Predictors of deterioration indicating a requirement for surgery in mild to moderate traumatic brain injury

Plasma D-dimer levels are a biomarker for in-hospital complications and long-term mortality in patients with traumatic brain injury

Introduction

Traumatic brain injury (TBI) is a major health concern worldwide. D-dimer levels, commonly used in the diagnosis and treatment of neurological diseases, may be associated with adverse events in patients with TBI. However, the relationship between D-dimer levels, TBI-related in-hospital complications, and long-term mortality in patients with TBI has not been investigated. Here, examined whether elevated D-dimer levels facilitate the prediction of in-hospital complications and mortality in patients with TBI.

Methods

Overall, 1,338 patients with TBI admitted to our institute between January 2016 and June 2022 were retrospectively examined. D-dimer levels were assessed within 24 h of admission, and propensity score matching was used to adjust for baseline characteristics.

Results

Among the in-hospital complications, high D-dimer levels were associated with electrolyte metabolism disorders, pulmonary infections, and intensive care unit admission (p < 0.05). Compared with patients with low (0.00-1.54 mg/L) D-dimer levels, the odds of long-term mortality were significantly higher in all other patients, including those with D-dimer levels between 1.55 mg/L and 6.35 mg/L (adjusted hazard ratio [aHR] 1.655, 95% CI 0.9632.843), 6.36 mg/L and 19.99 mg/L (aHR 2.38, 95% CI 1.416-4.000), and >20 mg/L (aHR 3.635, 95% CI 2.195-6.018; p < 0.001). D-dimer levels were positively correlated with the risk of death when the D-dimer level reached 6.82 mg/L.

Conclusion

Overall, elevated D-dimer levels at admission were associated with adverse outcomes and may predict poor prognosis in patients with TBI. Our findings will aid in the acute diagnosis, classification, and management of TBI.

Hyperosmolar therapies for neurological deterioration in mild and moderate traumatic brain injury: A scoping review

OBJECTIVE

To explore the available evidence on hyperosmolar therapies(HT) in mild and moderate traumatic brain injury(TBI) and to evaluate the effects on outcomes.A scoping review was conducted according to the Joanna Briggs Institute methodology. Inclusion criteria: (a)randomized controlled trials(RCTs), prospective and retrospective cohort studies and case-control studies; (b)all-ages mild and moderate TBIs; (c)HT administration; (d)functional outcomes recorded; (e)comparator group.

RESULTS

From 4424 records, only 3 respected the inclusion criteria. In a retrospective cohort study of adult moderate TBIs, the Glasgow Coma Scale(GCS) remained the same at 48 hours in those treated with hypertonic saline(HTS) while it worsened in the non-treated. A trend toward increased pulmonary infections and length of stay was found. In an RCT of adult severe and moderate TBIs, moderate TBIs treated with HTS showed a trend toward better secondary outcomes than standard care alone, with similar odds of adverse effects. An RCT enrolling children with mild TBI found a significant improvement in concussive pain immediately after HTS administration and after 2-3 days. No adverse events occurred.

CONCLUSIONS

A gap in the literature about HTs' role in mild and moderate TBI was found. Some benefits may exist with limited side effects and further studies are desirable.

Trauma-induced pulmonary thromboembolism: What's update?

Trauma-induced pulmonary thromboembolism is the second leading cause of death in severe trauma patients. Primary fibrinolytic hyperactivity combined with hemorrhage and consequential hypercoagulability in severe trauma patients create a huge challenge for clinicians. It is crucial to ensure a safe anticoagulant therapy for trauma patients, but a series of clinical issues need to be answered first, for example, what are the risk factors for traumatic venous thromboembolism? How to assess and determine the status of coagulation dysfunction of patients? When is the optimal timing to initiate pharmacologic prophylaxis for venous thromboembolism? What types of prophylactic agents should be used? How to manage the anticoagulation-related hemorrhage and to determine the optimal timing of restarting chemoprophylaxis? The present review attempts to answer the above questions.

Changes in Outcomes after Discharge from an Acute Hospital in Severe Traumatic Brain Injury

Neurological improvement occurs from the subacute to chronic phases in severe traumatic brain injury. We analyzed factors associated with improved neurological findings in the subacute phase, using data from the Japan Neurotrauma Data Bank (JNTDB). The subjects were 1345 patients registered in the JNTDB (Project 2015). Clinical improvement was evaluated by comparing the Glasgow Outcome Scale (GOS) at discharge and 6 months after injury. Of these patients, 157 with severe disability (SD) on the discharge GOS were examined to evaluate factors associated with neurological improvement in the subacute phase. Cases were defined as those with (group I) and without (group N) improvement: a change from SD at discharge to good recovery (GR) or moderate disability (MD) at 6 months after injury. Patient background, admission findings, treatment, and discharge destination were examined. In all patients, the favorable outcome (GR, MD) rate improved from 30.2% at discharge to 35.7% at 6 months after injury. Of SD cases at discharge, 44.6% had a favorable outcome at 6 months (group I). Patients in group I were significantly younger, and had a significantly lower D-dimer level in initial blood tests and a lower incidence of convulsions. In multivariate analysis, discharge to home was a significant factor associated with an improved outcome. Many SD cases at discharge ultimately showed neurological improvement, and the initial D-dimer level may be a predictor of such improvement. The environment after discharge from an acute care hospital may also contribute to an improved long-term prognosis.

Combined Radiomics Model for Prediction of Hematoma Progression and Clinical Outcome of Cerebral Contusions in Traumatic Brain Injury

BACKGROUND

Traumatic brain injury is a common and devastating injury that is the leading cause of neurological disability and death worldwide. Patients with cerebral lobe contusion received conservative treatment because of their mild manifestations, but delayed intracranial hematoma may increase and even become life-threatening. We explored the noninvasive method to predict the prognosis of progression and Glasgow Outcome Scale (GOS) by using a quantitative radiomics approach and statistical analysis.

METHODS

Eighty-eight patients who were pathologically diagnosed were retrospectively studied. The radiomics method developed in this work included image segmentation, feature extraction, and feature selection. The nomograms were established based on statistical analysis and a radiomics method. We conducted a comparative study of hematoma progression and GOS between the clinical factor alone and fusion radiomics features.

RESULTS

Nineteen clinical factors, 513 radiomics features, and 116 locational features were considered. Among clinical factors, international normalized ratio, prothrombin time, and fibrinogen were enrolled for hematoma progression. As for GOS, treatment strategy, age, Glasgow Coma Scale score, and blood platelet were associated factors. Eight features for GOS and five features for hematoma progression were filtered by using sparse representation and locality preserving projection-combined method. Four nomograms were constructed. After fusion radiomics features, area under the curve of hematoma progression prediction increased from 0.832 to 0.899, whereas GOS prediction went from 0.794 to 0.844.

CONCLUSIONS

A radiomic-based model that merges radiomics and clinical features is a noninvasive approach to predict hematoma progression and clinical outcomes of cerebral contusions in traumatic brain injury.

Poor prognostic factors in elderly patients aged 75 years old or older with mild traumatic brain injury

The incidence of traumatic brain injury (TBI) in elderly patients is increasing. We retrospectively investigated the poor prognostic factors at discharge in elderly patients aged 75 years or older admitted to hospital with mild TBI. We continuously enrolled 83 patients aged 75 years or older with mild TBI, in a private general Japanese hospital. The Glasgow Coma Scale scores on admission were within the range of 13-15. Patients with good recovery or moderate disability were included in the "good outcome" group, and those with severe disability, in a persistent vegetative state, or who died were included in the "poor outcome" group. We performed statistical analyses using 8 parameters. We conducted a univariate analysis on each item. Next, we conducted a logistic regression analysis on variables where the p < 0.20 in the univariate analysis. Elderly patients had a poor prognosis when they had dementia (odds ratio [OR]: 20.357, 95% confidence interval [CI]: 2.075-199.683, p = 0.010), cancer (OR: 14.005, 95% CI: 1.262-154.444, p = 0.032), or a history of antithrombotic therapy before admission (OR: 6.673, 95% CI: 1.072-41.526, p = 0.042). When elderly patients aged 75 years or older with mild TBI have the 3 poor prognostic factors of dementia, cancer, or a history of antithrombotic therapy, their outcomes might be worse compared to other elderly patients. Elderly patients who have these factors should be carefully managed.

Intracranial pressure management and neurological outcome for patients with mild traumatic brain injury who required neurosurgical intervention: a Japanese database study

Purpose: Among mild traumatic brain injuries (mTBI; a Glasgow Coma Scale score ≥13 on arrival), few result in severe neurological deficit, especially when they needed neurosurgical intervention. We investigated the association of intracranial pressure (ICP) control management with neurological outcome in patients with mTBI who needed neurosurgical intervention. Methods: From 1,092 records of the Japan Neurotrauma Data Bank during 2009-2011, we retrospectively identified 195 patients with neurosurgical intervention for mTBI. Using the Glasgow Outcome Scale, we grouped records into two: favorable and poor outcome. We analyzed neurological outcomes using a logistic regression analysis adjusted for ICP control managements. Results: Seventy patients had a poor outcome. Logistic regression analysis revealed that sedatives, hyperosmotic agents, and hyperventilation therapy were significantly associated with poor outcome (odds ratio [OR]: 2.36, 95% confidence interval [CI]: 1.31-4.26; OR: 2.81, 95% CI: 1.17-6.75; OR: 9.36, 95% CI: 1.81-48.35). However, temperature management was significantly related with favorable outcome (OR: 0.26, 95% CI: 0.10-0.66). Conclusions: Our study, using a Japanese multicenter brain trauma registry, suggested that requirement of sedatives, hyperosmotic agents, and hyperventilation is associated with poor neurological outcome for patients with mTBI who underwent neurosurgical intervention, although temperature management was associated with favorable neurological outcome.

Probability of Soluble Tissue Factor Release Lead to the Elevation of D-dimer as a Biomarker for Traumatic Brain Injury

D-dimer is a potential biomarker for the detection of traumatic brain injury (TBI). However, the mechanisms that trigger elevation of D-dimer in TBI remain unclear. The purpose of this study was to evaluate the reliability of D-dimer in blood as a biomarker for TBI and to determine the mechanisms involved in regulating its blood levels. Nine patients with moderate to severe isolated TBI (Glasgow Coma Scale [GCS] score 7–13) were admitted to our hospital from May 2013 to June 2014. Blood samples were collected from systemic arteries on arrival and at 1, 3, 5, and 7 days after injury. Blood levels of neuron specific enolase (NSE), D-dimer, and soluble tissue factor (sTF) were measured. NSE (33.4 ng/ml: normal <12.0 ng/ml) and D-dimer (56.1 μg/ml: normal <1.0 μg/ml) were elevated at admission and declined on day 1 after injury. At admission, there were significant correlations of D-dimer levels with NSE (R = 0.727, P = 0.026) and sTF (R = 0.803, P = 0.009) levels. The blood level of D-dimer accurately reflects the degree of brain tissue damage indicated by NSE levels. Our data suggest that release of sTF induced by brain tissue damage may activate the coagulation cascade, leading to elevation of D-dimer.

The significance of the levels of fibrin/fibrinogen degradation products for predicting trauma severity

Background:

On initial treatment in the emergency room, trauma patients should be assessed using simple clinical indicators that can be measured quickly.

Objectives:

The purpose of this study is to investigate the relationship between the injury severity score and blood test parameters measured on emergency room arrival in trauma patients.

Methods:

Trauma patients transferred to Gunma University Hospital between May 2013 and April 2014 were evaluated in this prospective, observational study. Blood samples were collected immediately on their arrival at our emergency room and their hematocrit, platelet, international normalized ratio of prothrombin time, activated partial thromboplastin time, fibrin/fibrinogen degradation products, and D-dimer were measured. We evaluated the correlations between the injury severity score and those biomarkers, and examined whether the correlation varied according to the injury severity score value. We also evaluated the correlations between the biomarkers and the abbreviated injury scale values of six regions.

Results:

We analyzed 371 patients. Fibrin/fibrinogen degradation products and D-dimer showed the greatest coefficients of correlation with injury severity score (0.556 and 0.543, respectively). The area under the curve of the receiver operating characteristic was larger in patients with injury severity score ⩾ 9 than in those with injury severity score ⩾ 4; however, patients with injury severity score ⩾ 9 or ⩾16 showed no significant differences. The area under the curve of fibrin/fibrinogen degradation products was larger than that of D-dimer at all injury severity score values. The chest abbreviated injury scale had the strongest relationship with fibrin/fibrinogen degradation products.

Conclusion:

Fibrin/fibrinogen degradation products and D-dimer were positively correlated with injury severity score, and the relationships varied according to trauma severity. Chest trauma contributed most strongly to fibrin/fibrinogen degradation product elevation.

Preoperative elevated FDP may predict severe intraoperative hypotension after dural opening during decompressive craniectomy of traumatic brain injury

Purpose

Coagulation disorder and intraoperative hypotension are representative complications of traumatic brain injury which cause worse perioperative outcome. The aim of this study was to survey the relation of coagulation disorder and intraoperative hypotension (IH) during decompressive craniectomy.

Method

Patients who underwent emergency decompressive craniectomy due to traumatic brain injury were retrospectively surveyed. The relation between preoperative coagulation date and intraoperative hypotension (systolic blood pressure < 60 mmHg after dural opening) was analyzed.

Results

Of 41 patients screened, 12 patients (27.9%) developed IH. Fibrinogen degradation products (314 vs 64.4 μg/mL; p = 0.01) were significantly higher in the IH group. In contrast, fibrinogen (181 vs 239 mg/dL; p = 0.01) was significantly lower in the IH group. Reduction rate of sBRP before and after dural opening (%) was higher in IH group than in non-IH group (49.1 vs 27.6%: p = 0.001).

Conclusions

Preoperative elevated FDP may predict IH after dural opening during traumatic decompressive craniectomy.

Hyperfibrinolysis in severe isolated traumatic brain injury may occur without tissue hypoperfusion: a retrospective observational multicentre study

BACKGROUND

Hyperfibrinolysis is a critical complication in severe trauma. Hyperfibrinolysis is traditionally diagnosed via elevated D-dimer or fibrin/fibrinogen degradation product levels, and recently, using thromboelastometry. Although hyperfibrinolysis is observed in patients with severe isolated traumatic brain injury (TBI) on arrival at the emergency department (ED), it is unclear which factors induce hyperfibrinolysis. The present study aimed to investigate the factors associated with hyperfibrinolysis in patients with isolated severe TBI.

METHODS

We conducted a multicentre retrospective review of data for adult trauma patients with an injury severity score ≥ 16, and selected patients with isolated TBI (TBI group) and extra-cranial trauma (non-TBI group). The TBI group included patients with an abbreviated injury score (AIS) for the head ≥ 4 and an extra-cranial AIS < 2. The non-TBI group included patients with an extra-cranial AIS ≥ 3 and head AIS < 2. Hyperfibrinolysis was defined as a D-dimer level ≥ 38 mg/L on arrival at the ED. We evaluated the relationships between hyperfibrinolysis and injury severity/tissue injury/tissue perfusion in TBI patients by comparing them with non-TBI patients.

RESULTS

We enrolled 111 patients in the TBI group and 126 in the non-TBI group. In both groups, patients with hyperfibrinolysis had more severe injuries and received transfusion more frequently than patients without hyperfibrinolysis. Tissue injury, evaluated on the basis of lactate dehydrogenase and creatine kinase levels, was associated with hyperfibrinolysis in both groups. Among patients with TBI, the mortality rate was higher in those with hyperfibrinolysis than in those without hyperfibrinolysis. Tissue hypoperfusion, evaluated on the basis of lactate level, was associated with hyperfibrinolysis in only the non-TBI group. Although the increase in lactate level was correlated with the deterioration of coagulofibrinolytic variables (prolonged prothrombin time and activated partial thromboplastin time, decreased fibrinogen levels, and increased D-dimer levels) in the non-TBI group, no such correlation was observed in the TBI group.

CONCLUSIONS

Hyperfibrinolysis is associated with tissue injury and trauma severity in TBI and non-TBI patients. However, tissue hypoperfusion is associated with hyperfibrinolysis in non-TBI patients, but not in TBI patients. Tissue hypoperfusion may not be a prerequisite for the occurrence of hyperfibrinolysis in patients with isolated TBI.

Update in mild traumatic brain injury

There has been concern for many years regarding the identification of patients with mild traumatic brain injury (TBI) at high risk of developing an intracranial lesion (IL) that would require neurosurgical intervention. The small percentage of patients with these characteristics and the exceptional mortality associated with mild TBI with IL have led to the high use of resources such as computerised tomography (CT) being reconsidered. The various protocols developed for the management of mild TBI are based on the identification of risk factors for IL, which ultimately allows more selective indication or discarding both the CT application and the hospital stay for neurological monitoring. Finally, progress in the study of brain injury biomarkers with prognostic utility in different clinical categories of TBI has recently been incorporated by several clinical practice guidelines, which has allowed, together with clinical assessment, a more accurate prognostic approach for these patients to be established.

Clinical Significance of Fibrinogen Degradation Product Among Traumatized Patients

OBJECTIVE

We retrospectively analyzed trauma patients who were transported by a physician-staffed helicopter (doctor helicopter) to investigate the clinical significance of the fibrinogen degradation product (FDP) level on arrival.

METHODS

From February 2011 to July 2016, a medical chart review was retrospectively performed for all patients with trauma who were transported by the doctor helicopter. The subjects were divided into 2 groups: a survival group and a fatal group.

RESULTS

There were 135 patients in the survival group and 16 in the fatal group. The ratio of head injury, value of Injury Severity Score (ISS), and level of FDP in the fatal group were significantly greater than in the survival group. The average Glasgow Coma Scale and systolic blood pressure in the fatal group were significantly smaller than in the survival group. The FDP level at arrival was positively associated with the ISS (R = 0.74, P < .0001). After excluding subjects with shock, unconsciousness, and head injury, the FDP level was still positively associated with the ISS (R = 0.60, P < .0001).

CONCLUSION

Therefore, the FDP level may be a useful biochemical parameter for the initial evaluation of the severity of trauma, even in blunt trauma patients without head injury or with stable vital signs.

Fibrinogen degradation product levels on arrival for trauma patients requiring a transfusion even without head injury

BACKGROUND

There have been few reports on the clinical significance of the fibrinogen degradation product (FDP) level in trauma patients with and without head injury. We retrospectively analyzed trauma patients with or without head injury to investigate the clinical significance of the FDP level.

METHODS

From April 2013 to June 2015, a medical chart review was retrospectively performed for all patients with trauma. The exclusion criteria included patients who did not receive a transfusion. The patients were divided into two groups: a FDP>100 group, which included patients who had an FDP level on arrival over 100 ng/mL, and a FDP≤100 group.

RESULTS

The ratio of open fractures and the prothrombin ratio in the FDP>100 group were significantly smaller than those observed in the FDP≤100 group. The average age, ratio of blunt injury, Injury Severity Score (ISS), volume of transfusion and mortality ratio in the FDP>100 group were significantly greater than those in the FDP≤100 group. There was a weakly positive correlation between the FDP level and ISS (R=0.35, P=0.002), but it was not associated with the transfusion volume. The results of an analysis excluding patients with head injury showed a similar tendency.

CONCLUSION

The FDP levels may be a useful biochemical parameter for the initial evaluation of the severity of trauma and mortality even in blunt traumatized patients without head injury or with stable vital signs.