department of Neurosurgery, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Sherry Sixta
- Department of Trauma Surgery, Envision Physician Services, Plano, TX 75093, USA;
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Biofluid Biomarkers in Traumatic Brain Injury: A Systematic Scoping Review. Neurocrit Care 2021; 35:559-572. [PMID: 33403583 DOI: 10.1007/s12028-020-01173-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 12/01/2020] [Indexed: 02/05/2023]
Abstract
Emerging evidence suggests that biofluid-based biomarkers have diagnostic and prognostic potential in traumatic brain injuries (TBI). However, owing to the lack of a conceptual framework or comprehensive review, it is difficult to visualize the breadth of materials that might be available. We conducted a systematic scoping review to map and categorize the evidence regarding biofluid-based biochemical markers of TBI. A comprehensive search was undertaken in January 2019. Of 25,354 records identified through the literature search, 1036 original human studies were included. Five hundred forty biofluid biomarkers were extracted from included studies and classified into 19 distinct categories. Three categories of biomarkers including cytokines, coagulation tests, and nerve tissue proteins were investigated more than others and assessed in almost half of the studies (560, 515, and 502 from 1036 studies, respectively). S100 beta as the most common biomarker for TBI was tested in 21.2% of studies (220 articles). Cortisol was the only biomarker measured in blood, cerebrospinal fluid, urine, and saliva. The most common sampling time was at admission and within 24 h of injury. The included studies focused mainly on biomarkers from blood and central nervous system sources, the adult population, and severe and blunt injuries. The most common outcome measures used in studies were changes in biomarker concentration level, Glasgow coma scale, Glasgow outcome scale, brain computed tomography scan, and mortality rate. Biofluid biomarkers could be clinically helpful in the diagnosis and prognosis of TBI. However, there was no single definitive biomarker with accurate characteristics. The present categorization would be a road map to investigate the biomarkers of the brain injury cascade separately and detect the most representative biomarker of each category. Also, this comprehensive categorization could provide a guiding framework to design combined panels of multiple biomarkers.
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Use of Thromboelastography in the Evaluation and Management of Patients With Traumatic Brain Injury: A Systematic Review and Meta-Analysis. Crit Care Explor 2021; 3:e0526. [PMID: 34549189 PMCID: PMC8443808 DOI: 10.1097/cce.0000000000000526] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Supplemental Digital Content is available in the text. Traumatic brain injury is associated with coagulopathy that increases mortality risk. Viscoelastic hemostatic assays such as thromboelastography (Haemonetics SA, Signy, Switzerland) provide rapid coagulopathy assessment and may be particularly useful for goal-directed treatment of traumatic brain injury patients. We conducted a systematic review to assess thromboelastography in the evaluation and management of coagulopathy in traumatic brain injury patients.
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Krishnamoorthy V, Komisarow JM, Laskowitz DT, Vavilala MS. Multiorgan Dysfunction After Severe Traumatic Brain Injury: Epidemiology, Mechanisms, and Clinical Management. Chest 2021; 160:956-964. [PMID: 33460623 PMCID: PMC8448997 DOI: 10.1016/j.chest.2021.01.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 10/10/2020] [Accepted: 01/07/2021] [Indexed: 01/20/2023] Open
Abstract
Traumatic brain injury (TBI) is a major global health problem and a major contributor to morbidity and mortality following multisystem trauma. Extracranial organ dysfunction is common after severe TBI and significantly impacts clinical care and outcomes following injury. Despite this, extracranial organ dysfunction remains an understudied topic compared with organ dysfunction in other critical care paradigms. In this review, we will: 1) summarize the epidemiology of extracranial multiorgan dysfunction following severe TBI; 2) examine relevant mechanisms that may be involved in the development of multi-organ dysfunction following severe TBI; and 3) discuss clinical management strategies to care for these complex patients.
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Affiliation(s)
- Vijay Krishnamoorthy
- Department of Anesthesiology, Duke University, Chapel Hill, NC; Critical Care and Perioperative Population Health Research Unit, Department of Anesthesiology, Duke University, Chapel Hill, NC.
| | - Jordan M Komisarow
- Critical Care and Perioperative Population Health Research Unit, Department of Anesthesiology, Duke University, Chapel Hill, NC; Department of Neurosurgery, Duke University, Chapel Hill, NC
| | | | - Monica S Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA
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Fang J, Yuan Q, Du Z, Liu C, Xu H, Yang W, Chen L, Zhao J, Xie R, Hu J, Wu X. Contribution of factor VII polymorphisms to coagulopathy in patients with isolated traumatic brain injury. Clin Neurol Neurosurg 2021; 208:106836. [PMID: 34371385 DOI: 10.1016/j.clineuro.2021.106836] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 07/08/2021] [Accepted: 07/09/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Coagulopathy is a severe complication of traumatic brain injury (TBI) and can cause secondary injuries and death. Decrease of FVII activity contributes to the coagulopathy and progressive hemorrhagic injury (PHI) in patients with isolated TBI. Some polymorphic loci of coagulation factor VII (FVII) are shown to be essential for FVII activity. However, the relationship between FVII gene polymorphisms and coagulopathy in patients with isolated TBI is still unknown. Therefore, the present study aimed to investigate the relationship between FVII gene polymorphisms and plasma FVIIa levels, and assess whether FVII polymorphisms were associated with TBI-related coagulopathy, PHI, and 6 months GOS in patients with isolated TBI. METHODS One-hundred-forty-nine patients with isolated TBI (from East of China) admitted to Huashan Hospital's Neurological Trauma Center from March 2012 to March 2016 were enrolled in this study. The Polymorphism-Polymerase Chain Reaction (PCR) method was used to analyze the five FVII polymorphism loci (-323P0/P10, R353Q, -401G/T, -402G/A, and -670A/C) of these patients. Patients' blood was collected to test the activated partial thromboplastin time, international normalized ratio, platelet, and FVIIa concentrations. Other clinical characteristics were also recorded. RESULTS The minor alleles of three genotypes of -323 P0/P10, R353Q, and -401G/T each independently associated with 23.3%, 28.6%, and 27.6% lower FVIIa levels, respectively. These polymorphisms explained 21% of the total variance of FVIIa levels (adjusted R2:0.206). The genotype of -323P0/P10 was an independent risk factor for coagulopathy (OR = 2.77, p = 0.043) and PHI (OR = 3.47, p = 0.03) after adjustment for confounding factors in the logistic regression model. Polymorphisms of FVII were not independently associated with 6 months Glasgow Outcome Scale (GOS) of isolated TBI patients. CONCLUSION -323P0/P10, R353Q, and -401 G/T genotypes were associated with FVIIa levels. -323P0/P10 genotype was independently associated with traumatic coagulopathy and PHI in isolated TBI patients.
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Affiliation(s)
- Jiang Fang
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, China; Neurosurgical Institute of Fudan University, China; Shanghai Clinical Medical Center of Neurosurgery, China; Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, China
| | - Qiang Yuan
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, China; Neurosurgical Institute of Fudan University, China; Shanghai Clinical Medical Center of Neurosurgery, China; Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, China
| | - Zhuoying Du
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, China; Neurosurgical Institute of Fudan University, China; Shanghai Clinical Medical Center of Neurosurgery, China; Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, China
| | - Chaobo Liu
- Neurosurgery Department, PuDong hospital, FuDan University, 2800 Gongwei Road, Shanghai, China
| | - Hao Xu
- Neurosurgery Department, PuDong hospital, FuDan University, 2800 Gongwei Road, Shanghai, China
| | - Weijian Yang
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, China; Neurosurgical Institute of Fudan University, China; Shanghai Clinical Medical Center of Neurosurgery, China; Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, China
| | - Long Chen
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, China; Neurosurgical Institute of Fudan University, China; Shanghai Clinical Medical Center of Neurosurgery, China; Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, China
| | - Jianlan Zhao
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, China; Neurosurgical Institute of Fudan University, China; Shanghai Clinical Medical Center of Neurosurgery, China; Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, China
| | - Rong Xie
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, China; Neurosurgical Institute of Fudan University, China; Shanghai Clinical Medical Center of Neurosurgery, China; Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, China.
| | - Jin Hu
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, China; Neurosurgical Institute of Fudan University, China; Shanghai Clinical Medical Center of Neurosurgery, China; Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, China.
| | - Xing Wu
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, China; Department of Neurosurgery, Shigatse People's Hospital, 28 Shanghai Zhong Road, Shigatse, Tibet, China; Neurosurgical Institute of Fudan University, China; Shanghai Clinical Medical Center of Neurosurgery, China; Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, China.
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47
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Zou Z, Li L, Schäfer N, Huang Q, Maegele M, Gu Z. Endothelial glycocalyx in traumatic brain injury associated coagulopathy: potential mechanisms and impact. J Neuroinflammation 2021; 18:134. [PMID: 34126995 PMCID: PMC8204552 DOI: 10.1186/s12974-021-02192-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/01/2021] [Indexed: 02/07/2023] Open
Abstract
Traumatic brain injury (TBI) remains one of the leading causes of death and disability worldwide; more than 10 million people are hospitalized for TBI every year around the globe. While the primary injury remains unavoidable and not accessible to treatment, the secondary injury which includes oxidative stress, inflammation, excitotoxicity, but also complicating coagulation abnormalities, is potentially avoidable and profoundly affects the therapeutic process and prognosis of TBI patients. The endothelial glycocalyx, the first line of defense against endothelial injury, plays a vital role in maintaining the delicate balance between blood coagulation and anticoagulation. However, this component is highly vulnerable to damage and also difficult to examine. Recent advances in analytical techniques have enabled biochemical, visual, and computational investigation of this vascular component. In this review, we summarize the current knowledge on (i) structure and function of the endothelial glycocalyx, (ii) its potential role in the development of TBI associated coagulopathy, and (iii) the options available at present for detecting and protecting the endothelial glycocalyx.
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Affiliation(s)
- Zhimin Zou
- Academy of Orthopedics, Guangdong Province, Guangdong Provincial Key Laboratory of Bone and Joint Degenerative Diseases, The Third Affiliated Hospital of Southern Medical University, Guangzhou, Guangdong, 515630, China.,Department of Treatment Center for Traumatic Injuries, The Third Affiliated Hospital of Southern Medical University, Guangzhou, Guangdong, 515630, China.,Guangdong Provincial Key Lab of Shock and Microcirculation, Department of Pathophysiology, School of Basic Medical Sciences, Southern Medical University, Guangzhou, 510515, China
| | - Li Li
- Academy of Orthopedics, Guangdong Province, Guangdong Provincial Key Laboratory of Bone and Joint Degenerative Diseases, The Third Affiliated Hospital of Southern Medical University, Guangzhou, Guangdong, 515630, China.,Department of Treatment Center for Traumatic Injuries, The Third Affiliated Hospital of Southern Medical University, Guangzhou, Guangdong, 515630, China
| | - Nadine Schäfer
- Institute for Research in Operative Medicine (IFOM), University Witten/Herdecke (UW/H), Campus Cologne-Merheim, Ostmerheimerstr. 200, D-51109, Köln, Germany
| | - Qiaobing Huang
- Academy of Orthopedics, Guangdong Province, Guangdong Provincial Key Laboratory of Bone and Joint Degenerative Diseases, The Third Affiliated Hospital of Southern Medical University, Guangzhou, Guangdong, 515630, China.,Department of Treatment Center for Traumatic Injuries, The Third Affiliated Hospital of Southern Medical University, Guangzhou, Guangdong, 515630, China.,Guangdong Provincial Key Lab of Shock and Microcirculation, Department of Pathophysiology, School of Basic Medical Sciences, Southern Medical University, Guangzhou, 510515, China
| | - Marc Maegele
- Academy of Orthopedics, Guangdong Province, Guangdong Provincial Key Laboratory of Bone and Joint Degenerative Diseases, The Third Affiliated Hospital of Southern Medical University, Guangzhou, Guangdong, 515630, China. .,Department of Treatment Center for Traumatic Injuries, The Third Affiliated Hospital of Southern Medical University, Guangzhou, Guangdong, 515630, China. .,Institute for Research in Operative Medicine (IFOM), University Witten/Herdecke (UW/H), Campus Cologne-Merheim, Ostmerheimerstr. 200, D-51109, Köln, Germany. .,Department for Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center (CMMC), University Witten/Herdecke (UW/H), Campus Cologne-Merheim, Ostmerheimerstr. 200, D-51109, Köln, Germany.
| | - Zhengtao Gu
- Academy of Orthopedics, Guangdong Province, Guangdong Provincial Key Laboratory of Bone and Joint Degenerative Diseases, The Third Affiliated Hospital of Southern Medical University, Guangzhou, Guangdong, 515630, China. .,Department of Treatment Center for Traumatic Injuries, The Third Affiliated Hospital of Southern Medical University, Guangzhou, Guangdong, 515630, China.
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Todd J, Bharadwaj VN, Nellenbach K, Nandi S, Mihalko E, Copeland C, Brown AC, Stabenfeldt SE. Platelet-like particles reduce coagulopathy-related and neuroinflammatory pathologies post-experimental traumatic brain injury. J Biomed Mater Res B Appl Biomater 2021; 109:2268-2278. [PMID: 34117693 DOI: 10.1002/jbm.b.34888] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 02/03/2021] [Accepted: 02/22/2021] [Indexed: 12/16/2022]
Abstract
Coagulopathy may occur following traumatic brain injury (TBI), thereby negatively affecting patient outcomes. Here, we investigate the use of platelet-like particles (PLPs), poly(N-isopropylacrylamide-co-acrylic-acid) microgels conjugated with a fibrin-specific antibody, to improve hemostasis post-TBI. The objective of this study was to diminish coagulopathy in a mouse TBI model (controlled cortical impact) via PLP treatment, and subsequently decrease blood-brain barrier (BBB) permeability and neuroinflammation. Following an acute intravenous injection of PLPs post-TBI, we analyzed BBB permeability, ex vivo coagulation parameters, and neuroinflammation at 24 hr and 7 days post-TBI. Both PLP-treatment and control particle-treatment had significantly decreased BBB permeability and improved clot structure 24 hr post-injury. Additionally, no significant change in tissue sparing was observed between 24 hr and 7 days for PLP-treated cohorts compared to that observed in untreated cohorts. Only PLP-treatment resulted in significant reduction of astrocyte expression at 7 days and percent difference from 24 hr to 7 days. Finally, PLP-treatment significantly reduced the percent difference from 24 hr to 7 days in microglia/macrophage density compared to the untreated control. These results suggest that PLP-treatment addressed acute hypocoagulation and decreased BBB permeability followed by decreased neuroinflammation and fold-change tissue loss by 7 days post-injury. These promising results indicate that PLPs could be a potential therapeutic modality for TBI.
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Affiliation(s)
- Jordan Todd
- School of Biological and Health Systems Engineering, Arizona State University, Tempe, Arizona, USA
| | - Vimala N Bharadwaj
- School of Biological and Health Systems Engineering, Arizona State University, Tempe, Arizona, USA
| | - Kimberly Nellenbach
- Joint Department of Biomedical Engineering, North Carolina State University and The University of North Carolina at Chapel Hill, Raleigh, North Carolina, USA.,Comparative Medicine Institute, North Carolina State University, Raleigh, North Carolina, USA
| | - Seema Nandi
- Joint Department of Biomedical Engineering, North Carolina State University and The University of North Carolina at Chapel Hill, Raleigh, North Carolina, USA.,Comparative Medicine Institute, North Carolina State University, Raleigh, North Carolina, USA
| | - Emily Mihalko
- Joint Department of Biomedical Engineering, North Carolina State University and The University of North Carolina at Chapel Hill, Raleigh, North Carolina, USA.,Comparative Medicine Institute, North Carolina State University, Raleigh, North Carolina, USA
| | - Connor Copeland
- School of Biological and Health Systems Engineering, Arizona State University, Tempe, Arizona, USA
| | - Ashley C Brown
- Joint Department of Biomedical Engineering, North Carolina State University and The University of North Carolina at Chapel Hill, Raleigh, North Carolina, USA.,Comparative Medicine Institute, North Carolina State University, Raleigh, North Carolina, USA
| | - Sarah E Stabenfeldt
- School of Biological and Health Systems Engineering, Arizona State University, Tempe, Arizona, USA
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Zeineddin A, Dong JF, Wu F, Terse P, Kozar RA. Role of Von Willebrand Factor after Injury: It May Do More Than We Think. Shock 2021; 55:717-722. [PMID: 33156241 PMCID: PMC10363401 DOI: 10.1097/shk.0000000000001690] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Acute traumatic coagulopathy is a complex phenomenon following injury and a main contributor to hemorrhage. It remains a leading cause of preventable death in trauma patients. This phenomenon is initiated by systemic injury to the vascular endothelium that is exacerbated by hypoperfusion, acidosis, and hypothermia and leads to systemic activation of the coagulation cascades and resultant coagulopathy. Many previous studies have focused on endotheliopathy with targeted markers such as syndecan-1, soluble thrombomodulin, and plasma adrenaline as potential culprits for initiation and propagation of this state. However, in more recent studies, hyperadhesive von Willebrand factor (VWF), which is released following endothelial injury, and its cleaving metalloprotease ADAMTS13 have emerged as significant targets of the downstream effect of endothelial breakdown and coagulation dysregulation. Elucidation of the mechanism by which the dysregulated VWF-ADAMTS13 axis leads to endothelial dysfunction and coagulopathy after trauma can help identify new targets for therapy and sites for intervention. Much of what is known mechanistically regarding VWF stems from work done in traumatic brain injury. Following localized brain injury, brain-derived extracellular vesicles are released into circulation where they induce a hypercoagulable state that rapidly turns into consumptive coagulopathy. VWF released from injured endothelial cells binds to these extracellular vesicles to enhance their activity in promoting coagulopathy and increasing endothelial permeability. However, there are numerous gaps in our knowledge of VWF following injury, providing a platform for further investigation.
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Affiliation(s)
- Ahmad Zeineddin
- Shock Trauma Center and the University of Maryland School of Medicine, Baltimore, Maryland; and
| | - Jing-Fei Dong
- Bloodworks Research Institute and Hematology Division, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Feng Wu
- Shock Trauma Center and the University of Maryland School of Medicine, Baltimore, Maryland; and
| | - Pranaya Terse
- Shock Trauma Center and the University of Maryland School of Medicine, Baltimore, Maryland; and
| | - Rosemary A. Kozar
- Shock Trauma Center and the University of Maryland School of Medicine, Baltimore, Maryland; and
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50
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Sabet N, Soltani Z, Khaksari M. Multipotential and systemic effects of traumatic brain injury. J Neuroimmunol 2021; 357:577619. [PMID: 34058510 DOI: 10.1016/j.jneuroim.2021.577619] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 05/07/2021] [Accepted: 05/24/2021] [Indexed: 02/06/2023]
Abstract
Traumatic brain injury (TBI) is one of the leading causes of disability and mortality of people at all ages. Biochemical, cellular and physiological events that occur during primary injury lead to a delayed and long-term secondary damage that can last from hours to years. Secondary brain injury causes tissue damage in the central nervous system and a subsequent strong and rapid inflammatory response that may lead to persistent inflammation. However, this inflammatory response is not limited to the brain. Inflammatory mediators are transferred from damaged brain tissue to the bloodstream and produce a systemic inflammatory response in peripheral organs, including the cardiovascular, pulmonary, gastrointestinal, renal and endocrine systems. Complications of TBI are associated with its multiple and systemic effects that should be considered in the treatment of TBI patients. Therefore, in this review, an attempt was made to examine the systemic effects of TBI in detail. It is hoped that this review will identify the mechanisms of injury and complications of TBI, and open a window for promising treatment in TBI complications.
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Affiliation(s)
- Nazanin Sabet
- Endocrinology and Metabolism Research Center, Institute of Basic and Clinical Physiology Sciences, Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran; Department of Physiology and Pharmacology, Afzalipour Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Zahra Soltani
- Endocrinology and Metabolism Research Center, Institute of Basic and Clinical Physiology Sciences, Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran; Department of Physiology and Pharmacology, Afzalipour Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran.
| | - Mohammad Khaksari
- Physiology Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran
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