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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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Menditto VG, Rossetti G, Sampaolesi M, Buzzo M, Pomponio G. Traumatic Brain Injury in Patients under Anticoagulant Therapy: Review of Management in Emergency Department. J Clin Med 2024; 13:3669. [PMID: 38999235 PMCID: PMC11242576 DOI: 10.3390/jcm13133669] [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: 04/26/2024] [Revised: 06/15/2024] [Accepted: 06/17/2024] [Indexed: 07/14/2024] Open
Abstract
The best management of patients who suffer from traumatic brain injury (TBI) while on oral anticoagulants is one of the most disputed problems of emergency services. Indeed, guidelines, clinical decision rules, and observational studies addressing this topic are scarce and conflicting. Moreover, relevant issues such as the specific treatment (and even definition) of mild TBI, rate of delayed intracranial injury, indications for neurosurgery, and anticoagulant modulation are largely empiric. We reviewed the most recent evidence on these topics and explored other clinically relevant aspects, such as the promising role of dosing brain biomarkers, the strategies to assess the extent of anticoagulation, and the indications of reversals and tranexamic acid administration, in cases of mild TBI or as a bridge to neurosurgery. The appropriate timing of anticoagulant resumption was also discussed. Finally, we obtained an insight into the economic burden of TBI in patients on oral anticoagulants, and future directions on the management of this subpopulation of TBI patients were proposed. In this article, at the end of each section, a "take home message" is stated.
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Affiliation(s)
- Vincenzo G Menditto
- Emergency and Internal Medicine Department, Azienda Ospedaliero Universitaria delle Marche, 60126 Ancona, Italy
| | - Giulia Rossetti
- Internal Medicine, Santa Croce Hospital AST1 Pesaro Urbino, 61032 Fano, Italy
| | - Mattia Sampaolesi
- Emergency and Internal Medicine Department, Azienda Ospedaliero Universitaria delle Marche, 60126 Ancona, Italy
| | - Marta Buzzo
- Emergency and Internal Medicine Department, Azienda Ospedaliero Universitaria delle Marche, 60126 Ancona, Italy
| | - Giovanni Pomponio
- Clinica Medica, Azienda Ospedaliero Universitaria delle Marche, 60126 Ancona, Italy
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Iranmanesh N, Hosseini M, Tajaddini A, Shayan L, Fazeli P, Akerdi AT, Abbasi HR, Bolandparvaz S, Abdolrahimzadeh Fard H, Paydar S. Improving trauma patient management: Predisposing factors for trauma-induced physiological disorders and the importance of damage control surgery. Curr Probl Surg 2024; 61:101473. [PMID: 38823892 DOI: 10.1016/j.cpsurg.2024.101473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 02/29/2024] [Accepted: 03/11/2024] [Indexed: 06/03/2024]
Affiliation(s)
- Najmeh Iranmanesh
- Truama Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maryam Hosseini
- Truama Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ali Tajaddini
- Department of surgery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Leila Shayan
- Truama Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Pooria Fazeli
- Truama Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ali Taheri Akerdi
- Truama Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hamid Reza Abbasi
- Truama Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Shahram Bolandparvaz
- Truama Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hossein Abdolrahimzadeh Fard
- Truama Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Shahram Paydar
- Truama Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
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Manda-Handzlik A, Stojkov D, Wachowska M, Surmiak M. Editorial: Neutrophil extracellular traps: mechanistic and functional insight. Front Immunol 2024; 15:1407232. [PMID: 38698859 PMCID: PMC11063356 DOI: 10.3389/fimmu.2024.1407232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 04/09/2024] [Indexed: 05/05/2024] Open
Affiliation(s)
- Aneta Manda-Handzlik
- Department of Laboratory Diagnostics and Clinical Immunology of Developmental Age, Medical University of Warsaw, Warsaw, Poland
| | - Darko Stojkov
- Institute of Pharmacology, University of Bern, Bern, Switzerland
| | - Malgorzata Wachowska
- Department of Laboratory Diagnostics and Clinical Immunology of Developmental Age, Medical University of Warsaw, Warsaw, Poland
| | - Marcin Surmiak
- Department of Internal Medicine, Jagiellonian University Medical College, Krakow, Poland
- Center for the Development of Therapies for Civilization and Age-Related Diseases, Jagiellonian University Medical College, Krakow, Poland
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Favors L, Harrell K, Miles V, Hicks RC, Rippy M, Parmer H, Edwards A, Brown C, Stewart K, Day L, Wilson A, Maxwell R. Analysis of fibrinolytic shutdown in trauma patients with traumatic brain injury. Am J Surg 2024; 227:72-76. [PMID: 37802703 DOI: 10.1016/j.amjsurg.2023.09.034] [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: 06/30/2023] [Revised: 09/01/2023] [Accepted: 09/25/2023] [Indexed: 10/08/2023]
Abstract
BACKGROUND Coagulation profiles following major trauma vary depending on injury pattern and degree of shock. The physiologic mechanisms involved in coagulation function at any given time are varied and remain poorly understood. Thromboelastography (TEG) has been used evaluate coagulation profiles in the trauma population with some reports demonstrating a spectrum of fibrinolysis to fibrinolytic shutdown on initial presentation. The objective of this study was to evaluate the fibrinolytic profile of patients with TBI using thromboelastography (TEG). We hypothesized that patients with TBI would demonstrate low fibrinolytic activity. METHODS All trauma activations at an ACS-verified level 1 trauma center received a TEG analysis upon arrival from December 2019 to June 2021. A retrospective review of the results and outcomes was conducted, and TBI patients were compared to patients without TBI. Linear regression was used to evaluate the effect of patient and injury factors on fibrinolysis. Hyperfibrinolysis was defined as LY30 > 7.7%, physiologic fibrinolysis as LY30 0.6-7.7%, and fibrinolytic shutdown as LY30 < 0.6%. RESULTS A total of 1369 patients received an admission TEG analysis. Patients with TBI had a significantly higher median ISS (16 vs. 8, p < 0.001), lower median admission Glasgow Coma Scale (14 vs. 15, p < 0.001), longer intensive care unit length of stay (3 vs. 2 days, p < 0.0001), increased ventilator days (216 vs. 183, p < 0.001), higher mortality (14.6% vs. 5.1%, p < 0.001), but lower shock index (0.6 vs. 0.7, p < 0.0001) compared to those without TBI. Median LY30 was found to be decreased in the TBI group (0.1 vs. 0.2, p = 0.0006). Patients with TBI were found to have a higher rate of fibrinolytic shutdown compared those without TBI (68.7% vs. 63.5%, p = 0.054). ISS, sex, and shock index were found to be predictive of LY30 on linear regression, but TBI was not (Β: 0.09, SE: 0.277, p = 0.745). The rate of DVT/PE did not appear to be elevated in patients with TBI (0.8%) and without TBI (1.2%). CONCLUSIONS Trauma patients with and without TBI were found to have high rates of fibrinolytic shutdown. Although there was a high incidence of fibrinolytic shutdown, it did not appear to have an impact on the rate of thrombotic complications. The clinical significance of these results is unclear and differs significantly from recent reports which demonstrated that TBI is associated with a 25% rate of fibrinolytic shutdown. Further investigation is needed to better define the fibrinolytic pathway in patients with trauma and TBI to develop optimal treatment algorithms.
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Affiliation(s)
- L Favors
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA.
| | - K Harrell
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA.
| | - V Miles
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA.
| | - R C Hicks
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA
| | - M Rippy
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA
| | - H Parmer
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA
| | - A Edwards
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA
| | - C Brown
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA
| | - K Stewart
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA
| | - L Day
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA
| | - A Wilson
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA
| | - R Maxwell
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA.
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Emleek EMQ, Khalil AA. The International Society of Thrombosis and Hemostasis (ISTH) criteria in intensive care units. JOURNAL OF VASCULAR NURSING 2023; 41:158-163. [PMID: 38072567 DOI: 10.1016/j.jvn.2023.06.004] [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: 11/16/2022] [Revised: 06/23/2023] [Accepted: 06/27/2023] [Indexed: 12/18/2023]
Abstract
BACKGROUND Disseminated Intravascular Coagulation (DIC) has been assessed by the International Society of Thrombosis and Hemostasis (ISTH) 2001 and the ISTH 2018-modified version. More investigations are needed to assess usability and visibility of those DIC scoring systems in the intensive care units (ICU). AIMS This study investigated the predictive performance of the ISTH-Overt DIC versions of 28-day mortality in ICUs compared to SOFA as a gold standard assessment tool of sepsis. METHODS A retrospective design (2015-2017) included 220 adult patients enrolled from medical and surgical ICUs in two major hospitals in Jordan. We calculated ISTH-Overt DIC scores and SOFA score on time of DIC diagnosis. Overt DIC was categorized based on a score of ≥ five for ISTH DIC 2001; and ≥ 4 for ISTH DIC 2018. Provided, a score > 12 was categorized as Multiple-Organ- Dysfunction-Syndrome (MODS) for Sequential Organ Failure Assessment (SOFA) score. Then, 28-day mortality follow-up was performed. RESULTS More than half of sample died before 28-days of follow-up. The analysis of Receiver Operating Characteristic (ROC) showed that higher scores of ISTH DIC 2001(≥ 5), ISTH DIC 2018 (≥ 4), and SOFA score (>12) were highly associated with 28-day mortality. The ISTH DIC 2001 and SOFA score were superior on the modified ISTH 2018 in predicting 28-day mortality, with an Area Under the Curve (AUC) of (0.724 vs. 0.822 vs. 0.507, respectively). Yet, the accuracy of the SOFA score was better than the ISTH DIC 2001. CONCLUSION This study suggests that ISTH DIC 2001 score is helpful when applied on medical and surgical ICU Jordanian populations. It showed better results compared to the Modified ISTH DIC 2018 in mortality prediction, regardless of the underlying diseases.
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Affiliation(s)
- Eman Mahmoud Qasim Emleek
- King Hussein Cancer Center (KHCC), Department of Bone Marrow Transplantation, Queen Rania Street, next to The University of Jordan, Jordan
| | - Amani Anwar Khalil
- Prof in nursing, Clinical Nursing Department, The University of Jordan, School of Nursing, Amman 11942, Jordan.
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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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Jin J, Wang F, Tian J, Zhao X, Dong J, Wang N, Liu Z, Zhao H, Li W, Mang G, Hu S. Neutrophil extracellular traps contribute to coagulopathy after traumatic brain injury. JCI Insight 2023; 8:141110. [PMID: 36802340 PMCID: PMC10070118 DOI: 10.1172/jci.insight.141110] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 02/17/2023] [Indexed: 02/23/2023] Open
Abstract
Coagulopathy contributes to the majority of deaths and disabilities associated with traumatic brain injury (TBI). Whether neutrophil extracellular traps (NETs) contribute to an abnormal coagulation state in the acute phase of TBI remains unknown. Our objectives were to demonstrate the definitive role of NETs in coagulopathy in TBI. We detected NET markers in 128 TBI patients and 34 healthy individuals. Neutrophil-platelet aggregates were detected in blood samples from TBI patients and healthy individuals using flow cytometry and staining for CD41 and CD66b. Endothelial cells were incubated with isolated NETs and we detected the expression of vascular endothelial cadherin, syndecan-1, thrombomodulin, von Willebrand factor, phosphatidylserine, and tissue factor. In addition, we established a TBI mouse model to determine the potential role of NETs in TBI-associated coagulopathy. NET generation was mediated by high mobility group box 1 (HMGB1) from activated platelets and contributed to procoagulant activity in TBI. Furthermore, coculture experiments indicated that NETs damaged the endothelial barrier and caused these cells to assume a procoagulant phenotype. Moreover, the administration of DNase I before or after brain trauma markedly reduced coagulopathy and improved the survival and clinical outcome of mice with TBI.
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Affiliation(s)
- Jiaqi Jin
- Department of Neurosurgery, Cancer Center, Zhejiang Provincial People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
- Department of Neurosurgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Fang Wang
- Department of Neurosurgery, Cancer Center, Zhejiang Provincial People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
- Department of Neurosurgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Jiawei Tian
- Department of Neurosurgery, Cancer Center, Zhejiang Provincial People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
- Department of Neurosurgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Xinyi Zhao
- Department of Cardiology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Jiawei Dong
- Department of Neurosurgery, Cancer Center, Zhejiang Provincial People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
- Department of Neurosurgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Nan Wang
- Department of Neurosurgery, Cancer Center, Zhejiang Provincial People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
- Department of Neurosurgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Zhihui Liu
- Department of Neurosurgery, Cancer Center, Zhejiang Provincial People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
- Department of Neurosurgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Hongtao Zhao
- Department of Neurosurgery, Cancer Center, Zhejiang Provincial People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
- Department of Neurosurgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Wenqiang Li
- Department of Vascular Surgery, Jinshan Hospital of Fudan University, Shanghai, China
| | - Ge Mang
- Department of Cardiology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Shaoshan Hu
- Department of Neurosurgery, Cancer Center, Zhejiang Provincial People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
- Department of Neurosurgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
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Krämer TJ, Pickart F, Pöttker B, Gölz C, Neulen A, Pantel T, Goetz H, Ritter K, Schäfer MKE, Thal SC. Early DNase-I therapy delays secondary brain damage after traumatic brain injury in adult mice. Sci Rep 2023; 13:4348. [PMID: 36928073 PMCID: PMC10018640 DOI: 10.1038/s41598-023-30421-5] [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: 10/26/2022] [Accepted: 02/22/2023] [Indexed: 03/18/2023] Open
Abstract
Traumatic brain injury (TBI) causes the release of danger-associated molecular patterns (DAMP) from damaged or dead cells, which contribute to secondary brain damage after TBI. Cell-free DNA (cfDNA) is a DAMP known to cause disruption of the blood-brain barrier (BBB), promote procoagulant processes, brain edema, and neuroinflammation. This study tested the hypothesis that administration of deoxyribonuclease-I (DNase-I) has a beneficial effect after TBI. Mice (n = 84) were subjected to controlled cortical impact (CCI) and posttraumatic intraperitoneal injections of low dose (LD) or high dose (HD) of DNase-I or vehicle solution at 30 min and 12 h after CCI. LD was most effective to reduce lesion volume (p = 0.003), brain water content (p < 0.0001) and to stabilize BBB integrity (p = 0.019) 1 day post-injury (dpi). At 6 h post injury LD-treated animals showed less cleavage of fibrin (p = 0.0014), and enhanced perfusion as assessed by micro-computer-tomography (p = 0.027). At 5 dpi the number of Iba1-positive cells (p = 0.037) were reduced, but the number of CD45-positive cells, motoric function and brain lesion volume was not different. Posttraumatic-treatment with DNase-I therefore stabilizes the BBB, reduces the formation of brain edema, immune response, and delays secondary brain damage. DNase-I might be a new approach to extend the treatment window after TBI.
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Affiliation(s)
- Tobias J Krämer
- Department of Anesthesiology, University Medical Center of Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany.
- Faculty of Health, University Witten/Herdecke, Witten, Germany.
| | - Florian Pickart
- Department of Anesthesiology, University Medical Center of Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Bruno Pöttker
- Department of Anesthesiology, University Medical Center of Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Christina Gölz
- Department of Anesthesiology, University Medical Center of Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Axel Neulen
- Department of Neurosurgery, University Medical Center of Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Tobias Pantel
- Department of Neurosurgery, University Medical Center of Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Hermann Goetz
- Cell Biology Unit, University Medical Center of Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Katharina Ritter
- Department of Anesthesiology, University Medical Center of Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Michael K E Schäfer
- Department of Anesthesiology, University Medical Center of Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
- Focus Program Translational Neurosciences, University Medical Center of Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
- Research Center for Immunotherapy, University Medical Center of Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
- Center for Molecular Surgical Research, University Medical Center of Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Serge C Thal
- Department of Anesthesiology, University Medical Center of Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
- Focus Program Translational Neurosciences, University Medical Center of Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
- Center for Molecular Surgical Research, University Medical Center of Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
- Department of Anesthesiology, Helios University Hospital Wuppertal, University Witten/Herdecke, Heusnerstrasse 40, 42283, Wuppertal, Germany
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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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11
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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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12
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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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13
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Shammassian BH, Ronald A, Smith A, Sajatovic M, Mangat HS, Kelly ML. Viscoelastic Hemostatic Assays and Outcomes in Traumatic Brain Injury: A Systematic Literature Review. World Neurosurg 2022; 159:221-236.e4. [PMID: 34844010 DOI: 10.1016/j.wneu.2021.10.180] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 10/27/2021] [Accepted: 10/28/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Coagulopathy in traumatic brain injury (TBI) occurs frequently and is associated with poor outcomes. Conventional coagulation assays (CCA) traditionally used to diagnose coagulopathy are often not time sensitive and do not assess complete hemostatic function. Viscoelastic hemostatic assays (VHAs) including thromboelastography and rotational thromboelastography provide a useful rapid and comprehensive point-of-care alternative for identifying coagulopathy, which is of significant consequence in patients with TBI with intracranial hemorrhage. METHODS A systematic review was performed in accordance with PRISMA guidelines to identify studies comparing VHA with CCA in adult patients with TBI. The following differences in outcomes were assessed based on ability to diagnose coagulopathy: mortality, need for neurosurgical intervention, and progression of traumatic intracranial hemorrhage (tICH). RESULTS Abnormal reaction time (R time), maximum amplitude, and K value were associated with increased mortality in certain studies but not all studies. This association was reflected across studies using different statistical parameters with different outcome definitions. An abnormal R time was the only VHA parameter found to be associated with the need for neurosurgical intervention in 1 study. An abnormal R time was also the only VHA parameter associated with progression of tICH. Overall, many studies also reported abnormal CCAs, mainly activated partial thromboplastin time, to be associated with poor outcomes. CONCLUSIONS Given the heterogenous nature of the available evidence including methodology and study outcomes, the comparative difference between VHA and CCA in predicting rates of neurosurgical intervention, tICH progression, or mortality in patients with TBI remains inconclusive.
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Affiliation(s)
- Berje H Shammassian
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA; Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.
| | - Andrew Ronald
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Arvin Smith
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Martha Sajatovic
- Neurological and Behavioral Outcomes Center, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Halinder S Mangat
- Department of Neurology, Division of Neurocritical Care, University of Kansas Medical Center Kansas City, Kansas, USA
| | - Michael L Kelly
- Metrohealth Medical Center, Department of Neurological Surgery, Cleveland, Ohio, USA
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14
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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: 1] [Impact Index Per Article: 0.5] [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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15
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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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Early thrombocytopenia is associated with an increased risk of mortality in patients with traumatic brain injury treated in the intensive care unit: a Finnish Intensive Care Consortium study. Acta Neurochir (Wien) 2022; 164:2731-2740. [PMID: 35838800 PMCID: PMC9519714 DOI: 10.1007/s00701-022-05277-9] [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: 01/25/2022] [Accepted: 06/06/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Coagulopathy after traumatic brain injury (TBI) is associated with poor prognosis. PURPOSE To assess the prevalence and association with outcomes of early thrombocytopenia in patients with TBI treated in the intensive care unit (ICU). METHODS This is a retrospective multicenter study of adult TBI patients admitted to ICUs during 2003-2019. Thrombocytopenia was defined as a platelet count < 100 × 109/L during the first day. The association between thrombocytopenia and hospital and 12-month mortality was tested using multivariable logistic regression, adjusting for markers of injury severity. RESULTS Of 4419 patients, 530 (12%) had early thrombocytopenia. In patients with thrombocytopenia, hospital and 12-month mortality were 26% and 48%, respectively; in patients with a platelet count > 100 × 109/L, they were 9% and 22%, respectively. After adjusting for injury severity, a higher platelet count was associated with decreased odds of hospital mortality (OR 0.998 per unit, 95% CI 0.996-0.999) and 12-month mortality (OR 0.998 per unit, 95% CI 0.997-0.999) in patients with moderate-to-severe TBI. Compared to patients with a normal platelet count, patients with thrombocytopenia not receiving platelet transfusion had an increased risk of 12-month mortality (OR 2.2, 95% CI 1.6-3.0), whereas patients with thrombocytopenia receiving platelet transfusion did not (OR 1.0, 95% CI 0.6-1.7). CONCLUSION Early thrombocytopenia occurs in approximately one-tenth of patients with TBI treated in the ICU, and it is an independent risk factor for mortality in patients with moderate-to-severe TBI. Further research is necessary to determine whether this is modifiable by platelet transfusion.
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17
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Wu B, Lu Y, Yu Y, Yue H, Wang J, Chong Y, Cui W. Effect of tranexamic acid on the prognosis of patients with traumatic brain injury undergoing craniotomy: study protocol for a randomised controlled trial. BMJ Open 2021; 11:e049839. [PMID: 34824110 PMCID: PMC8627390 DOI: 10.1136/bmjopen-2021-049839] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Abnormal coagulation function aggravates the prognosis of patients with traumatic brain injury (TBI). It was reported that the antifibrinolytic drug tranexamic acid (TXA) could reduce intracranial haemorrhage and mortality in non-operative patients with TBI. However, there is a lack of evaluation of TXA in patients with TBI undergoing craniotomy. METHODS AND ANALYSIS This is a single-centre randomised controlled, double-blind, parallel study aiming to investigate the effectiveness and safety of TXA in patients with TBI during the perioperative period. Blood loss and transfusion, neurological function, adverse events, mortality and serum immune-inflammatory cytokines will be collected and analysed. ETHICS AND DISSEMINATION Ethical approval has been granted by the Medical Ethics Committee of Beijing Tian Tan Hospital, Capital Medical University (reference number KY 2020-136-03). The results of this study will be disseminated through presentations at scientific conferences and publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER ChiCTR2100041911.
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Affiliation(s)
- Bei Wu
- Department of Anaesthesiology, Beijing Tian Tan hospital, Capital Medical University, Beijing, China
| | - Yu Lu
- Department of Anaesthesiology, Beijing Tian Tan hospital, Capital Medical University, Beijing, China
| | - Yun Yu
- Department of Anaesthesiology, Beijing Tian Tan hospital, Capital Medical University, Beijing, China
| | - Hongli Yue
- Department of Anaesthesiology, Beijing Tian Tan hospital, Capital Medical University, Beijing, China
| | - Jie Wang
- Department of Anaesthesiology, Beijing Tian Tan hospital, Capital Medical University, Beijing, China
| | - Yingzi Chong
- Department of Anaesthesiology, Beijing Tian Tan hospital, Capital Medical University, Beijing, China
| | - Weihua Cui
- Department of Anaesthesiology, Beijing Tian Tan hospital, Capital Medical University, Beijing, China
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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: 11] [Impact Index Per Article: 3.7] [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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19
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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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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: 11] [Impact Index Per Article: 3.7] [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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Platelet Receptor Activity for Predicting Survival in Patients with Intracranial Bleeding. J Clin Med 2021; 10:jcm10102205. [PMID: 34069736 PMCID: PMC8160693 DOI: 10.3390/jcm10102205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/06/2021] [Accepted: 05/17/2021] [Indexed: 11/16/2022] Open
Abstract
Blood coagulation disorders in patients with intracranial bleeding as a result of head injuries or ruptured aneurysms are a diagnostic and therapeutic problem and appropriate assessments are needed to limit CNS damage and to implement preventive measures. The aim of the study was to monitor changes in platelet aggregation and to assess the importance of platelet dysfunction for predicting survival. Platelet receptor function analysis was performed using the agonists arachidonic acid (ASPI), adenosine diphosphate (ADP), collagen (COL), thrombin receptor activating protein (TRAP), ristocetin (RISTO) upon admission to the ICU and on days 2, 3, and 5. On admission, the ASPI, ADP, COL, TRAP, and RISTO tests indicated there was reduced platelet aggregation, despite there being a normal platelet count. In ‘Non-survivors’, the platelet response to all agonists was suppressed throughout the study period, while in ‘Survivors’ it improved. Measuring platelet function in ICU patients with intracranial bleeding is a strong predictor related to outcome: patients with impaired platelet aggregation had a lower 28-day survival rate compared to patients with normal platelet aggregation (log-rank test p = 0.014). The results indicated that measuring platelet aggregation can be helpful in the early detection, diagnosis, and treatment of bleeding disorders.
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22
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Cui W, Wu X, Feng D, Luo J, Shi Y, Guo W, Liu H, Wang Q, Wang L, Ge S, Qu Y. Acrolein Induces Systemic Coagulopathy via Autophagy-dependent Secretion of von Willebrand Factor in Mice after Traumatic Brain Injury. Neurosci Bull 2021; 37:1160-1175. [PMID: 33939120 PMCID: PMC8353051 DOI: 10.1007/s12264-021-00681-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 12/05/2020] [Indexed: 12/11/2022] Open
Abstract
Traumatic brain injury (TBI)-induced coagulopathy has increasingly been recognized as a significant risk factor for poor outcomes, but the pathogenesis remains poorly understood. In this study, we aimed to investigate the causal role of acrolein, a typical lipid peroxidation product, in TBI-induced coagulopathy, and further explore the underlying molecular mechanisms. We found that the level of plasma acrolein in TBI patients suffering from coagulopathy was higher than that in those without coagulopathy. Using a controlled cortical impact mouse model, we demonstrated that the acrolein scavenger phenelzine prevented TBI-induced coagulopathy and recombinant ADAMTS-13 prevented acrolein-induced coagulopathy by cleaving von Willebrand factor (VWF). Our results showed that acrolein may contribute to an early hypercoagulable state after TBI by regulating VWF secretion. mRNA sequencing (mRNA-seq) and transcriptome analysis indicated that acrolein over-activated autophagy, and subsequent experiments revealed that acrolein activated autophagy partly by regulating the Akt/mTOR pathway. In addition, we demonstrated that acrolein was produced in the perilesional cortex, affected endothelial cell integrity, and disrupted the blood-brain barrier. In conclusion, in this study we uncovered a novel pro-coagulant effect of acrolein that may contribute to TBI-induced coagulopathy and vascular leakage, providing an alternative therapeutic target.
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Affiliation(s)
- Wenxing Cui
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, 710038, China
| | - Xun Wu
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, 710038, China
| | - Dayun Feng
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, 710038, China
| | - Jianing Luo
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, 710038, China
| | - Yingwu Shi
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, 710038, China
| | - Wei Guo
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, 710038, China
| | - Haixiao Liu
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, 710038, China
| | - Qiang Wang
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, 710038, China
| | - Liang Wang
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, 710038, China
| | - Shunnan Ge
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, 710038, China.
| | - Yan Qu
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, 710038, China.
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23
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Kinnunen J, Satopää J, Niemelä M, Putaala J. Coagulopathy and its effect on treatment and mortality in patients with traumatic intracranial hemorrhage. Acta Neurochir (Wien) 2021; 163:1391-1401. [PMID: 33759013 PMCID: PMC8053656 DOI: 10.1007/s00701-021-04808-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 03/10/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND The role of coagulopathy in patients with traumatic brain injury has remained elusive. In the present study, we aim to assess the prevalence of coagulopathy in patients with traumatic intracranial hemorrhage, their clinical features, and the effect of coagulopathy on treatment and mortality. METHODS An observational, retrospective single-center cohort of consecutive patients with traumatic intracranial hemorrhage treated at Helsinki University Hospital between 01 January and 31 December 2010. We compared clinical and radiological parameters in patients with and without coagulopathy defined as drug- or disease-induced, i.e., antiplatelet or anticoagulant medication at a therapeutic dose, thrombocytopenia (platelet count < 100 E9/L), international normalized ratio > 1.2, or thromboplastin time < 60%. Primary outcome was 30-day all-cause mortality. Logistic regression analysis allowed to assess for factors associated with coagulopathy and mortality. RESULTS Of our 505 patients (median age 61 years, 65.5% male), 206 (40.8%) had coagulopathy. Compared to non-coagulopathy patients, coagulopathy patients had larger hemorrhage volumes (mean 140.0 mL vs. 98.4 mL, p < 0.001) and higher 30-day mortality (18.9% vs. 9.7%, p = 0.003). In multivariable analysis, older age, lower admission Glasgow Coma Scale score, larger hemorrhage volume, and conservative treatment were independently associated with mortality. Surgical treatment was associated with lower mortality in both patients with and without coagulopathy. CONCLUSIONS Coagulopathy was more frequent in patients with traumatic intracranial hemorrhage presenting larger hemorrhage volumes compared to non-coagulopathy patients but was not independently associated with higher 30-day mortality. Hematoma evacuation, in turn, was associated with lower mortality irrespective of coagulopathy.
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Affiliation(s)
- Janne Kinnunen
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, 00290, Helsinki, Finland.
| | - Jarno Satopää
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Topeliuksenkatu 5, 00260, Helsinki, Finland
| | - Mika Niemelä
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Topeliuksenkatu 5, 00260, Helsinki, Finland
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, 00290, Helsinki, Finland
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24
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Riojas CM, Ekaney ML, Ross SW, Cunningham KW, Furay EJ, Brown CVR, Evans SL. Platelet Dysfunction after Traumatic Brain Injury: A Review. J Neurotrauma 2021; 38:819-829. [PMID: 33143502 DOI: 10.1089/neu.2020.7301] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Coagulopathy is a known sequela of traumatic brain injury (TBI) and can lead to increased morbidity and mortality. Platelet dysfunction has been identified as one of several etiologies of coagulopathy following TBI and has been associated with poor outcomes. Regardless of whether the platelet dysfunction occurs as a direct consequence of the injury or because of pre-existing medical comorbidities or medication use, accurate detection and monitoring of response to therapy is key to optimal patient care. Platelet transfusion has been proposed as a potential therapeutic intervention to treat platelet dysfunction, with several studies using platelet function assays to monitor response. The development of increasingly precise diagnostic testing is providing enhanced understanding of the specific derangement in the hemostatic process, allowing clinicians to provide patient-specific treatment plans. There is wide variability in the currently available literature on the incidence and clinical significance of platelet dysfunction following TBI, which creates challenges with developing evidence-based management guidelines. The relatively high prevalence of platelet inhibitor therapy serves as an additional confounding factor. In addition, the data are largely retrospective in nature. We performed a literature review to provide clarity on this clinical issue. We reviewed 348 abstracts, and included 97 manuscripts in our final literature review. Based on the currently available research, platelet dysfunction has been consistently demonstrated in patients with moderate-severe TBI. We recommend the use of platelet functional assays to evaluate patients with TBI. Platelet transfusion directed at platelet dysfunction may lead to improved clinical outcome. A randomized trial guided by implementation science could improve the applicability of these practices.
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Affiliation(s)
- Christina M Riojas
- FH "Sammy" Ross Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Michael L Ekaney
- FH "Sammy" Ross Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Samuel W Ross
- FH "Sammy" Ross Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Kyle W Cunningham
- FH "Sammy" Ross Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Elisa J Furay
- Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | - Carlos V R Brown
- Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | - Susan L Evans
- FH "Sammy" Ross Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
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25
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Esnault P, Mathais Q, Gueguen S, Cotte J, Montcriol A, Cardinale M, Goutorbe P, Bordes J, Meaudre E. Fibrin monomers and association with significant hemorrhage or mortality in severely injured trauma patients. Injury 2020; 51:2483-2492. [PMID: 32741604 DOI: 10.1016/j.injury.2020.07.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 07/04/2020] [Accepted: 07/26/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Post-traumatic hemorrhage is still the leading cause of potentially preventable death in patients with severe trauma. Traumatic-induced coagulopathy has been described as a risk factor for significant hemorrhage and mortality in this population. Fibrin monomers (FMs) are a direct marker of thrombin action, and thus reflect coagulation activation. This study sought to determine the association of FMs levels at admission with significant hemorrhage and 28-day mortality after a severe trauma. METHODS We conducted a retrospective, observational study including all severe trauma patients admitted in a level-1 trauma center between January 2012 and December 2017. Patients with severe traumatic brain injury or previous anticoagulant / antiaggregant therapies were excluded. FMs measurements and standard coagulation test were taken at admission. Significant hemorrhage was defined as a hemorrhage requiring the transfusion of ≥ 4 Red Blood Cells units during the first 6 h. Multivariable analysis was applied to identify predictors of significant hemorrhage and a simple logistic regression analysis was applied to identify an association between FMs and 28-day mortality. RESULTS Overall, 299 patients were included. A total of 47 (16%) experienced a significant hemorrhage. The ROC curve demonstrated that FMs had a poor accuracy to predict the occurrence of significant hemorrhage with an AUC of 0.65 (0.57-0.74). The best threshold at 92.45 µg/ml had excellent sensitivity (87%) and negative predictive value (95%), but was not independently associated with significant hemorrhage (OR = 1.5; 95%CI (0.5-4.2)). The 28-day mortality rate was 5%. In simple logistic regression analysis, FMs values ≥109.5 µg/ml were significantly associated with 28-day mortality (unadjusted OR = 13.2; 95%CI (1.7-102)). CONCLUSIONS FMs levels at admission are not associated with the occurrence of a significant hemorrhage in patients with severe trauma. However, the excellent sensitivity and NPV of FMs could help to identify patients with a low risk of severe bleeding during hospital care. In addition, FMs levels ≥109.5 µg/ml might be predictive of 28-day mortality.
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Affiliation(s)
- Pierre Esnault
- Intensive Care Unit, Sainte Anne Military Hospital, Toulon, France.
| | - Quentin Mathais
- Intensive Care Unit, Sainte Anne Military Hospital, Toulon, France
| | | | - Jean Cotte
- Intensive Care Unit, Sainte Anne Military Hospital, Toulon, France
| | | | | | | | - Julien Bordes
- Intensive Care Unit, Sainte Anne Military Hospital, Toulon, France; French Military Health Service Academy Unit, Ecole du Val-de-Grâce, Paris, France
| | - Eric Meaudre
- Intensive Care Unit, Sainte Anne Military Hospital, Toulon, France; French Military Health Service Academy Unit, Ecole du Val-de-Grâce, Paris, France
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26
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Chen H, Jing Y, Xu Z, Yang D, Ju S, Guo Y, Tian H, Xue L. Upregulation of C Terminus of Hsc70-Interacting Protein Attenuates Apoptosis and Procoagulant Activity and Facilitates Brain Repair After Traumatic Brain Injury. Front Neurosci 2020; 14:925. [PMID: 33013306 PMCID: PMC7506102 DOI: 10.3389/fnins.2020.00925] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 08/11/2020] [Indexed: 12/16/2022] Open
Abstract
Traumatic brain injury (TBI) could highly induce coagulopathy through breaking the dynamic balance between coagulation and fibrinolysis systems, which may be a major contributor to the progressive secondary injury cascade that occurs after TBI. Phosphatase and tensin homolog deleted on chromosome 10 (PTEN) inhibition is reported to exert neuroprotection in TBI, making it a potential regulatory target involved in TBI-induced coagulation disorder. PTEN level is controlled in a major way by E3 ligase-mediated degradation through the ubiquitin-proteasome system. The C terminus of Hsc70-interacting protein (CHIP) has been shown to regulate proteasomal degradation and ubiquitination level of PTEN. In the present study, CHIP was overexpressed and knocked down in mouse brain microvascular endothelial cells (bEnd.3) and tissues during the early phase of TBI. In vitro cell proliferation, cell apoptosis, migration capacity, and invasion capacity were determined. The changes of procoagulant and apoptosis molecules after TBI were also detected as well as the micrangium density and blood-brain barrier permeability after in vivo TBI. In vitro results demonstrated that CHIP overexpression facilitated bEnd.3 cell proliferation, migration, and invasion and downregulated cell apoptosis and the expressions of procoagulant molecules through promoting PTEN ubiquitination in a simulated TBI model with stretch-induced injury treatment. In vivo experiments also demonstrated that CHIP overexpression suppressed post-TBI apoptosis and procoagulant protein expressions, as well as increased microvessel density, reduced hemorrhagic injury, and blood-brain barrier permeability. These findings suggested that the upregulation of CHIP may attenuate apoptosis and procoagulant activity, facilitate brain repair, and thus exerts neuroprotective effects in TBI.
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Affiliation(s)
- Hao Chen
- Department of Neurosurgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Yao Jing
- Department of Neurosurgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Zhiming Xu
- Department of Neurosurgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Dianxu Yang
- Department of Neurosurgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Shiming Ju
- Department of Neurosurgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Yan Guo
- Department of Neurosurgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Hengli Tian
- Department of Neurosurgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Lixia Xue
- Department of Neurology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
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27
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Waits CMK, Bower A, Simms KN, Feldman BC, Kim N, Sergeant S, Chilton FH, VandeVord PJ, Langefeld CD, Rahbar E. A Pilot Study Assessing the Impact of rs174537 on Circulating Polyunsaturated Fatty Acids and the Inflammatory Response in Patients with Traumatic Brain Injury. J Neurotrauma 2020; 37:1880-1891. [PMID: 32253986 DOI: 10.1089/neu.2019.6734] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Traumatic brain injury (TBI) is a leading cause of death and disability in persons under age 45. The hallmark secondary injury profile after TBI involves dynamic interactions between inflammatory and metabolic pathways including fatty acids. Omega-3 polyunsaturated fatty acids (PUFAs) such as docosahexaenoic acid (DHA) have been shown to provide neuroprotective benefits by minimizing neuroinflammation in rodents. These effects have been less conclusive in humans, however. We postulate genetic variants influencing PUFA metabolism in humans could contribute to these disparate findings. Therefore, we sought to (1) characterize the circulating PUFA response and (2) evaluate the impact of rs174537 on inflammation after TBI. A prospective, single-center, observational pilot study was conducted to collect blood samples from Level-1 trauma patients (N = 130) on admission and 24 h post-admission. Plasma was used to quantify PUFA levels and inflammatory cytokines. Deoxyribonucleic acid was extracted and genotyped at rs174537. Associations between PUFAs and inflammatory cytokines were analyzed for all trauma cases and stratified by race (Caucasians only), TBI (TBI: N = 47; non-TBI = 83) and rs174537 genotype (GG: N = 33, GT/TT: N = 44). Patients with TBI had higher plasma DHA levels compared with non-TBI at 24 h post-injury (p = 0.013). The SNP rs174537 was associated with both PUFA levels and inflammatory cytokines (p < 0.05). Specifically, TBI patients with GG genotype exhibited the highest plasma levels of DHA (1.33%) and interleukin-8 (121.5 ± 43.3 pg/mL), which were in turn associated with poorer outcomes. These data illustrate the impact of rs174537 on the post-TBI response. Further work is needed to ascertain how this genetic variant directly influences inflammation after trauma.
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Affiliation(s)
- Charlotte Mae K Waits
- Department of Biomedical Engineering, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Virginia Tech-Wake Forest University School of Biomedical Engineering and Sciences, Winston-Salem, North Carolina, USA
| | - Aaron Bower
- Bowman Gray Center for Medical Education, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Kelli N Simms
- Department of Biomedical Engineering, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Virginia Tech-Wake Forest University School of Biomedical Engineering and Sciences, Winston-Salem, North Carolina, USA
| | - Bradford C Feldman
- Department of Biology, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Nathan Kim
- Bowman Gray Center for Medical Education, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Susan Sergeant
- Department of Biochemistry, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Floyd H Chilton
- Department of Physiology and Pharmacology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Nutritional Sciences and the BIO5 Institute, University of Arizona, Tucson, Arizona, USA
| | - Pamela J VandeVord
- Virginia Tech-Wake Forest University School of Biomedical Engineering and Sciences, Winston-Salem, North Carolina, USA
- Department of Biomedical Engineering and Mechanics, Virginia Tech, Blacksburg, Virginia, USA
| | - Carl D Langefeld
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Elaheh Rahbar
- Department of Biomedical Engineering, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Virginia Tech-Wake Forest University School of Biomedical Engineering and Sciences, Winston-Salem, North Carolina, USA
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28
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Prothrombin complex concentrate for vitamin K antagonist reversal in traumatic intracranial hemorrhage. J Clin Neurosci 2020; 79:197-202. [PMID: 33070895 DOI: 10.1016/j.jocn.2020.07.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/28/2020] [Accepted: 07/03/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Administration of prothrombin complex concentrate (PCC) is recommended for vitamin K antagonist (VKA) reversal in patients with severe bleeding complications. However, there are only limited data available on its use for VKA reversal in patients with traumatic intracranial hemorrhage (ICH). METHODS Data from all anticoagulated patients referred to our hospital for treatment of traumatic ICH and who received PCC for anticoagulation reversal were retrospectively analysed with specific focus on bleeding and thromboembolic complications during the further in-hospital course. RESULTS A total of 142 patients were included in the present study. The median age was 78 years (Interquartile range [IQR]: 72-84) and the median Glasgow Coma Scale (GCS) score on admission was 12 (IQR: 7-14). Median International Normalized Ratio (INR) on admission was 2.5 [IQR: 2.0-3.3] and decreased to 1.2 [IQR: 1.1-1.3] following administration of a median dose of 2000 I.U. PCC [IQR: 1500-2625]. The in-hospital mortality rate was 13% and the median GCS of survivors at discharge was 14 [IQR: 12-15]. Thromboembolic events after PCC administration occurred in 4 patients (2.8%). The overall one-year mortality rate in this patient cohort was 49%. CONCLUSIONS PCC administration rapidly normalises INR and facilitates urgent neurosurgical procedures in anticoagulated patients with traumatic ICH.
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Rimaitis M, Bilskienė D, Tamošuitis T, Vilcinis R, Rimaitis K, Macas A. Implementation of Thromboelastometry for Coagulation Management in Isolated Traumatic Brain Injury Patients Undergoing Craniotomy. Med Sci Monit 2020; 26:e922879. [PMID: 32620738 PMCID: PMC7357252 DOI: 10.12659/msm.922879] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Coagulopathy (CP) is a modifiable factor linked with secondary brain damage and poor outcome of traumatic brain injury (TBI). A shift towards goal-directed coagulation management has been observed recently. We investigated whether rotational thromboelastometry (ROTEM) based management could be successfully implemented in TBI patients and improve outcomes. MATERIAL AND METHODS A prospective, case-control study was performed. Adult patients with isolated TBI requiring craniotomy were included in this study. All patients underwent standard coagulation tests (SCT). Patients were identified as either in control group or in case group. Patients in the case group were additionally tested with ROTEM to specify their coagulation status. Management of the patients in the control group was based on SCT, whereas management of patients in the case group was guided by ROTEM. Outcome measures were as follows: CP rate, protocol adhesion, blood loss, transfusions, progressive hemorrhagic injury (PHI), re-intervention, Glasgow coma score (GCS) and Glasgow outcome score (GOS) at discharge, and in-hospital mortality. RESULTS There were 134 patients enrolled (65 patients in the control group and 69 patients in the case group). Twenty-six patients in the control group (40%) were found to be coagulopathic (control-CP subgroup) and 34 patients in the case group (49.3%) were found to be coagulopathic (case-CP subgroup). Twenty-five case-CP patients had ROTEM abnormalities triggering protocolized intervention, and 24 of them were treated. Overall ROTEM-based protocol adhesion rate was 85.3%. Postoperative ROTEM parameters of case-CP patients significantly improved, and the number of coagulopathic patients decreased. The incidence of PHI (control versus case group) and neurosurgical re-intervention (control-CP versus case-CP subgroup) was in favor of ROTEM guidance (P<0.05). Mortality and GCS and GOS at discharge did not differ significantly between groups. CONCLUSIONS ROTEM led to consistent coagulation management, improved clot quality, and decreased incidence of PHI and neurosurgical re-intervention. Further studies are needed to confirm benefits of ROTEM in cases of TBI.
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Affiliation(s)
- Marius Rimaitis
- Department of Anesthesiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Diana Bilskienė
- Department of Anesthesiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Tomas Tamošuitis
- Department of Neurosurgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Rimantas Vilcinis
- Department of Neurosurgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Kęstutis Rimaitis
- Department of Anesthesiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Andrius Macas
- Department of Anesthesiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
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30
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Incremental Prognostic Value of Coagulopathy in Addition to the Crash Score in Traumatic Brain Injury Patients. Neurocrit Care 2020; 34:130-138. [PMID: 32445108 PMCID: PMC7940299 DOI: 10.1007/s12028-020-00991-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background/objective Multivariable prognostic scores play an important role for clinical decision-making, information giving to patients/relatives, benchmarking and guiding clinical trial design. Coagulopathy has been implicated on trauma and critical care outcomes, but few studies have evaluated its role on traumatic brain injury (TBI) outcomes. Our objective was to verify the incremental prognostic value of routine coagulopathy parameters in addition to the CRASH-CT score to predict 14-day mortality in TBI patients. Methods This is a prospective cohort of consecutive TBI patients admitted to a tertiary university hospital Trauma intensive care unit (ICU) from March/2012 to January/2015. The prognostic performance of the coagulation parameters platelet count, prothrombin time (international normalized ratio, INR) and activated partial thromboplastin time (aPTT) ratio was assessed through logistic regression adjusted for the original CRASH-CT score. A new model, CRASH-CT-Coag, was created and its calibration (Brier scores and Hosmer–Lemeshow (H–L) test), discrimination [area under the receiver operating characteristic curve (AUC-ROC) and the integrated discrimination improvement (IDI)] and clinical utility (net reclassification index) were compared to the original CRASH-CT score. Results A total 517 patients were included (median age 39 years, 85.1% male, median admission glasgow coma scale 8, neurosurgery on 44.9%). The 14-day mortality observed and predicted by the original CRASH-CT was 22.8% and 26.2%, respectively. Platelet count < 100,000/mm3, INR > 1.2 and aPTT ratio > 1.2 were present on 11.3%, 65.0% and 27.2%, respectively, (at least one of these was altered on 70.6%). All three variables maintained statistical significance after adjustment for the CRASH-CT score. The CRASH-CT-Coag score outperformed the original score on calibration (brier scores 0.122 ± 0.216 vs 0.132 ± 0.202, mean difference 0.010, 95% CI 0.005–0.019, p = 0.036, respectively) and discrimination (AUC-ROC 0.854 ± 0.020 vs 0.813 ± 0.024, p = 0.014; IDI 5.0%, 95% CI 1.3–11.0%). Both scores showed the satisfactory H–L test results. The net reclassification index favored the new model. Considering the strata of low (< 10%), moderate (10–30%) and high (> 30%) risk of death, the CRASH-CT-Coag model yielded a global net correct reclassification of 22.9% (95% CI 3.8–43.4%). Conclusions The addition of early markers of coagulopathy—platelet count, INR and aPTT ratio—to the CRASH-CT score increased its accuracy. Additional studies are required to externally validate this finding and further investigate the coagulopathy role on TBI outcomes.
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31
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van Gent JAN, van Essen TA, Bos MHA, Cannegieter SC, van Dijck JTJM, Peul WC. Coagulopathy after hemorrhagic traumatic brain injury, an observational study of the incidence and prognosis. Acta Neurochir (Wien) 2020; 162:329-336. [PMID: 31741112 PMCID: PMC6982633 DOI: 10.1007/s00701-019-04111-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 10/14/2019] [Indexed: 01/28/2023]
Abstract
Background Traumatic brain injury is associated with high rates of mortality and morbidity. Trauma patients with a coagulopathy have a 10-fold increased mortality risk compared to patients without a coagulopathy. The aim of this study was to identify the incidence of coagulopathy and relate early coagulopathy to clinical outcome in patients with traumatic intracranial hemorrhages. Methods Between September 2015 and December 2016, 108 consecutive cranial trauma patients with traumatic intracranial hemorrhages were included in this study. To assess the relationship between patients with a coagulopathy and outcome, a chi-squared test was performed. Results A total of 29 out of the 108 patients (27%) with a traumatic intracranial hemorrhage developed a coagulopathy within 72 h after admission. Overall, a total of 22 patients (20%) died after admission of which ten were coagulopathic at emergency department presentation. Early coagulopathy in patients with traumatic brain injury is associated with progression of hemorrhagic injury (odds ratio 2.4 (95% confidence interval 0.8–8.0)), surgical intervention (odds ratio 2.8 (95% confidence interval 0.87–9.35)), and increased in-hospital mortality (odds ratio 23.06 (95% confidence interval 5.5–95.9)). Conclusion Patients who sustained a traumatic intracranial hemorrhage remained at risk for developing a coagulopathy until 72 h after trauma. Patients who developed a coagulopathy had a worse clinical outcome than patients who did not develop a coagulopathy.
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Affiliation(s)
- Jort A. N. van Gent
- Department of Neurosurgery, Leiden University Medical Center, University Neurosurgical Center Holland (UNCH), Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- HAGA Teaching Hospital, The Hague, The Netherlands
- Haaglanden Medical Center, The Hague, The Netherlands
| | - Thomas A. van Essen
- Department of Neurosurgery, Leiden University Medical Center, University Neurosurgical Center Holland (UNCH), Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- HAGA Teaching Hospital, The Hague, The Netherlands
- Haaglanden Medical Center, The Hague, The Netherlands
| | - Mettine H. A. Bos
- Division of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Suzanne C. Cannegieter
- Division of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeroen T. J. M. van Dijck
- Department of Neurosurgery, Leiden University Medical Center, University Neurosurgical Center Holland (UNCH), Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- HAGA Teaching Hospital, The Hague, The Netherlands
- Haaglanden Medical Center, The Hague, The Netherlands
| | - Wilco C. Peul
- Department of Neurosurgery, Leiden University Medical Center, University Neurosurgical Center Holland (UNCH), Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- HAGA Teaching Hospital, The Hague, The Netherlands
- Haaglanden Medical Center, The Hague, The Netherlands
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Ability of Fibrin Monomers to Predict Progressive Hemorrhagic Injury in Patients with Severe Traumatic Brain Injury. Neurocrit Care 2019; 33:182-195. [PMID: 31797276 DOI: 10.1007/s12028-019-00882-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Progressive hemorrhagic injury (PHI) is common in patients with severe traumatic brain injury (TBI) and is associated with poor outcomes. TBI-associated coagulopathy is frequent and has been described as risk factor for PHI. This coagulopathy is a dynamic process involving hypercoagulable and hypocoagulable states either one after the other either concomitant. Fibrin monomers (FMs) are a direct marker of thrombin action and thus reflect coagulation activation. This study sought to determine the ability of FM to predict PHI after severe TBI. METHODS We conducted a prospective, observational study including all severe TBI patients admitted in the trauma center. Between September 2011 and September 2016, we enrolled patients with severe TBI into the derivation cohort. Between October 2016 and December 2018, we recruited the validation cohort on the same basis. Study protocol included FM measurements and standard coagulation test at admission and two computed tomography (CT) scans (upon arrival and at least 6 h thereafter). A PHI was defined by an increment in size of initial lesion (25% or more) or the development of a new hemorrhage in the follow-up CT scan. Multivariate logistic regression analysis was applied to identify predictors of PHI. RESULTS Overall, 106 patients were included in the derivation cohort. Fifty-four (50.9%) experienced PHI. FM values were higher in these patients (151 [136.8-151] vs. 120.5 [53.3-151], p < 0.0001). The ROC curve demonstrated that FM had a fair accuracy to predict the occurrence of PHI with an area under curve of 0.7 (95% CI [0.6-0.79]). The best threshold was determined at 131.7 μg/ml. In the validation cohort of 54 patients, this threshold had a negative predictive value of 94% (95% CI [71-100]) and a positive predictive value of 49% (95% CI [32-66]). The multivariate logistic regression analysis identified 2 parameters associated with PHI: FM ≥ 131.7 (OR 6.8; 95% CI [2.8-18.1]) and Marshall category (OR 1.7; 95% CI [1.3-2.2]). Coagulopathy was not associated with PHI (OR 1.3; 95% CI [0.5-3.0]). The proportion of patients with an unfavorable functional neurologic outcome at 6-months follow-up was higher in patients with positive FM: 59 (62.1%) versus 16 (29.1%), p < 0.0001. CONCLUSIONS FM levels at admission had a fair accuracy to predict PHI in patients with severe TBI. FM values ≥ 131.7 μg/ml are independently associated with the occurrence of PHI.
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Rani P, Panda NB, Hazarika A, Ahluwalia J, Chhabra R. Trauma-Induced Coagulopathy: Incidence and Outcome in Patients with Isolated Traumatic Brain Injury in a Level I Trauma Care Center in India. Asian J Neurosurg 2019; 14:1175-1180. [PMID: 31903359 PMCID: PMC6896631 DOI: 10.4103/ajns.ajns_126_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Context: Trauma-induced coagulopathy (TIC) is life-threatening in head injury patients, and there is a lack of Indian data on its incidence and outcome. Aims: In this study, incidence and outcome related to coagulopathy were assessed in patients with moderate-to-severe isolated traumatic brain injury (iTBI). Settings and Design: A prospective observational study carried out in patients admitted within 24 h of injury. Materials and Methods: One hundred patients with moderate-to-severe iTBI were included. Samples for coagulation tests (prothrombin time [PT], PT index [PTI], international normalization ratio [INR], activated partial thromboplastin time, and platelet count) were collected at 5 points of time for 72 h. TIC was diagnosed if any three readings were abnormal during this period. Patients were also followed up posthospital discharge using the Glasgow Outcome Score (GOS) at 1 and 3 months. Statistical Analysis: Data were analyzed using SPSS ver. 21. Logistic regression analysis was employed to determine individual coagulation test as best predictors for mortality. P < 0.05 was considered statistically significant. Results: The incidence of TIC was found to be 62%; it was 63.75% in severe head injury and 55% in moderate head injury patients. Deranged INR at the time of hospital admission (odds ratio [OR] 4.38) and PTI at 24 h (OR 3.913) are highly predictive of mortality. There was no significant difference in GOS score at 1 and 3 months. Conclusions: The incidence of TIC in our study was 62% among iTBI patients. It contributes to increased mortality at 1 and 3 months. However, the neurological outcome was not different in between the groups.
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Affiliation(s)
- Poonam Rani
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nidhi Bidyut Panda
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Amarjyoti Hazarika
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Jasmina Ahluwalia
- Department of Pathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajesh Chhabra
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Yates AG, Anthony DC, Ruitenberg MJ, Couch Y. Systemic Immune Response to Traumatic CNS Injuries-Are Extracellular Vesicles the Missing Link? Front Immunol 2019; 10:2723. [PMID: 31824504 PMCID: PMC6879545 DOI: 10.3389/fimmu.2019.02723] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 11/06/2019] [Indexed: 12/16/2022] Open
Abstract
Inflammation following traumatic injury to the central nervous system (CNS) persists long after the primary insult and is known to exacerbate cell death and worsen functional outcomes. Therapeutic interventions targeting this inflammation have been unsuccessful, which has been attributed to poor bioavailability owing to the presence of blood-CNS barrier. Recent studies have shown that the magnitude of the CNS inflammatory response is dependent on systemic inflammatory events. The acute phase response (APR) to CNS injury presents an alternative strategy to modulating the secondary phase of injury. However, the communication pathways between the CNS and the periphery remain poorly understood. Extracellular vesicles (EVs) are membrane bound nanoparticles that are regulators of intercellular communication. They are shed from cells of the CNS including microglia, astrocytes, neurons and endothelial cells, and are able to cross the blood-CNS barrier, thus providing an attractive candidate for initiating the APR after acute CNS injury. The purpose of this review is to summarize the current evidence that EVs play a critical role in the APR following CNS injuries.
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Affiliation(s)
- Abi G Yates
- Department of Pharmacology, Medical Sciences Division, University of Oxford, Oxford, United Kingdom.,School of Biomedical Sciences, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Daniel C Anthony
- Department of Pharmacology, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
| | - Marc J Ruitenberg
- School of Biomedical Sciences, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Yvonne Couch
- Acute Stroke Programme, RDM-Investigative Medicine, University of Oxford, Oxford, United Kingdom
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Desmopressin is a transfusion sparing option to reverse platelet dysfunction in patients with severe traumatic brain injury. J Trauma Acute Care Surg 2019; 88:80-86. [DOI: 10.1097/ta.0000000000002521] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Goal-directed platelet transfusions correct platelet dysfunction and may improve survival in patients with severe traumatic brain injury. J Trauma Acute Care Surg 2019; 85:881-887. [PMID: 30124626 DOI: 10.1097/ta.0000000000002047] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Platelet dysfunction, defined as adenosine diphosphate inhibition greater than 60% on thromboelastogram, is an independent predictor of increased mortality in patients with severe traumatic brain injury (TBI). We changed our practice to transfuse platelets for all patients with severe TBI and platelet dysfunction. We hypothesized that platelet transfusions would correct platelet dysfunction and improve mortality in patients with severe TBI. METHODS This retrospective review included adult trauma patients admitted to our Level I trauma center from July 2015 to October 2016 with severe TBI (head Abbreviated Injury Scale score ≥ 3) who presented with platelet dysfunction and subsequently received a platelet transfusion. Serial thromboelastograms were obtained to characterize the impact of platelet transfusion on clot strength. Subsequently, the platelet transfusion group was compared to a group of historical controls with severe TBI patients and platelet dysfunction who did not receive platelet transfusion. RESULTS A total of 35 patients with severe TBI presented with platelet dysfunction. Following platelet transfusion clot strength improved as represented by decreased K time, increased α angle, maximum amplitude, and G-value, as well as correction of adenosine diphosphate inhibition. When comparing to 51 historic controls with severe TBI and platelet dysfunction, the 35 study patients who received a platelet transfusion had a lower mortality (9% vs. 35%; p = 0.005). In stepwise logistic regression, platelet transfusion was independently associated with decreased mortality (odds ratio, 0.23; 95% confidence interval, 0.06-0.92; p = 0.038). CONCLUSION In patients with severe TBI and platelet dysfunction, platelet transfusions correct platelet inhibition and may be associated with decreased mortality. LEVEL OF EVIDENCE Therapeutic, level II.
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Adediran T, Drumheller BC, McCunn M, Stein DM, Albrecht JS. Sex Differences in In-hospital Complications Among Older Adults After Traumatic Brain Injury. J Surg Res 2019; 243:427-433. [PMID: 31279269 DOI: 10.1016/j.jss.2019.05.053] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 05/23/2019] [Accepted: 05/30/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Older adults have the highest rates of hospitalization and mortality after traumatic brain injury (TBI) and suffer poorer outcomes compared with younger adults with similar injuries. Non-neurological complications can significantly impact outcomes. Evidence suggests that women may have better outcomes after TBI. However, sex differences in in-hospital complications among older adults after TBI have not been studied. The objective of this study was to assess sex differences in in-hospital complications after TBI among adults aged 65 y and older. METHODS We conducted a retrospective cohort study of adults aged ≥65 y treated for isolated moderate to severe TBI at the R Adams Cowley Shock Trauma Center between 1996 and 2012. Using the Shock Trauma Center registry, we identified TBI using the International Classification of Disease, Ninth Revision, Clinical Modification codes and required an abbreviated injury scale head score ≥3, abbreviated injury scale scores for other body regions ≤2, and a blunt injury mechanism. We searched the Shock Trauma Center registry for the International Classification of Disease, Ninth Revision, Clinical Modification codes representing in-hospital complications. RESULTS Of 2511 patients meeting inclusion criteria, 1283 (51.1%) were men and 635 (25.1%) developed an in-hospital complication. Men were more likely than women to develop an in-hospital complication (28.1% versus 22.0, P < 0.001). In an adjusted analysis, men were at increased risk of any in-hospital complication (hazards ratio 1.23; 95% confidence interval 1.05, 1.44) compared with women. CONCLUSIONS Older men were more likely to have any in-hospital complications than women.
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Affiliation(s)
- Timileyin Adediran
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland.
| | - Byron C Drumheller
- Program in Trauma, Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Maureen McCunn
- Department of Anesthesiology, Divisions of Trauma Anesthesiology and Surgical Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Deborah M Stein
- Program in Trauma, Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jennifer S Albrecht
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
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Salem AM, Roh D, Kitagawa RS, Choi HA, Chang TR. Assessment and management of coagulopathy in neurocritical care. JOURNAL OF NEUROCRITICAL CARE 2019. [DOI: 10.18700/jnc.190086] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Albert V, Arulselvi S, Agrawal D, Pati HP, Pandey RM. Early posttraumatic changes in coagulation and fibrinolysis systems in isolated severe traumatic brain injury patients and its influence on immediate outcome. Hematol Oncol Stem Cell Ther 2019; 12:32-43. [DOI: 10.1016/j.hemonc.2018.09.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 08/23/2018] [Accepted: 09/06/2018] [Indexed: 12/27/2022] Open
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Hussmann B, Schoeneberg C, Jungbluth P, Heuer M, Lefering R, Maek T, Hildebrand F, Lendemans S, Pape HC. Enhanced prehospital volume therapy does not lead to improved outcomes in severely injured patients with severe traumatic brain injury. BMC Emerg Med 2019; 19:13. [PMID: 30674281 PMCID: PMC6343344 DOI: 10.1186/s12873-019-0221-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 01/04/2019] [Indexed: 11/25/2022] Open
Abstract
Background Whether enhanced prehospital volume therapy leads to outcome improvements in severely injured patients with severe traumatic brain injury (TBI) remains controversial. The aim of this study was to investigate the influence of prehospital volume therapy on the clinical course of severely injured patients with severe TBI. Methods Data for 122,672 patients from TraumaRegister DGU® (TR-DGU) was analyzed. Inclusion criteria were defined as follows: Injury Severety Score (ISS) ≥ 16, primary admission, age ≥ 16 years, Abbreviated Injury Scale (AIS) head ≥3, administration of at least one unit of packed red blood cells (pRBCs), and available volume and blood pressure data. Stratification based on the following matched-pair criteria was performed: group 1: prehospital volumes of 0-1000 ml; group 2: prehospital volumes of ≥1501 ml; AIS head (3, 4, 5 + 6 and higher than for other body regions); age (16-54, 55-69, ≥ 70 years); gender; prehospital intubation (yes/no); emergency treatment time +/− 30 min.; rescue resources (rescue helicopter, emergency ambulance); blood pressure (20-60, 61-90, ≥ 91 mmHg); year of accident (2002-2005, 2006-2009, 2010-2012); AIS thorax, abdomen, and extremities plus pelvis. Results A total of 169 patients per group fulfilled the inclusion criteria. Increasing volume administration was associated with reduced coagulation capability and reduced hemoglobin (Hb) levels (prothrombin ratio: group 1: 68%, group 2: 63.7%; p ≤ 0.04; Hb: group 1: 11.2 mg/dl, group 2: 10.2 mg/dl; p ≤ 0.001). It was not possible to show a significant reduction in the mortality rate with increasing volumes (group 1: 45.6, group 2: 45.6; p = 1). Conclusions The data presented in this study demonstrates that prehospital volume administration of more than 1500 ml does not improve severely injured patients with severe traumatic brain injury (TBI).
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Affiliation(s)
- Bjoern Hussmann
- Trauma Surgery Department, Alfried Krupp Hospital, Alfried-Krupp-Str. 21, 45131, Essen, Germany.
| | - Carsten Schoeneberg
- Trauma Surgery Department, Alfried Krupp Hospital, Alfried-Krupp-Str. 21, 45131, Essen, Germany
| | - Pascal Jungbluth
- Department of Trauma and Hand Surgery, University Hospital, Duesseldorf, Germany
| | | | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Witten, Germany
| | - Teresa Maek
- Trauma Surgery Department, Alfried Krupp Hospital, Alfried-Krupp-Str. 21, 45131, Essen, Germany
| | - Frank Hildebrand
- Clinic for Trauma and Reconstructive Surgery, University Hospital RWTH, Aachen, Germany
| | - Sven Lendemans
- Trauma Surgery Department, Alfried Krupp Hospital, Alfried-Krupp-Str. 21, 45131, Essen, Germany
| | - Hans-Christoph Pape
- Department of Trauma, University Hospital and University of Zurich, Zürich, Switzerland
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Nakae R, Yokobori S, Yokota H. Coagulopathy and Brain Injury. Neurocrit Care 2019. [DOI: 10.1007/978-981-13-7272-8_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Podolsky-Gondim GG, Furlanetti LL, Viana DC, Ballestero MFM, de Oliveira RS. The role of coagulopathy on clinical outcome following traumatic brain injury in children: analysis of 66 consecutive cases in a single center institution. Childs Nerv Syst 2018; 34:2455-2461. [PMID: 30334071 DOI: 10.1007/s00381-018-3989-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 10/10/2018] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Head injury is a significant economic, social, and medical problem in developing countries and remains one of the leading causes of pediatric morbidity and mortality. The association of traumatic brain injury and coagulopathy in children is linked with an increase in mortality and poor functional outcomes. However, its impact on long-term outcome has not been discussed in the literature so far. OBJECTIVES The aim of this paper was to investigate the effect of coagulopathy diagnosed by routine laboratory tests on neurological outcome following traumatic brain injury in children. METHODS A retrospective review was carried out using medical records of children with a traumatic brain injury admitted at a level I trauma center, between January 2013 and December 2016, submitted to any neurosurgical procedures. Statistical analysis was performed accordingly to identify factors predicting unfavorable or favorable outcomes at 1- and 6-month follow-ups. Data regarding age, gender, trauma mechanism, Glasgow Coma Scale at admission and at discharge, highest and lowest stable intracranial pressure, serum glucose and coagulation assessment, radiological findings, and length of stay were analyzed. RESULTS We identified 66 children with surgical head trauma. Mean age was 10.9 years (ranges from 3 months to 17 years), with male predominance (77.3%). Common mechanisms were road traffic accidents (66.7%), falls (19.7%), and blunt trauma (10.6%). Brain edema was detected in 68.2% of the patients, surgical fractures or intracranial bleeding in 75.8%. ICP monitoring was performed in 24.2% of the patients, and of these, 18.7% underwent consecutive decompressive craniectomy. Mean length of in-patient treatment was 16.3 ± 28.2 days. At 1- and 6-month follow-ups, favorable outcome was detected in 71.2 and 78.7% of the patients, respectively. The mortality rate was 12.1%. Routine coagulation assessments such as prothrombin time, fibrinogen levels, and thrombocyte count upon admission were potential prognostic variables identified. CONCLUSIONS The present study concluded that a trauma-related coagulopathy is an important predictor of unfavorable neurological outcome following TBI in pediatric patients. Initial GCS score, age, and neuroradiological findings, such as severe brain edema and different types of intracranial bleeding, correlated with GOS in the first 6 months following TBI. Sustained intracranial hypertension also predicted unfavorable outcome and death in this series.
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Affiliation(s)
- Guilherme Gozzoli Podolsky-Gondim
- Division of Pediatric Neurosurgery, Department of Surgery and Anatomy, University Hospital, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, 14049-900, Brazil
| | | | - Dinark Conceição Viana
- Division of Pediatric Neurosurgery, Department of Surgery and Anatomy, University Hospital, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, 14049-900, Brazil
| | - Matheus Fernando Manzolli Ballestero
- Division of Pediatric Neurosurgery, Department of Surgery and Anatomy, University Hospital, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, 14049-900, Brazil
| | - Ricardo Santos de Oliveira
- Division of Pediatric Neurosurgery, Department of Surgery and Anatomy, University Hospital, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, 14049-900, Brazil.
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Condron M, Rowell S, Dewey E, Anderson T, Lealiiee L, Farrell D, Hinson H. The procoagulant molecule plasminogen activator inhibitor-1 is associated with injury severity and shock in patients with and without traumatic brain injury. J Trauma Acute Care Surg 2018; 85:888-893. [PMID: 30086072 PMCID: PMC6309418 DOI: 10.1097/ta.0000000000002040] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Traumatic injury is associated with an increased risk of coagulopathy and venous thrombosis. plasminogen activator inhibitor-1 (PAI-1) is a procoagulant molecule that inhibits tPA/uPA, thrombomodulin, and activated protein C. We hypothesized that elevated PAI-1 levels would be associated with increased Injury Severity Score (ISS) in injured patients with and without traumatic brain injury and that PAI-1 levels would vary with injury type. METHODS We retrospectively analyzed demographic, ISS, and hemodynamic data from a prospectively collected database. Patients with traumatic injury requiring intensive care unit admission (n = 268) were classified as multiple injuries, isolated body, or isolated head based on Abbreviated Injury Severity score. Admission PAI-1 levels were quantified using a Luminex analyte platform. Univariate tests for association informed the construction of a multivariate model of the relationship between PAI-1 and ISS. RESULTS Plasminogen activator inhibitor-1 positively associated with ISS (p < 0.0001) and was highest in patients with ISS greater than 35 (p < 0.0001). Plasminogen activator inhibitor-1 was significantly different between multiple injuries, isolated body, and isolated head patients (p < 0.0001). On univariate analysis, age (p = 0.0011), hypotension (p = 0.0076), and alcohol intoxication (p = 0.0024) were all positively associated with PAI-1 level. Admission international normalized ratio was not associated with PAI-1 level (p = 0.638). After adjusting for age, sex, hypotension, and alcohol intoxication, higher PAI-1 levels were associated with higher ISS (p < 0.0001). CONCLUSION Elevated PAI-1 at admission is associated with higher ISS. This association is more pronounced in patients with hypotension. These findings suggest that PAI-1 levels may reflect the burden of endothelial damage and platelet activation after injury. LEVEL OF EVIDENCE Prognostic, level III.
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Affiliation(s)
- Mary Condron
- From the Division of Trauma, Critical Care & Acute Care Surgery (M.C., S.R., E.D., T.A., L.L., D.F., H.H.), Oregon Health & Science University, Portland, Oregon
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Tang Z, Huang Q, Zhang J, Yang R, Wei W, Liu H. Fourteen-Day Mortality in Pediatric Patients with Traumatic Brain Injury After Early Decompressive Craniectomy: A Single-Center Retrospective Study. World Neurosurg 2018; 119:e389-e394. [PMID: 30071325 DOI: 10.1016/j.wneu.2018.07.173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 07/18/2018] [Accepted: 07/20/2018] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The purpose of this study was to analyze the risk factors for 14-day mortality in pediatric patients undergoing early decompressive craniectomy (DC) after traumatic brain injury (TBI). METHODS This retrospective analysis included all pediatric patients (≤16 years of age) undergoing DC within 12 hours of TBI between August 2011 and July 2017 at the authors' institute. Demographic information, clinical characteristics, surgical information, and laboratory parameters were retrieved from medical records. Risk factors for 14-day mortality were analyzed using multivariate logistic regression models. First, potentially relevant variables were compared between those who died within 14 days versus those who did not. Variables with P < 0.10 were entered into the final multivariate regression analysis. RESULTS A total of 36 patients (23 boys and 13 girls; median age, 7 years) were included in the analysis. Fall (n = 19, 52.8%) was the leading cause of injury. The 14-day mortality was 38.9% (14/36). At the time of admission, the median Glasgow Score Scale (GCS) was 6 (IQR 4-8), and the mean Injury Severity Score (ISS) (± standard deviation) was 29.03 ± 8.54. Preoperative hypoxia, defined as oxyhemoglobin arterial saturation <90% or apnea >20 seconds, was observed in 6 patients (16.7%). Coagulopathy was present in 14 patients (38.9%). Multivariate logistic regression analysis suggested an association between 14-day mortality and younger age (odds ratio [OR] = 0.708, 95% confidence interval [CI]: 0.513-0.978; P = 0.036) and higher ISS (OR = 1.399; 95% CI: 1.023-1.914; P = 0.035). CONCLUSIONS In children undergoing early DC after TBI, risk factors for 14-day mortality include younger age and higher ISS.
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Affiliation(s)
- Zhiji Tang
- Department of Neurosurgery, the Affiliated Brain Hospital, Nanjing Medical University, Nanjing, People's Republic of China; Department of Neurosurgery, Ganzhou People's Hospital, Ganzhou, People's Republic of China
| | - Qianliang Huang
- Department of Neurosurgery, Ganzhou People's Hospital, Ganzhou, People's Republic of China
| | - Jinshi Zhang
- Department of Neurosurgery, Ganzhou People's Hospital, Ganzhou, People's Republic of China
| | - Ruijin Yang
- Department of Neurosurgery, Ganzhou People's Hospital, Ganzhou, People's Republic of China
| | - Wenjin Wei
- Department of Neurosurgery, Ganzhou People's Hospital, Ganzhou, People's Republic of China
| | - Hongyi Liu
- Department of Neurosurgery, the Affiliated Brain Hospital, Nanjing Medical University, Nanjing, People's Republic of China.
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Hendrickson CM, Gibb SL, Miyazawa BY, Keating SM, Ross E, Conroy AS, Calfee CS, Pati S, Cohen MJ. Elevated plasma levels of TIMP-3 are associated with a higher risk of acute respiratory distress syndrome and death following severe isolated traumatic brain injury. Trauma Surg Acute Care Open 2018; 3:e000171. [PMID: 30023434 PMCID: PMC6045722 DOI: 10.1136/tsaco-2018-000171] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 05/10/2018] [Indexed: 01/15/2023] Open
Abstract
Background: Complications after injury, such as acute respiratory distress syndrome (ARDS), are common after traumatic brain injury (TBI) and associated with poor clinical outcomes. The mechanisms driving non-neurologic organ dysfunction after TBI are not well understood. Tissue inhibitor of matrix metalloproteinase-3 (TIMP-3) is a regulator of matrix metalloproteinase activity, inflammation, and vascular permeability, and hence has plausibility as a biomarker for the systemic response to TBI. Methods: In a retrospective study of 182 patients with severe isolated TBI, we measured TIMP-3 in plasma obtained on emergency department arrival. We used non-parametric tests and logistic regression analyses to test the association of TIMP-3 with the incidence of ARDS within 8 days of admission and in-hospital mortality. Results: TIMP-3 was significantly higher among subjects who developed ARDS compared with those who did not (median 2810 pg/mL vs. 2260 pg/mL, p=0.008), and significantly higher among subjects who died than among those who survived to discharge (median 2960 pg/mL vs. 2080 pg/mL, p<0.001). In an unadjusted logistic regression model, for each SD increase in plasma TIMP-3, the odds of ARDS increased significantly, OR 1.5 (95% CI 1.1 to 2.1). This association was only attenuated in multivariate models, OR 1.4 (95% CI 1.0 to 2.0). In an unadjusted logistic regression model, for each SD increase in plasma TIMP-3, the odds of death increased significantly, OR 1.7 (95% CI 1.2 to 2.3). The magnitude of this association was greater in a multivariate model adjusted for markers of injury severity, OR 1.9 (95% CI 1.2 to 2.8). Discussion: TIMP-3 may play an important role in the biology of the systemic response to brain injury in humans. Along with clinical and demographic data, early measurements of plasma biomarkers such as TIMP-3 may help identify patients at higher risk of ARDS and death after severe isolated TBI. Level of evidence III.
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Affiliation(s)
- Carolyn M Hendrickson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Stuart L Gibb
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, California, USA.,Blood Systems Research Institute, San Francisco, California, USA
| | - Byron Y Miyazawa
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, California, USA.,Blood Systems Research Institute, San Francisco, California, USA.,Department of Surgery, University of California San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Sheila M Keating
- Blood Systems Research Institute, San Francisco, California, USA
| | - Erin Ross
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Amanda S Conroy
- Department of Surgery, University of California San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Carolyn S Calfee
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Shibani Pati
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, California, USA.,Blood Systems Research Institute, San Francisco, California, USA
| | - Mitchell J Cohen
- Department of Surgery, University of California San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California, USA.,Department of Surgery, University of Colorado, Denver, Colorado, USA
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Sympathoadrenal Activation is Associated with Acute Traumatic Coagulopathy and Endotheliopathy in Isolated Brain Injury. Shock 2018; 46:96-103. [PMID: 27206278 PMCID: PMC4978599 DOI: 10.1097/shk.0000000000000642] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background: Acute coagulopathy after traumatic brain injury (TBI) involves a complex multifactorial hemostatic response that is poorly characterized. Objectives: To examine early posttraumatic alterations in coagulofibrinolytic, endothelial, and inflammatory blood biomarkers in relation to sympathetic nervous system (SNS) activation and 6-month patient outcomes, using multivariate partial least-squares (PLS) analysis. Patients and Methods: A multicenter observational study of 159 adult isolated TBI patients admitted to the emergency department at an urban level I trauma center, was performed. Plasma concentrations of 6 coagulofibrinolytic, 10 vascular endothelial, 19 inflammatory, and 2 catecholamine biomarkers were measured by immunoassay on admission and 24 h postinjury. Neurological outcome at 6 months was assessed using the Extended Glasgow Outcome Scale. PLS-discriminant analysis was used to identify salient biomarker contributions to unfavorable outcome, whereas PLS regression analysis was used to evaluate the covariance between SNS correlates (catecholamines) and biomarkers of coagulopathy, endotheliopathy, and inflammation. Results: Biomarker profiles in patients with an unfavorable outcome displayed procoagulation, hyperfibrinolysis, glycocalyx and endothelial damage, vasculature activation, and inflammation. A strong covariant relationship was evident between catecholamines and biomarkers of coagulopathy, endotheliopathy, and inflammation at both admission and 24 h postinjury. Conclusions: Biomarkers of coagulopathy and endotheliopathy are associated with poor outcome after TBI. Catecholamine levels were highly correlated with endotheliopathy and coagulopathy markers within the first 24 h after injury. Further research is warranted to characterize the pathogenic role of SNS-mediated hemostatic alterations in isolated TBI.
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Acute Traumatic Endotheliopathy in Isolated Severe Brain Injury and Its Impact on Clinical Outcome. Med Sci (Basel) 2018; 6:medsci6010005. [PMID: 29337920 PMCID: PMC5872162 DOI: 10.3390/medsci6010005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 01/08/2018] [Accepted: 01/10/2018] [Indexed: 12/31/2022] Open
Abstract
Study design: Prospective observational cohort. Objective: To investigate the difference in plasma levels of syndecan-1 (due to glycocalyx degradation) and soluble thrombomodulin (due to endothelial damage) in isolated severe traumatic brain injury (TBI) patients with/without early coagulopathy. A secondary objective was to compare the effects of the degree of TBI endotheliopathy on hospital mortality among patients with TBI-associated coagulopathy (TBI-AC). Methods: Data was prospectively collected on isolated severe TBI (sTBI) patients with Glasgow Coma Scale (GCS) ≤8 less than 12 h after injury admitted to a level I trauma centre. Isolated sTBI patients with samples withdrawn prior to blood transfusion were stratified by conventional coagulation tests as coagulopathic (prothrombin time (PT) ≥ 16.7 s, international normalized ratio (INR) ≥ 1.27, and activated partial thromboplastin time (aPTT) ≥ 28.8 s) and non-coagulopathic. Twenty healthy controls were also included. Plasma levels of thrombomodulin and syndecan-1 were estimated by ELISA. With receiver operating characteristic curve (ROC) analysis, we defined endotheliopathy as a syndecan-1 cut-off level that maximized the sum of sensitivity and specificity for predicting TBI-AC. Results: Inclusion criteria were met in 120 cases, with subjects aged 35.5 ± 12.6 years (88.3% males). TBI-AC was identified in 50 (41.6%) patients, independent of age, gender, and GCS, but there was an association with acidosis (60%; p = 0.01). Following isolated sTBI, we found insignificant changes in soluble thrombomodulin (sTM) levels between patients with isolated TBI and controls, and sTM levels were lower in coagulopathic compared to non-coagulopathic patients. Elevations in plasma syndecan-1 (ng/mL) levels were seen compared to control (31.1(21.5–30.6) vs. 24.8(18.5–30.6); p = 0.08). Syndecan-1(ng/mL) levels were significantly elevated in coagulopathic compared to non-coagulopathic patients (33.7(21.6–109.5) vs. 29.9(19.239.5); p = 0.03). Using ROC analysis (area under the curve = 0.61; 95% Confidence Interval (CI) 0.50 to 0.72), we established a plasma syndecan-1 level cutoff of ≥30.5 ng/mL (sensitivity % = 55.3, specificity % = 52.3), with a significant association with TBI-associated coagulopathy. Conclusion: Subsequent to brain injury, elevated syndecan-1 shedding and endotheliopathy may be associated with early coagulation abnormalities. A syndecan-1 level ≥30.5 ng/mL identified patients with TBI-AC, and may be of importance in guiding management and clinical decision-making.
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Yuan Q, Yu J, Wu X, Sun YR, Li ZQ, Du ZY, Wu XH, Hu J. Prognostic value of coagulation tests for in-hospital mortality in patients with traumatic brain injury. Scand J Trauma Resusc Emerg Med 2018; 26:3. [PMID: 29304855 PMCID: PMC5756421 DOI: 10.1186/s13049-017-0471-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 12/27/2017] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Coagulopathy is commonly observed after traumatic brain injury (TBI). However, it is not known whether using the standard independent predictors in conjunction with coagulation tests would improve their prognostic value. We determined the incidence of TBI-associated coagulopathy in patients with isolated TBI (iTBI), evaluated the prognostic value of coagulation tests for in-hospital mortality, and tested their predictive power for in-hospital mortality in patients with iTBI. METHODS We conducted a retrospective, observational database study on 2319 consecutive patients with iTBI who attended the Huashan Hospital Department of the Neurosurgery Neurotrauma Center at Fudan University in China between December 2004 and June 2015. Two models based on the admission characteristics were developed: model A included predictors such as age, Glasgow Coma Scale (GCS) score, pupil reactivity, type of injury, and hemoglobin and glucose levels, while model B included the predictors from model A as well as coagulation test results. A total of 1643 patients enrolled between December 2004 and December 2011 were used to derive the prognostic models, and 676 patients enrolled between January 2012 and June 2015 were used to validate the models. RESULTS Overall, 18.6% (n = 432) of the patients developed coagulopathy after iTBI. The prevalence of acute traumatic coagulopathy is associated with the severity of brain injury. The percentage of platelet count <100 × 109/L, international normalized ratio (INR) > 1.25, the prothrombin time (PT) > 14 s, activated partial thromboplastin time (APTT) > 36 s, D-dimer >5 mg/L and fibrinogen (FIB) < 1.5 g/L was also closely related to the severity of brain injury, significance being found among three groups. Age, pupillary reactivity, GCS score, epidural hematoma (EDH), and glucose levels were independent prognostic factors for in-hospital mortality in model A, whereas age, pupillary reactivity, GCS score, EDH, glucose levels, INR >1.25, and APTT >36 s exhibited strong prognostic effects in model B. Discrimination and calibration were good for the development group in both prediction models. However, the external validation test showed that calibration was better in model B than in model A for patients from the validation population (Hosmer-Lemeshow test, p = 0.152 vs. p = 0.046, respectively). CONCLUSIONS Coagulation tests can improve the predictive power of the standard model for in-hospital mortality after TBI.
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Affiliation(s)
- Qiang Yuan
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040, People's Republic of China
| | - Jian Yu
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040, People's Republic of China
| | - Xing Wu
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040, People's Republic of China
| | - Yi-Rui Sun
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040, People's Republic of China
| | - Zhi-Qi Li
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040, People's Republic of China
| | - Zhuo-Ying Du
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040, People's Republic of China
| | - Xue-Hai Wu
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040, People's Republic of China
| | - Jin Hu
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040, People's Republic of China.
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Cheng SX, Xu ZW, Yi TL, Sun HT, Yang C, Yu ZQ, Yang XS, Jin XH, Tu Y, Zhang S. iTRAQ-Based Quantitative Proteomics Reveals the New Evidence Base for Traumatic Brain Injury Treated with Targeted Temperature Management. Neurotherapeutics 2018; 15:216-232. [PMID: 29247448 PMCID: PMC5794703 DOI: 10.1007/s13311-017-0591-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
This study aimed to investigate the effects of targeted temperature management (TTM) modulation on traumatic brain injury (TBI) and the involved mechanisms using quantitative proteomics technology. SH-SY5Y and HT-22 cells were subjected to moderate stretch injury using the cell injury controller (CIC), followed by incubation at TTM (mild hypothermia, 32°C), or normothermia (37°C). The real-time morphological changes, cell cycle phase distribution, death, and cell viability were evaluated. Moderate TBI was produced by the controlled cortical impactor (CCI), and the effects of TTM on the neurological damage, neurodegeneration, cerebrovascular histopathology, and behavioral outcome were determined in vivo. Results showed that TTM treatment prevented TBI-induced neuronal necrosis in the brain, achieved a substantial reduction in neuronal death both in vitro and in vivo, reduced cortical lesion volume and neuronal loss, attenuated cerebrovascular histopathological damage, brain edema, and improved behavioral outcome. Using an iTRAQ proteomics approach, proteins that were significantly associated with TTM in experimental TBI were identified. Importantly, changes in four candidate molecules (plasminogen [PLG], antithrombin III [AT III], fibrinogen gamma chain [FGG], transthyretin [TTR]) were verified using TBI rat brain tissues and TBI human cerebrospinal fluid (CSF) samples. This study is one of the first to investigate the neuroprotective effects of TTM on the proteome of human and experimental models of TBI, providing an overall landscape of the TBI brain proteome and a scientific foundation for further assessment of candidate molecules associated with TTM for the promotion of reparative strategies post-TBI.
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Affiliation(s)
- Shi-Xiang Cheng
- Tianjin Key Laboratory of Neurotrauma Repair, Institute of Traumatic Brain Injury and Neuroscience, Center for Neurology and Neurosurgery of Affiliated Hospital, Logistics University of Chinese People's Armed Police Force (PAP), Tianjin, China.
| | - Zhong-Wei Xu
- Central Laboratory of Logistics University of Chinese People's Armed Police Force (PAP), Tianjin, China
| | - Tai-Long Yi
- Tianjin Key Laboratory of Neurotrauma Repair, Institute of Traumatic Brain Injury and Neuroscience, Center for Neurology and Neurosurgery of Affiliated Hospital, Logistics University of Chinese People's Armed Police Force (PAP), Tianjin, China
| | - Hong-Tao Sun
- Tianjin Key Laboratory of Neurotrauma Repair, Institute of Traumatic Brain Injury and Neuroscience, Center for Neurology and Neurosurgery of Affiliated Hospital, Logistics University of Chinese People's Armed Police Force (PAP), Tianjin, China
| | - Cheng Yang
- Tianjin Key Laboratory of Neurotrauma Repair, Institute of Traumatic Brain Injury and Neuroscience, Center for Neurology and Neurosurgery of Affiliated Hospital, Logistics University of Chinese People's Armed Police Force (PAP), Tianjin, China
| | - Ze-Qi Yu
- Tianjin Key Laboratory of Neurotrauma Repair, Institute of Traumatic Brain Injury and Neuroscience, Center for Neurology and Neurosurgery of Affiliated Hospital, Logistics University of Chinese People's Armed Police Force (PAP), Tianjin, China
| | - Xiao-Sa Yang
- Tianjin Key Laboratory of Neurotrauma Repair, Institute of Traumatic Brain Injury and Neuroscience, Center for Neurology and Neurosurgery of Affiliated Hospital, Logistics University of Chinese People's Armed Police Force (PAP), Tianjin, China
| | - Xiao-Han Jin
- Central Laboratory of Logistics University of Chinese People's Armed Police Force (PAP), Tianjin, China
| | - Yue Tu
- Tianjin Key Laboratory of Neurotrauma Repair, Institute of Traumatic Brain Injury and Neuroscience, Center for Neurology and Neurosurgery of Affiliated Hospital, Logistics University of Chinese People's Armed Police Force (PAP), Tianjin, China.
| | - Sai Zhang
- Tianjin Key Laboratory of Neurotrauma Repair, Institute of Traumatic Brain Injury and Neuroscience, Center for Neurology and Neurosurgery of Affiliated Hospital, Logistics University of Chinese People's Armed Police Force (PAP), Tianjin, China.
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Folkerson LE, Sloan D, Davis E, Kitagawa RS, Cotton BA, Holcomb JB, Tomasek JS, Wade CE. Coagulopathy as a predictor of mortality after penetrating traumatic brain injury. Am J Emerg Med 2018; 36:38-42. [DOI: 10.1016/j.ajem.2017.06.057] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 06/20/2017] [Accepted: 06/21/2017] [Indexed: 11/29/2022] Open
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