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Iaccarino C, Carretta A, Demetriades AK, Di Minno G, Giussani C, Marcucci R, Marklund N, Mastrojanni G, Pompucci A, Stefini R, Zona G, Cividini A, Petrella G, Coluccio V, Marietta M. Management of Antithrombotic Drugs in Patients with Isolated Traumatic Brain Injury: An Intersociety Consensus Document. Neurocrit Care 2024; 40:314-327. [PMID: 37029314 DOI: 10.1007/s12028-023-01715-3] [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: 01/04/2023] [Accepted: 03/07/2023] [Indexed: 04/09/2023]
Abstract
BACKGROUND All available recommendations about the management of antithrombotic therapies (ATs) in patients who experienced traumatic brain injury (TBI) are mainly based on expert opinion because of the lack of strength in the available evidence-based medicine. Currently, the withdrawal and the resumption of AT in these patients is empirical, widely variable, and based on the individual assessment of the attending physician. The main difficulty is to balance the thrombotic and hemorrhagic risks to improve patient outcome. METHODS Under the endorsement of the Neurotraumatology Section of Italian Society of Neurosurgery, the Italian Society for the Study about Haemostasis and Thrombosis, the Italian Society of Anaesthesia, Analgesia, Resuscitation, and Intensive Care, and the European Association of Neurosurgical Societies, a working group (WG) of clinicians completed two rounds of questionnaires, using the Delphi method, in a multidisciplinary setting. A table for thrombotic and bleeding risk, with a dichotomization in high risk and low risk, was established before questionnaire administration. In this table, the risk is calculated by matching different isolated TBI (iTBI) scenarios such as acute and chronic subdural hematomas, extradural hematoma, brain contusion (intracerebral hemorrhage), and traumatic subarachnoid hemorrhage with patients under active AT treatment. The registered indication could include AT primary prevention, cardiac valve prosthesis, vascular stents, venous thromboembolism, and atrial fibrillation. RESULTS The WG proposed a total of 28 statements encompassing the most common clinical scenarios about the withdrawal of antiplatelets, vitamin K antagonists, and direct oral anticoagulants in patients who experienced blunt iTBI. The WG voted on the grade of appropriateness of seven recommended interventions. Overall, the panel reached an agreement for 20 of 28 (71%) questions, deeming 11 of 28 (39%) as appropriate and 9 of 28 (32%) as inappropriate interventions. The appropriateness of intervention was rated as uncertain for 8 of 28 (28%) questions. CONCLUSIONS The initial establishment of a thrombotic and/or bleeding risk scoring system can provide a vital theoretical basis for the evaluation of effective management in individuals under AT who sustained an iTBI. The listed recommendations can be implemented into local protocols for a more homogeneous strategy. Validation using large cohorts of patients needs to be developed. This is the first part of a project to update the management of AT in patients with iTBI.
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Affiliation(s)
- Corrado Iaccarino
- Department of Biomedical, Metabolic and Neural Sciences, School of Neurosurgery, University of Modena and Reggio Emilia, Modena, Italy
- Neurosurgery Division, "Nocsae" Hospital of Baggiovara, University Hospital of Modena, Modena, Italy
- Emergency Neurosurgery Unit, AUSL RE IRCCS, "ASMN" Hospital of Reggio Emilia, Reggio Emilia, Italy
| | - Alessandro Carretta
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy.
| | | | - Giovanni Di Minno
- Regional Reference Center for Coagulation Disorders, Federico II University Hospital, Naples, Italy
- Department of Clinical and Surgical Medicine, Federico II University of Naples, Naples, Italy
| | - Carlo Giussani
- Department of Neurosurgery, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Rossella Marcucci
- Center for Atherothrombotic Disease, Department of Experimental and Clinical Medicine, Careggi University Hospital, University of Florence, Florence, Italy
| | - Niklas Marklund
- Department of Neuroscience, Neurosurgery, Uppsala University, Uppsala, Sweden
- Department of Clinical Sciences, Department of Neurosurgery, Skåne University Hospital, Lund University, Lund, Sweden
| | | | - Angelo Pompucci
- Neurosurgery Division, ASL Latina Ospedale Santa Maria Goretti, Latina, Italy
| | - Roberto Stefini
- Neurosurgery Division, Department of Neurosciences, Head, Neck and Neurosurgery, Ospedale Civile di Legnano, Legnano, Italy
| | - Gianluigi Zona
- Neurosurgery Division, Department of Neurosciences (DINOGMI), IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Andrea Cividini
- Neurosurgery Division, Department of Neurosciences, Head, Neck and Neurosurgery, Ospedale Civile di Legnano, Legnano, Italy
| | - Gianpaolo Petrella
- Neurosurgery Division, ASL Latina Ospedale Santa Maria Goretti, Latina, Italy
| | - Valeria Coluccio
- Department of Hematology and Oncology, Hemostasis and Thrombosis Unit, University Hospital of Modena, Modena, Italy
| | - Marco Marietta
- Department of Hematology and Oncology, Hemostasis and Thrombosis Unit, University Hospital of Modena, Modena, Italy
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Chen X, Wang X, Liu Y, Guo X, Wu F, Yang Y, Hu W, Zheng F, He H. Plasma D-dimer levels are a biomarker for in-hospital complications and long-term mortality in patients with traumatic brain injury. Front Mol Neurosci 2023; 16:1276726. [PMID: 37965038 PMCID: PMC10641409 DOI: 10.3389/fnmol.2023.1276726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 10/11/2023] [Indexed: 11/16/2023] Open
Abstract
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.
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Affiliation(s)
- Xinli Chen
- Department of Anesthesiology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Xiaohua Wang
- Department of Anesthesiology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Yingchao Liu
- Department of Anesthesiology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Xiumei Guo
- Department of Neurosurgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Fan Wu
- Department of Anesthesiology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Yushen Yang
- Department of Anesthesiology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Weipeng Hu
- Department of Neurosurgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Feng Zheng
- Department of Neurosurgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Hefan He
- Department of Anesthesiology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
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Dowlati E, Chesney K, Carpenter AB, Rock M, Patel N, Mai JC, Liu AH, Armonda RA, Felbaum DR. Awake transradial middle meningeal artery embolization and twist drill craniostomy for chronic subdural hematomas in the elderly: case series and technical note. J Neurosurg Sci 2023; 67:471-479. [PMID: 34114433 DOI: 10.23736/s0390-5616.21.05335-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Due to prohibitive perioperative risk factors, optimal treatment for chronic subdural hematomas (cSDH) in the elderly remains unclear. Minimally invasive techniques are a viable option and include bedside subdural evacuation port system (SEPS), as well as prevention of recurrence with middle meningeal artery (MMA) embolization. We present a case series of elderly patients undergoing combined transradial MMA embolization and bed-side craniostomy as primary treatment for cSDH. METHODS Patients 70 years and older from 2019 to 2020 that underwent single setting, awake transradial MMA embolization with concurrent SEPS placement under local anesthesia were included. Those with prior treatments, interventions performed under general anesthesia, or with less than 60-day follow-up were excluded. Descriptive analyses of baseline characteristics, radiologic parameters, comorbidities, and outcome measures were completed. RESULTS Twenty elderly patients (mean age of 81.0 years) with multiple comorbidities underwent 28 MMA embolization+SEPS procedures as primary treatment for cSDH. Mean cSDH thickness was 1.8cm±0.6 cm with 7.3±3.9 mm midline shift. All patients tolerated the procedure well. 1/20 (5.0%) patients died within 30 days of the procedure. A majority of patients were discharged to home (12/20; 60.0%). There was an average of 3.6-month follow-up and one patient (5.0%) developed recurrence in the follow-up period requiring further intervention. CONCLUSIONS In select elderly patients with high perioperative risk factors, primary treatment of cSDH using awake transradial MMA embolization+SEPS placement is a minimally invasive, feasible, and safe option. Further comparative studies are warranted to evaluate efficacy of the treatment.
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Affiliation(s)
- Ehsan Dowlati
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA -
| | - Kelsi Chesney
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | | | - Mitchell Rock
- Georgetown University School of Medicine, Washington, DC, USA
| | - Nirali Patel
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Jeffrey C Mai
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
- Department of Neurosurgery, MedStar Washington Hospital Center, Washington, DC, USA
| | - Ai-Hsi Liu
- Department of Radiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Rocco A Armonda
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
- Department of Neurosurgery, MedStar Washington Hospital Center, Washington, DC, USA
| | - Daniel R Felbaum
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
- Department of Neurosurgery, MedStar Washington Hospital Center, Washington, DC, USA
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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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Siahaan AMP, Susanto M, Luis D, Chairul M, Saragih SGR, Harahap AR. Delayed progressive intracranial bleeding in pediatric acute epidural hemorrhage treated expectantly. Int J Surg Case Rep 2023; 105:108005. [PMID: 36948051 PMCID: PMC10040690 DOI: 10.1016/j.ijscr.2023.108005] [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: 10/17/2022] [Revised: 03/07/2023] [Accepted: 03/16/2023] [Indexed: 03/24/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Progressive epidural hematoma (PEDH) after traumatic brain injury is usually found in the first 24 h after accident. However, EDH enlargement on day six after admission is rarely observed. PRESENTATION OF CASE We present the case of a 14-year-old boy who presented to the emergency room after a car accident with only a headache without any neurological deficit. The computed tomography (CT) scan revealed a slight epidural hematoma, which then treated expectantly. On day 6, the patient developed severe headache. CT-Scan showed enlarged epidural hematoma with significant mass effect. The emergency clot evacuation was completed successfully. CLINICAL DISCUSSION Progressive intracranial hemorrhage is any increase in pre-existing intracranial bleeding or the presence of a new hematoma on a CT scan. Young age and cranial fracture have been identified as risk factors for PEDH morbidity and mortality. Coagulation parameters may be a predictor of progressive intracranial bleeding, but their accuracy remains unclear. Still, the decision to conduct a CT scan as a follow-up is debatable, but it should be performed when neurological deterioration occurs. CONCLUSION Although rare, PEDH could still be occurred six days after trauma. Linear fracture and young age are among the risk factors. A thorough routine neurological examination is crucial in treating this condition.
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Affiliation(s)
| | - Martin Susanto
- Department of Neurosurgery, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia
| | - Donny Luis
- Division of Neurosurgery, Murni Teguh Memorial Hospital, Medan, Indonesia
| | - Muhammad Chairul
- Division of Neurosurgery, Mitra Sejati General Hospital, Medan, Indonesia
| | | | - Ade Ricky Harahap
- Division of Neurosurgery, Dr. M. Djamil General Hospital, Padang, Indonesia
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Wang R, Yang DX, Ding J, Guo Y, Ding WH, Tian HL, Yuan F. Classification, risk factors, and outcomes of patients with progressive hemorrhagic injury after traumatic brain injury. BMC Neurol 2023; 23:68. [PMID: 36782124 PMCID: PMC9926699 DOI: 10.1186/s12883-023-03112-x] [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: 06/30/2022] [Accepted: 02/08/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND According to the pathoanatomic classification system, progressive hemorrhagic injury (PHI) can be categorized into progressive intraparenchymal contusion or hematoma (pIPCH), epidural hematoma (pEDH), subdural hematoma (pSDH), and traumatic subarachnoid hemorrhage (ptSAH). The clinical features of each type differ greatly. The objective of this study was to determine the predictors, clinical management, and outcomes of PHI according to this classification. METHODS Multivariate logistic regression analysis was used to identify independent risk factors for PHI and each subgroup. Patients with IPCH or EDH were selected for subgroup propensity score matching (PSM) to exclude confounding factors before evaluating the association of hematoma progression with the outcomes by classification. RESULTS In the present cohort of 419 patients, 123 (29.4%) demonstrated PHI by serial CT scan. Of them, progressive ICPH (58.5%) was the most common type, followed by pEDH (28.5%), pSDH (9.8%), and ptSAH (3.2%). Old age (≥ 60 years), lower motor Glasgow Coma Scale score, larger primary lesion volume, and higher level of D-dimer were independent risk factors related to PHI. These factors were also independent predictors for pIPCH, but not for pEDH. The time to first CT scan and presence of skull linear fracture were robust risk factors for pEDH. After PSM, the 6-month mortality and unfavorable survival rates were significantly higher in the pIPCH group than the non-pIPCH group (24.2% vs. 1.8% and 12.1% vs. 7.3%, respectively, p < 0.001), but not significantly different between the pEDH group and the non-pEDH group. CONCLUSIONS Understanding the specific patterns of PHI according to its classification can help early recognition and suggest targeted prevention or treatment strategies to improve patients' neurological outcomes.
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Affiliation(s)
- Ren Wang
- grid.16821.3c0000 0004 0368 8293Department of Neurosurgery, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Dian-Xu Yang
- grid.16821.3c0000 0004 0368 8293Department of Neurosurgery, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jun Ding
- grid.16821.3c0000 0004 0368 8293Department of Neurosurgery, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yan Guo
- grid.16821.3c0000 0004 0368 8293Department of Neurosurgery, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Wan-Hai Ding
- grid.16821.3c0000 0004 0368 8293Department of Neurosurgery, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Heng-Li Tian
- Department of Neurosurgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
| | - Fang Yuan
- Department of Neurosurgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
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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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Fletcher-Sandersjöö A, Tatter C, Tjerkaski J, Bartek J, Maegele M, Nelson DW, Svensson M, Thelin EP, Bellander BM. Time Course and Clinical Significance of Hematoma Expansion in Moderate-to-Severe Traumatic Brain Injury: An Observational Cohort Study. Neurocrit Care 2023; 38:60-70. [PMID: 36167951 PMCID: PMC9935722 DOI: 10.1007/s12028-022-01609-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 09/09/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Preventing intracranial hematoma expansion has been advertised as a possible treatment opportunity in traumatic brain injury (TBI). However, the time course of hematoma expansion, and whether the expansion affects outcome, remains poorly understood. In light of this, the aim of this study was to use 3D volume rendering to determine how traumatic intracranial hematomas expand over time and evaluate its impact on outcome. METHODS Single-center, population-based, observational cohort study of adults with moderate-to-severe TBI. Hematoma expansion was defined as the change in hematoma volume from the baseline computed tomography scan until the lesion had stopped progressing. Volumes were calculated by using semiautomated volumetric segmentation. Functional outcome was measured by using the 12 month Glasgow outcome scale (GOS). RESULTS In total, 643 patients were included. The mean baseline hematoma volume was 4.2 ml, and the subsequent mean hematoma expansion was 3.8 ml. Overall, 33% of hematomas had stopped progressing within 3 h, and 94% of hematomas had stopped progressing within 24 h of injury. Contusions expanded significantly more, and for a longer period of time, than extra-axial hematomas. There was a significant dose-response relationship between hematoma expansion and 12 month GOS, even after adjusting for known outcome predictors, with every 1-ml increase in hematoma volume associated with a 6% increased risk of 1-point GOS deduction. CONCLUSIONS Hematoma expansion is a driver of unfavorable outcome in TBI, with small changes in hematoma volume also impacting functional outcome. This study also proposes a wider window of opportunity to prevent lesion progression than what has previously been suggested.
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Affiliation(s)
- Alexander Fletcher-Sandersjöö
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden. .,Department of Clinical Neuroscience, Karolinska Institutet, Bioclinicum J5:20, 171 64 , Solna, Stockholm, Sweden.
| | - Charles Tatter
- grid.24381.3c0000 0000 9241 5705Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden ,grid.4714.60000 0004 1937 0626Department of Clinical Neuroscience, Karolinska Institutet, Bioclinicum J5:20, 171 64 Solna, Stockholm, Sweden
| | - Jonathan Tjerkaski
- grid.4714.60000 0004 1937 0626Department of Clinical Neuroscience, Karolinska Institutet, Bioclinicum J5:20, 171 64 Solna, Stockholm, Sweden
| | - Jiri Bartek
- grid.24381.3c0000 0000 9241 5705Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden ,grid.4714.60000 0004 1937 0626Department of Clinical Neuroscience, Karolinska Institutet, Bioclinicum J5:20, 171 64 Solna, Stockholm, Sweden ,grid.475435.4Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
| | - Marc Maegele
- grid.412581.b0000 0000 9024 6397Department for Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center, Witten/Herdecke University, Cologne, Germany ,grid.412581.b0000 0000 9024 6397Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
| | - David W. Nelson
- grid.4714.60000 0004 1937 0626Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden ,grid.24381.3c0000 0000 9241 5705Function Perioperative Care and Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Mikael Svensson
- grid.24381.3c0000 0000 9241 5705Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden ,grid.4714.60000 0004 1937 0626Department of Clinical Neuroscience, Karolinska Institutet, Bioclinicum J5:20, 171 64 Solna, Stockholm, Sweden
| | - Eric Peter Thelin
- grid.4714.60000 0004 1937 0626Department of Clinical Neuroscience, Karolinska Institutet, Bioclinicum J5:20, 171 64 Solna, Stockholm, Sweden ,grid.24381.3c0000 0000 9241 5705Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Bo-Michael Bellander
- grid.24381.3c0000 0000 9241 5705Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden ,grid.4714.60000 0004 1937 0626Department of Clinical Neuroscience, Karolinska Institutet, Bioclinicum J5:20, 171 64 Solna, Stockholm, Sweden
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Mathur R, Suarez JI. Coagulopathy in Isolated Traumatic Brain Injury: Myth or Reality. Neurocrit Care 2022; 38:429-438. [PMID: 36513794 DOI: 10.1007/s12028-022-01647-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 11/09/2022] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Traumatic Brain Injury (TBI) has been shown to be associated with altered hemostasis and coagulopathy, that correlates with worsening secondary injury and clinical outcomes. Isolated Traumatic Brain Injury (iTBI), that is TBI without significant extracranial injuries, has also been shown to be associated with systemic coagulopathy and derangements in hemostasis. METHODS Literature Review. RESULTS Present your results in logical sequence in the text, tables, and figures, giving the main or most important findings first. Do not repeat all the data in the tables or figures in the text; emphasize or summarize only the most important observations. Provide data on all primary and secondary outcomes identified in the Methods section. Give numeric results not only as derivatives (e.g. percentages) but also as the absolute numbers from which the derivatives were calculated, and specify the statistical significance attached to them, if any. DISCUSSION In this review, we provide an overview of the pathophysiology of the hemostatic disturbances caused by iTBI, review key clinical findings and discrepancies in the way this question has been approached, describe the use and role of global viscoelastic assays such as the thromboelastrogram, and detail principles for reversal of pre-injury blood thinners. CONCLUSIONS iTBI is clearly associated with the development of coagulopathy, but the extent to which it occurs is confounded by the fact that many of the studies have included patients with moderate extracranial trauma into the iTBI category. The coagulopathy itself has been better studied in preclinical models, and the mechanisms driving it suggest a pattern consistent with disseminated intravascular coagulation with hyperfibrinolysis. We provide pragmatic clinical takeaways and suggestions for future research.
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Affiliation(s)
- Rohan Mathur
- Division of Neurosciences Critical Care, Departments of Neurology, Anesthesiology, and Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, 600 N Wolfe St, Phipps 455, Baltimore, MD, USA.
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Departments of Neurology, Anesthesiology, and Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, 600 N Wolfe St, Phipps 455, Baltimore, MD, USA
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10
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Jakowenko ND, Kopp BJ, Erstad BL. Appraising the use of tranexamic acid in traumatic and non‐traumatic intracranial hemorrhage: A narrative review. J Am Coll Emerg Physicians Open 2022; 3:e12777. [PMID: 35859856 PMCID: PMC9286528 DOI: 10.1002/emp2.12777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/06/2022] [Accepted: 06/16/2022] [Indexed: 11/17/2022] Open
Abstract
Recently there has been increasing interest and debate on the use of tranexamic acid (TXA), an antifibrinolytic drug, in both traumatic and non‐traumatic intracranial hemorrhage. In this review we aim to discuss recent investigations looking at TXA in traumatic brain injury (TBI) and different categories of spontaneous intracranial hemorrhage. We also discuss differences between setting (hospital vs pre‐hospital), dosing and timing strategies, and other logistical challenges surrounding optimal use of TXA for isolated intracranial hemorrhage. Last, we hope to provide guidance for clinicians when considering the use of TXA in a patient with traumatic or non‐traumatic intracranial hemorrhage based on appraisal of the available literature as well as some potential ideas for future research in this area.
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Affiliation(s)
| | - Brian J. Kopp
- Department of Pharmacy Banner University Medical Center–Tucson Tucson Arizona USA
| | - Brian L. Erstad
- Department of Pharmacy Practice and Science University of Arizona College of Pharmacy Tucson Arizona USA
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11
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Association of Thromboelastography with Progression of Hemorrhagic Injury in Children with Traumatic Brain Injury. Neurocrit Care 2022; 38:326-334. [PMID: 35896767 DOI: 10.1007/s12028-022-01562-8] [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: 04/18/2022] [Accepted: 06/16/2022] [Indexed: 10/16/2022]
Abstract
INTRODUCTION Progression of hemorrhagic injury (PHI) in children with traumatic brain injury portends poor outcomes. The association between thromboelastography (TEG), functional coagulation assays, and PHI is not well characterized in children. METHODS This was a retrospective cohort study of children presenting with PHI at a pediatric level I academic trauma center from 2015 to 2020. Inclusion criteria were as follows: age less than 18 years, intracranial hemorrhage on admission head computed tomography scan, and admission rapid TEG assay and conventional coagulation tests. PHI was defined by the following radiographic criteria: any expansion of or new intracranial hemorrhage on subsequent head computed tomography scan. Rapid TEG values included Activated Clotting Time (ACT), alpha angle, maximum amplitude, and lysis at 30 min. Wilcoxon rank-sum test was used to assess baseline differences between groups with PHI and without PHI, including laboratory assays. Univariate analysis was performed to examine the association between variables of interest and PHI. Patients were dichotomized on the basis of this cut point to generate a "low ACT" group and a "high ACT" group. These variables were included in a multivariable logistic regression model to determine independent association with traumatic brain injury progression. RESULTS In total, 219 patients met criteria for analysis. In this cohort, the median (interquartile range [IQR]) age = 6 (2-12) years, median (IQR) Injury Severity Score = 21 (11-27), 68% were boys, and 69% sustained blunt injury. The rate of PHI was 25% (54). Median (IQR) time to PHI was 1 (0-4) days. Children with PHI had a higher Injury Severity Score (p < 0.001), lower Glasgow Coma Scale (p < 0.001), greater incidence of shock (p = 0.04), and lower admission hemoglobin (p = 0.02) compared with those without PHI. Children with PHI had a higher International Normalized Ratio (INR) and longer TEG-ACT; other TEG values (alpha angle, maximum amplitude, and lysis at 30 min) were not associated with PHI. In the logistic regression model accounting for other covariates associated with PHI, elevated ACT remained an independent predictor of progression (odds ratio = 2.25, 95% confidence interval 1.09-4.66; p = 0.03; area under the receiver operating characteristic curve = 0.76). After adjusting for confounders, INR fell out of the model and was not an independent predictor of progression (odds ratio = 1.32, 95% confidence interval 0.60-2.93; p = 0.49). CONCLUSIONS Although INR was elevated in children with PHI and has been associated with poor clinical outcomes, only admission TEG-ACT was independently associated with PHI. Further study is warranted to determine whether TEG-ACT reflects an actionable therapeutic target.
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12
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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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13
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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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14
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Brill JB, Brenner M, Duchesne J, Roberts D, Ferrada P, Horer T, Kauvar D, Khan M, Kirkpatrick A, Ordonez C, Perreira B, Priouzram A, Cotton BA. The Role of TEG and ROTEM in Damage Control Resuscitation. Shock 2021; 56:52-61. [PMID: 33769424 PMCID: PMC8601668 DOI: 10.1097/shk.0000000000001686] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 12/05/2019] [Accepted: 10/20/2020] [Indexed: 11/26/2022]
Abstract
ABSTRACT Trauma-induced coagulopathy is associated with very high mortality, and hemorrhage remains the leading preventable cause of death after injury. Directed methods to combat coagulopathy and attain hemostasis are needed. The available literature regarding viscoelastic testing, including thrombelastography (TEG) and rotational thromboelastometry (ROTEM), was reviewed to provide clinically relevant guidance for emergency resuscitation. These tests predict massive transfusion and developing coagulopathy earlier than conventional coagulation testing, within 15 min using rapid testing. They can guide resuscitation after trauma, as well. TEG and ROTEM direct early transfusion of fresh frozen plasma when clinical gestalt has not activated a massive transfusion protocol. Reaction time and clotting time via these tests can also detect clinically significant levels of direct oral anticoagulants. Slowed clot kinetics suggest the need for transfusion of fibrinogen via concentrates or cryoprecipitate. Lowered clot strength can be corrected with platelets and fibrinogen. Finally, viscoelastic tests identify fibrinolysis, a finding associated with significantly increased mortality yet one that no conventional coagulation test can reliably detect. Using these parameters, guided resuscitation begins within minutes of a patient's arrival. A growing body of evidence suggests this approach may improve survival while reducing volumes of blood products transfused.
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Affiliation(s)
- Jason B. Brill
- Department of Surgery, University of Texas Health Science Center, Houston, Texas
| | - Megan Brenner
- Department of Surgery, University of California Riverside, Riverside, California
| | - Juan Duchesne
- Division Chief Acute Care Surgery, Department of Surgery Tulane, New Orleans, Louisiana
| | - Derek Roberts
- Division Chief Acute Care Surgery, Department of Surgery Tulane, New Orleans, Louisiana
| | - Paula Ferrada
- VCU Surgery Trauma, Critical Care and Emergency Surgery, Richmond, Virginia
| | - Tal Horer
- Department of Cardiothoracic and Vascular Surgery, Faculty of Life Science Örebro University Hospital and University, Örebro, Sweden
| | - David Kauvar
- Vascular Surgery Service, San Antonio Military Medical Center, San Antonio, Texas
| | - Mansoor Khan
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, UK
| | - Andrew Kirkpatrick
- Regional Trauma Services Foothills Medical Centre, Calgary, Alberta, Canada
- Departments of Surgery, Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
- Canadian Forces Health Services, Calgary, Alberta, Canada
| | - Carlos Ordonez
- Fundación Valle del Lili, Division of Trauma and Acute Care Surgery, Department of Surgery. Universidad del Valle, Valle, Colombia
| | - Bruno Perreira
- Department of Surgery and Surgical Critical Care, University of Campinas, Campinas, Brazil
| | - Artai Priouzram
- Department of Cardiothoracic and Vascular Surgery, Linköping University Hospital, Linköping, Sweden
| | - Bryan A. Cotton
- Department of Surgery, University of Texas Health Science Center, Houston, Texas
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15
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Wang R, He M, Zhang J, Wang S, Xu J. A Prognostic Model Incorporating Red Cell Distribution Width to Platelet Ratio for Patients with Traumatic Brain Injury. Ther Clin Risk Manag 2021; 17:1239-1248. [PMID: 34858027 PMCID: PMC8631984 DOI: 10.2147/tcrm.s337040] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 11/06/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND As an inflammation-based marker, red cell distribution width to platelet ratio (RPR) has been verified to be associated with disease severity and outcome in many clinical settings. We designed this study to evaluate the prognostic value of RPR in patients with traumatic brain injury (TBI). METHODS A total of 420 patients admitted with TBI were included in this study. Laboratory and clinical data were collected from an electronic medical record system. Univariate and multivariate logistic regression analyses were sequentially performed to discover risk factors of in-hospital mortality. Receiver operating characteristic (ROC) curves were drawn to confirm the predictive value of different markers including RPR in training set and testing set. RESULTS Non-survivors had higher level of RPR than survivors (P<0.001). Logistic regression analysis showed that RPR was significantly associated with mortality even after adjusting for confounding factors (P<0.001). The area under the ROC curve (AUC) value of Glasgow Coma Scale (GCS) for predicting mortality was 0.761 and 0775 in training set and testing set, respectively. And the constructed predictive model incorporating RPR had the highest AUC value of 0.858 and 0.884 in training set and testing set. CONCLUSION RPR is significantly associated with mortality in TBI patients. Utilizing RPR to construct a predictive model is valuable to evaluate prognosis of TBI patients.
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Affiliation(s)
- Ruoran Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People’s Republic of China
| | - Min He
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People’s Republic of China
| | - Jing Zhang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People’s Republic of China
| | - Shaobo Wang
- Department of Infectious Diseases, Xi’an Hospital of Traditional Chinese Medicine, Xi’an, Shannxi Province, People’s Republic of China
| | - Jianguo Xu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People’s Republic of 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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17
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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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Hinson HE, Li P, Myers L, Agarwal C, Pollock J, McWeeney S. Incorporating Immunoproteins in the Development of Classification Models of Progression of Intracranial Hemorrhage After Traumatic Brain Injury. J Head Trauma Rehabil 2021; 36:E322-E328. [PMID: 33656476 PMCID: PMC8380269 DOI: 10.1097/htr.0000000000000654] [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: 11/27/2022]
Abstract
OBJECTIVE To define clinical, radiographic, and blood-based biomarker features to be incorporated into a classification model of progression of intracranial hemorrhage (PICH), and to provide a pilot assessment of those models. METHODS Patients with hemorrhage on admission head computed tomography were identified from a prospectively enrolled cohort of subjects with traumatic brain injury. Initial and follow-up images were interpreted both by 2 independent readers, and disagreements adjudicated. Admission plasma samples were analyzed and principal components (PCs) composed of the immune proteins (IPs) significantly associated with the outcome of interest were selected for further evaluation. A series of logistic regression models were constructed based on (1) clinical variables (CV) and (2) clinical variables + immune proteins (CV+IP). Error rates of these models for correct classification of PICH were estimated; significance was set at P < .05. RESULTS We identified 106 patients, 36% had PICH. Dichotomized admission Glasgow Coma Scale (P = .004), Marshall score (P = .004), and 3 PCs were significantly associated with PICH. For the CV only model, sensitivity was 1.0 and specificity was 0.29 (95% CI, 0.07-0.67). The CV+IP model performed significantly better, with a sensitivity of 0.93 (95% CI, 0.64-0.99) and a specificity of 1.0 (P = .008). Adjustments to refine the definition of PICH and better define radiographic predictors of PICH did not significantly improve the models' performance. CONCLUSIONS In this pilot investigation, we observed that composites of IPs may improve PICH classification models when combined with CVs. However, overall model performance must be further optimized; results will inform feature inclusion included in follow-up models.
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Affiliation(s)
- H E Hinson
- Departments of Neurology (Drs Hinson and Agarwal and Mr Myers) and Radiology (Drs Li and Pollock), and Division of Bioinformatics & Computational Biology, Department of Medical Informatics and Clinical Epidemiology (Dr McWeeney), Oregon Health & Sciences University, Portland
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Anderson TN, Farrell DH, Rowell SE. Fibrinolysis in Traumatic Brain Injury: Diagnosis, Management, and Clinical Considerations. Semin Thromb Hemost 2021; 47:527-537. [PMID: 33878779 DOI: 10.1055/s-0041-1722970] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Posttraumatic coagulopathy involves disruption of both the coagulation and fibrinolytic pathways secondary to tissue damage, hypotension, and inflammatory upregulation. This phenomenon contributes to delayed complications after traumatic brain injury (TBI), including intracranial hemorrhage progression and systemic disseminated intravascular coagulopathy. Development of an early hyperfibrinolytic state may result in uncontrolled bleeding and is associated with increased mortality in patients with TBI. Although fibrinolytic assays are not routinely performed in the assessment of posttraumatic coagulopathy, circulating biomarkers such as D-dimer and fibrin degradation products have demonstrated potential utility in outcome prediction. Unfortunately, the relatively delayed nature of these tests limits their clinical utility. In contrast, viscoelastic tests are able to provide a rapid global assessment of coagulopathy, although their ability to reliably identify disruptions in the fibrinolytic cascade remains unclear. Limited evidence supports the use of hypertonic saline, cryoprecipitate, and plasma to correct fibrinolytic disruption; however, some studies suggest more harm than benefit. Recently, early use of tranexamic acid in patients with TBI and confirmed hyperfibrinolysis has been proposed as a strategy to further improve clinical outcomes. Moving forward, further delineation of TBI phenotypes and the clinical implications of fibrinolysis based on phenotypic variation is needed. In this review, we summarize the clinical aspects of fibrinolysis in TBI, including diagnosis, treatment, and clinical correlates, with identification of targeted areas for future research efforts.
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Affiliation(s)
- Taylor N Anderson
- School of Medicine, Division of Trauma, Critical Care and Acute Care Surgery, Oregon Health and Science University, Portland, Oregon
| | - David H Farrell
- School of Medicine, Division of Trauma, Critical Care and Acute Care Surgery, Oregon Health and Science University, Portland, Oregon
| | - Susan E Rowell
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
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Fair KA, Farrell DH, McCully BH, Rick EA, Dewey EN, Hilliard C, Dean R, Lin A, Hinson H, Barbosa R, Schreiber MA, Rowell SE. Fibrinolytic Activation in Patients with Progressive Intracranial Hemorrhage after Traumatic Brain Injury. J Neurotrauma 2021; 38:960-966. [PMID: 31382848 DOI: 10.1089/neu.2018.6234] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Progression of intracranial hemorrhage (PICH) is a significant cause of secondary brain injury in patients with traumatic brain injury (TBI). Previous studies have implicated a variety of mediators that contribute to PICH. We hypothesized that patients with PICH would display either a hypocoagulable state, hyperfibrinolysis, or both. We conducted a prospective study of adult trauma patients with isolated TBI. Blood was obtained for routine coagulation assays, platelet count, fibrinogen, thrombelastography, markers of thrombin generation, and markers of fibrinolysis at admission and 6, 12, 24, and 48 h. Univariate analyses were performed to compare baseline characteristics between groups. Linear regression models were created, adjusting for baseline differences, to determine the relationship between individual assays and PICH. One hundred forty-one patients met entry criteria, of whom 71 had hemorrhage progression. Patients with PICH had a higher Injury Severity Score and Abbreviated Injury Scale score (head), a lower Glasgow Coma Scale score, and lower plasma sodium on admission. Patients with PICH had higher D-dimers on admission. After adjusting for baseline differences, elevated D-dimers remained significantly associated with PICH compared to patients without PICH at admission. Hypocoagulation was not significantly associated with PICH in these patients. The association between PICH and elevated D-dimers early after injury suggests that fibrinolytic activation may contribute to PICH in patients with TBI.
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Affiliation(s)
- Kelly A Fair
- Oregon Health & Science University, Portland, Oregon, USA
| | | | | | | | | | - Cole Hilliard
- Oregon Health & Science University, Portland, Oregon, USA
| | - Rondi Dean
- Oregon Health & Science University, Portland, Oregon, USA
| | - Amber Lin
- Oregon Health & Science University, Portland, Oregon, USA
| | - Holly Hinson
- Oregon Health & Science University, Portland, Oregon, USA
| | - Ronald Barbosa
- Legacy Emanuel Hospital and Health Center, Portland, Oregon, USA
| | | | - Susan E Rowell
- Oregon Health & Science University, Portland, Oregon, USA
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22
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Webb AJ, Brown CS, Naylor RM, Rabinstein AA, Mara KC, Nei AM. Thromboelastography is a Marker for Clinically Significant Progressive Hemorrhagic Injury in Severe Traumatic Brain Injury. Neurocrit Care 2021; 35:738-746. [PMID: 33846901 DOI: 10.1007/s12028-021-01217-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 02/20/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Coagulopathy in traumatic brain injury (TBI) is associated with increased risk of poor outcomes, but accurate prediction of clinically significant progressive hemorrhagic injury (PHI) in patients with severe TBI remains a challenge. Thromboelastography (TEG) is a real-time test of whole blood coagulation that provides dynamic information about global hemostasis. This study aimed to identify differences in TEG values between patients with severe TBI who did or did not experience clinically significant PHI. METHODS This was a single-center retrospective cohort study of adult patients with severe TBI. Patients were eligible for inclusion if initial Glasgow coma scale (GCS) was ≤ 8 and baseline head computed tomography (CT) imaging and TEG were available. Exclusion criteria included receipt of hemostatic agents prior to TEG. PHI was defined as bleeding expansion on CT within 24 h associated with 2-point drop in GCS, neurosurgical intervention, or mortality within 24 h. The primary endpoint was TEG value differences between patients with and without PHI. Secondary endpoints included differences in conventional coagulation tests (CCTs) between groups. RESULTS Of the 526 patients evaluated, 141 met inclusion criteria. The most common reason for exclusion was lack of baseline TEG and receipt of reversal product prior to TEG. Sixty-four patients experienced PHI in the first 24 h after presentation. K time (2.03 min vs. 1.33 min, P = 0.035) and alpha angle (65° vs. 69°, P = 0.015) were found to be significantly different in patients experiencing PHI. R time (5.25 min vs. 4.71 min), maximum amplitude (61 mm vs. 63 mm), and clot lysis at 30 min after maximum clot strength (3.5% vs. 1.7%) were not significantly different between groups. Of the CCTs, only activated partial thromboplastin time (30.3 s vs. 27.6 s, P = 0.014) was found to be different in patients with PHI. CONCLUSIONS Prolonged K time and narrower alpha angle were found to be associated with developing clinically significant PHI in patients with severe TBI. Despite differences detected in alpha angle, median values in both groups were within normal reference ranges. These abnormalities may reflect pathologic hypoactivity of fibrinogen, and further study is warranted to evaluate TEG-guided cryoprecipitate administration in this patient population.
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Affiliation(s)
- Andrew J Webb
- Department of Pharmacy, Oregon Health and Science University, Portland, OR, USA.
| | | | - Ryan M Naylor
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | | | - Kristin C Mara
- Department of Biomedical Statistics, Mayo Clinic, Rochester, MN, USA
| | - Andrea M Nei
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
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23
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Fletcher-Sandersjöö A, Thelin EP, Maegele M, Svensson M, Bellander BM. Time Course of Hemostatic Disruptions After Traumatic Brain Injury: A Systematic Review of the Literature. Neurocrit Care 2021; 34:635-656. [PMID: 32607969 PMCID: PMC8128788 DOI: 10.1007/s12028-020-01037-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Almost two-thirds of patients with severe traumatic brain injury (TBI) develop some form of hemostatic disturbance, which contributes to poor outcome. While the initial head injury often leads to impaired clot formation, TBI is also associated with an increased risk of thrombosis. Most likely there is a progression from early bleeding to a later prothrombotic state. In this paper, we systematically review the literature on the time course of hemostatic disruptions following TBI. A MEDLINE search was performed for TBI studies reporting the trajectory of hemostatic assays over time. The search yielded 5,049 articles, of which 4,910 were excluded following duplicate removal as well as title and abstract review. Full-text assessment of the remaining articles yielded 33 studies that were included in the final review. We found that the first hours after TBI are characterized by coagulation cascade dysfunction and hyperfibrinolysis, both of which likely contribute to lesion progression. This is then followed by platelet dysfunction and decreased platelet count, the clinical implication of which remains unclear. Later, a poorly defined prothrombotic state emerges, partly due to fibrinolysis shutdown and hyperactive platelets. In the clinical setting, early administration of the antifibrinolytic agent tranexamic acid has proved effective in reducing head-injury-related mortality in a subgroup of TBI patients. Further studies evaluating the time course of hemostatic disruptions after TBI are warranted in order to identify windows of opportunity for potential treatment options.
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Affiliation(s)
- Alexander Fletcher-Sandersjöö
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden.
- Department of Clinical Neuroscience, Karolinska Institutet, Bioclinicum J5:20, 171 64, Solna, Stockholm, Sweden.
| | - Eric Peter Thelin
- Department of Clinical Neuroscience, Karolinska Institutet, Bioclinicum J5:20, 171 64, Solna, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Marc Maegele
- Department for Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
- Institute for Research in Operative Medicine, University Witten/Herdecke, Cologne, Germany
| | - Mikael Svensson
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Bioclinicum J5:20, 171 64, Solna, Stockholm, Sweden
| | - Bo-Michael Bellander
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Bioclinicum J5:20, 171 64, Solna, Stockholm, Sweden
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Adatia K, Newcombe VFJ, Menon DK. Contusion Progression Following Traumatic Brain Injury: A Review of Clinical and Radiological Predictors, and Influence on Outcome. Neurocrit Care 2021; 34:312-324. [PMID: 32462411 PMCID: PMC7253145 DOI: 10.1007/s12028-020-00994-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Secondary injuries remain an important cause of the morbidity and mortality associated with traumatic brain injury (TBI). Progression of cerebral contusions occurs in up to 75% of patients with TBI, and this contributes to subsequent clinical deterioration and requirement for surgical intervention. Despite this, the role of early clinical and radiological factors in predicting contusion progression remains relatively poorly defined due to studies investigating progression of all types of hemorrhagic injuries as a combined cohort. In this review, we summarize data from recent studies on factors which predict contusion progression, and the effect of contusion progression on clinical outcomes.
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Affiliation(s)
- Krishma Adatia
- Division of Anaesthesia, University of Cambridge, Cambridge, UK.
| | | | - David K Menon
- Division of Anaesthesia, University of Cambridge, Cambridge, UK
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25
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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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26
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The diagnosis and prognostic value of plasma copeptin in traumatic brain injury: a systematic review and meta-analysis. Neurol Sci 2021; 42:539-551. [PMID: 33389249 DOI: 10.1007/s10072-020-05019-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 12/19/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The purpose of this meta-analysis was to assess the diagnosis and prognostic value of plasma copeptin levels after traumatic brain injury (TBI). METHODS The databases PubMed, Cochrane Library, OvidSP, Google Scholar, VIP, CNKI, and WFSD were systematically searched from the inception dates to May 9, 2020. The pooled analysis of relevant data was conducted by the RevMan 5.3 software. Subgroups analysis was performed to explore the impact of age, country, male ratio, follow-up time, and Glasgow coma score (GCS) on the pooled area under curve (AUC) values of assessment mortality. RESULTS A total of 17 studies involving 2654 participants were included in the current meta-analysis. The pooled results demonstrated that increased plasma copeptin levels were significantly associated with TBI [SMD, 2.44; 95%CI, 1.59 ~ 3.29; P < 0.00001] and also were significantly associated with mortality [SMD, 1.37; 95%CI, 1.16 ~ 1.58; P < 0.00001], and poor functional outcomes (PFO) [SMD, 1.44; 95%CI, 1.20 ~ 1.68; P < 0.00001] in patients with TBI. Furthermore, the copeptin had a significant value in diagnosing brain concussion [AUC, 0.90; 95%CI, 0.84 ~ 0.95; P < 0.00001] and predicting progressive hemorrhagic injury [AUC, 0.83; 95%CI, 0.80 ~ 0.87; P < 0.00001], acute traumatic coagulopathy [AUC, 0.84; 95%CI, 0.79 ~ 0.89; P < 0.00001], mortality [AUC, 0.89; 95%CI, 0.87 ~ 0.92; P < 0.00001], and PFO [AUC, 0.88; 95%CI, 0.84 ~ 0.92; P < 0.00001] in patients with TBI. The subgroup analysis findings suggested that the age, country, male ratio, follow-up time, and GCS were not obvious factors influencing the pooled AUC values of assessment mortality. CONCLUSIONS The authors indicate that the plasma copeptin is a potentially promising biomarker for TBI diagnosis and prognosis prediction.
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27
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Ochiai H, Abe T, Okuyama H, Nagamine Y, Morisada S, Kanemaru K. Factors associated with the progression of traumatic intracranial hematoma during interventional radiology to establish hemostasis of extracranial hemorrhagic injury in severe multiple trauma patients. Acute Med Surg 2020; 7:e580. [PMID: 33133615 PMCID: PMC7590586 DOI: 10.1002/ams2.580] [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: 03/05/2020] [Revised: 08/14/2020] [Accepted: 09/14/2020] [Indexed: 11/25/2022] Open
Abstract
Aim To identify factors affecting the progression of traumatic intracranial hemorrhagic injury (t‐ICH) during interventional radiology (IVR) for the hemostasis of extracranial hemorrhagic injury. Methods This was a retrospective comparative study. Fifty‐two patients with t‐ICH who underwent hemostasis using IVR for extracranial trauma at our institute were included. Clinical and computed tomography scan data were collected to investigate factors associated with t‐ICH progression. Results Fifty‐two subjects (36 men/16 women) with a mean age of 70.9 ± 19.2 years were analyzed. The mean Injury Severity Score was 34.9 ± 11.2. In 29 patients (55.7%), t‐ICH progressed during IVR. Hematoma progression frequently occurred in patients with acute subdural hematoma (56.2%) and traumatic intracerebral hematoma/hemorrhagic brain contusion (66.6%). Factors associated with t‐ICH progression included age (P = 0.029), consciousness level at admission (P = 0.001), Revised Trauma Scale (P = 0.036), probability of survival (P = 0.043), platelet count (P = 0.005), fibrinogen level (P = 0.016), hemoglobin level (P = 0.003), D‐dimer level (P = 0.046), and red blood cell transfusion volume (P = 0.023). Conclusion Aggressive correction of anemia, thrombocytopenia, and low fibrinogen levels in severe consciousness disturbance patients with acute subdural hematoma and traumatic intracerebral hematoma/hemorrhagic brain contusion could improve the prognosis after IVR for hemostasis of extracranial hemorrhagic injuries.
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Affiliation(s)
- Hidenobu Ochiai
- Department of Emergency and Critical Care Medicine Faculty of Medicine University of Miyazaki Miyazaki Japan
| | - Tomohiro Abe
- Department of Emergency and Critical Care Medicine Faculty of Medicine University of Miyazaki Miyazaki Japan
| | - Hironobu Okuyama
- Department of Emergency and Critical Care Medicine Faculty of Medicine University of Miyazaki Miyazaki Japan
| | - Yasuhiro Nagamine
- Department of Emergency and Critical Care Medicine Faculty of Medicine University of Miyazaki Miyazaki Japan
| | - Sunao Morisada
- Department of Emergency and Critical Care Medicine Faculty of Medicine University of Miyazaki Miyazaki Japan
| | - Katsuhiro Kanemaru
- Department of Emergency and Critical Care Medicine Faculty of Medicine University of Miyazaki Miyazaki Japan
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28
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Tyler PD, Yang LM, Snider SB, Lerner AB, Aird WC, Shapiro NI. New Uses for Thromboelastography and Other Forms of Viscoelastic Monitoring in the Emergency Department: A Narrative Review. Ann Emerg Med 2020; 77:357-366. [PMID: 32988649 DOI: 10.1016/j.annemergmed.2020.07.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 07/10/2020] [Accepted: 07/14/2020] [Indexed: 12/17/2022]
Abstract
Patients frequently visit the emergency department with conditions that place them at risk of worse outcomes when accompanied by coagulopathy. Routine tests of coagulation-prothrombin time, partial thromboplastin time, platelets, and fibrinogen-have shortcomings that limit their use in providing emergency care. One alternative is to investigate coagulation disturbance with viscoelastic monitoring (VEM), a coagulation test that measures the timing and strength of blood clot development in real time. VEM is widely used and studied in cardiac surgery, liver transplant surgery, anesthesia, and trauma. In this article, we review the technique of VEM and the biologic rationale of using it in addition to routine tests of coagulation in emergency clinical situations. Then, we review the evidence (or lack thereof) for using VEM in the diagnosis and treatment of specific conditions. Finally, we describe the limitations of the test and future directions for clinical use and research in emergency medicine.
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Affiliation(s)
- Patrick D Tyler
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
| | - Lauren M Yang
- Department of Medicine, Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Samuel B Snider
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Adam B Lerner
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - William C Aird
- Department of Medicine, Division of Hematology and Oncology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Nathan I Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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29
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Wan X, Gan C, You C, Fan T, Zhang S, Zhang H, Wang S, Shu K, Wang X, Lei T. Association of APOE ε4 with progressive hemorrhagic injury in patients with traumatic intracerebral hemorrhage. J Neurosurg 2020; 133:496-503. [PMID: 31323634 DOI: 10.3171/2019.4.jns183472] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 04/18/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The intracranial hematoma volume in patients with traumatic brain injury is a key parameter for the determination of the management approach and outcome. Apolipoprotein E (APOE) ε4 is reported to be a risk factor for larger hematoma volume, which might contribute to a poor outcome. However, whether APOE ε4 is related to progressive hemorrhagic injury (PHI), a common occurrence in the clinical setting, remains unclear. In this study, the authors aimed to investigate the association between the APOE genotype and occurrence of PHI. METHODS This prospective study included a cohort of 123 patients with traumatic intracerebral hemorrhage who initially underwent conservative treatment. These patients were assigned to the PHI or non-PHI group according to the follow-up CT scan. A polymerase chain reaction and sequencing method were carried out to determine the APOE genotype. Multivariate logistic regression analysis was applied to identify predictors of PHI. RESULTS The overall frequency of the alleles was as follows: E2/2, 0%; E2/3, 14.6%; E3/3, 57.8%; E2/4, 2.4%; E3/4, 22.8%; and E4/4, 2.4%. Thirty-four patients carried at least one allele of ε4. In this study 60 patients (48.8%) experienced PHI, and the distribution of the alleles was as follows: E2/2, 0%; E2/3, 5.7%; E3/3, 22.8%; E2/4, 2.4%; E3/4, 16.3%; and E4/4, 1.6%, which was significantly different from that in the non-PHI group (p = 0.008). Additionally, the late operation rate in the PHI group was significantly higher than that in the non-PHI group (24.4% vs 11.4%, p = 0.002). Multivariate logistic regression identified APOE ε4 (OR 5.14, 95% CI 2.40-11.62), an elevated international normalized ratio (OR 3.57, 95% CI 1.61-8.26), and higher glucose level (≥ 10 mmol/L) (OR 3.88, 95% CI 1.54-10.77) as independent risk factors for PHI. Moreover, APOE ε4 was not a risk factor for the coagulopathy and outcome of the patients with traumatic intracerebral hemorrhage. CONCLUSIONS The presence of APOE ε4, an elevated international normalized ratio, and a higher glucose level (≥ 10 mmol/L) are predictors of PHI. Additionally, APOE ε4 is not associated with traumatic coagulopathy and patient outcome.
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Affiliation(s)
| | | | | | | | | | | | | | - Kai Shu
- 1Department of Neurosurgery and
| | - Xiong Wang
- 2Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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30
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Thromboelastography and rotational thromboelastometry for the surgical intensivist: A narrative review. J Trauma Acute Care Surg 2020; 86:710-721. [PMID: 30633093 DOI: 10.1097/ta.0000000000002206] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Viscoelastic tests (VETs), specifically thromboelastography (TEG) and rotational thromboelastometry (ROTEM), are gaining popularity in the management of critically ill surgical patients with hemorrhage or thrombosis due to their comprehensive characterization of the coagulation process and point-of-care availability in comparison to conventional coagulation tests (CCTs). We review current evidence for VET use in patients in the surgical intensive care unit (SICU). METHODS We searched PUBMED, EMBASE and the Cochrane Library through May 30, 2018 for articles that evaluated the use of VETs in patient populations and clinical scenarios germane to the surgical intensivist. Individual articles were critically evaluated for relevance and appropriate methodology using a structured technique. Information on patient characteristics, timing and methods of CCTs/VETs, and outcomes was collected and summarized in narrative form. RESULTS Of 2,589 identified articles, 36 were included. Five (14%) were interventional studies and 31 (86%) were observational. Twenty-five (69%) evaluated TEG, 11 (31%) ROTEM and 18 (50%) CCTs. Investigated outcomes included quantitative blood loss (13 (36%)), blood product transfusion (9 (25%)), thromboembolic events (9 (25%)) and mortality (6 (17%)). We identified 12 clinical scenarios with sufficient available evidence, much of which was of limited quantity and poor methodological quality. Nonetheless, research supports the use of VETs for guiding early blood product administration in severe traumatic hemorrhage and for the prediction of abstract excess bleeding following routine cardiac surgery. In contrast, evidence suggests VET-based heparin dosing strategies for venous thromboembolism prophylaxis are not superior to standard dosing in SICU patients. CONCLUSION While VETs have the potential to impact the care of critically ill surgical patients in many ways, current evidence for their use is limited, mainly because of poor methodological quality of most available studies. Further high-quality research, including several ongoing randomized controlled trials, is needed to elucidate the role of TEG/ROTEM in the SICU population. LEVEL OF EVIDENCE Systematic review, level IV.
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31
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Gilbert BW, Bissell BD, Santiago RD, Rech MA. Tracing the Lines: A Review of Viscoelastography for Emergency Medicine Clinicians. J Emerg Med 2020; 59:201-215. [PMID: 32418869 DOI: 10.1016/j.jemermed.2020.04.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 03/25/2020] [Accepted: 04/08/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Viscoelastography (VE) is an established method to identify coagulopathies in various disease processes. Clinical decisions can be made with real-time tracings and quantitative values at the bedside. Thromboelastography (TEG®) and rotational thromboelastometry (ROTEM®) have been utilized in several disease states with clinical varying success. OBJECTIVES This review will summarize the literature and provide recommendations pertaining to major disease processes where VE may be beneficial, including trauma, anticoagulation reversal, liver disease, acute ischemic stroke, and acquired brain injuries. DISCUSSION VE has a role in many emergency medicine patients encountered by clinicians. Reduced mortality, decreased blood product utilization, and prognostication ability makes VE an intriguing tool that can be utilized by providers to improve patient care. CONCLUSION This review serves as a way for emergency medicine clinicians to utilize VE in their practice and provides an insightful literature overview.
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Affiliation(s)
- Brian W Gilbert
- Department of Emergency Medicine, Wesley Medical Center, Wichita, Kansas
| | - Brittany D Bissell
- Medical Intensive Care Unit, University of Kentucky Healthcare, Lexington, Kentucky
| | - Ruben D Santiago
- Department of Emergency Medicine, Jackson Memorial Hospital, Miami, Florida
| | - Megan A Rech
- Department of Emergency Medicine, Loyola University Medical Center, Maywood, Illinois
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32
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D-dimer/fibrinogen ratio for the prediction of progressive hemorrhagic injury after traumatic brain injury. Clin Chim Acta 2020; 507:143-148. [PMID: 32333859 DOI: 10.1016/j.cca.2020.04.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 04/18/2020] [Accepted: 04/21/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Progressive hemorrhagic injury (PHI) greatly affects prognosis of traumatic brain injury (TBI). D-dimer/fibrinogen ratio (D/F ratio) may be a potential predictor for venous thromboembolism. This study sought to describe and evaluate any relationship between D/F ratio and PHI after TBI. METHODS This retrospective study included a cohort of 192 TBI patients. Plasma D-dimer and fibrinogen were measured, and subsequently D/F ratio was calculated. Multivariate logistic regression analysis was applied to identify predictors of PHI. Receiver operating characteristic (ROC) curve was conFig.d to analyze predictive capability for PHI. RESULTS A total of 43 patients (22.4%) experienced PHI. Both Glasgow coma scale (GCS) score (odds ratio [OR], 0.565; 95% CI, 0.464-0.689) and D/F ratio (OR, 4.026; 95% CI, 2.219-7.305) were the two independent predictor for PHI. Area under ROC curve (AUC) of D/F ratio was similar to that of GCS score (AUC, 0.816; 95% CI, 0.754-0.868 vs. AUC, 0.834; 95% CI, 0.773-0.883; P = 0.699). Moreover, D/F ratio significantly improved AUC of GCS score to 0.928 (95% CI, 0.881-0.960; P < 0.001). CONCLUSIONS D/F ratio was strongly predictive of PHI in the studied cohort and, thereby should be considered in the clinical management of TBI patients.
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Does Complement-Mediated Hemostatic Disturbance Occur in Traumatic Brain Injury? A Literature Review and Observational Study Protocol. Int J Mol Sci 2020; 21:ijms21051596. [PMID: 32111078 PMCID: PMC7084711 DOI: 10.3390/ijms21051596] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 02/07/2020] [Accepted: 02/25/2020] [Indexed: 12/11/2022] Open
Abstract
Despite improvements in medical triage and tertiary care, traumatic brain injury (TBI) remains associated with significant morbidity and mortality. Almost two-thirds of patients with severe TBI develop some form of hemostatic disturbance, which contributes to poor outcome. In addition, the complement system, which is abundant in the healthy brain, undergoes significant intra- and extracranial amplification following TBI. Previously considered to be structurally similar but separate systems, evidence of an interaction between the complement and coagulation systems in non-TBI cohorts has accumulated, with the activation of one system amplifying the activation of the other, independent of their established pathways. However, it is not known whether this interaction exists in TBI. In this review we summarize the available literature on complement activation following TBI, and the crosstalk between the complement and coagulation systems. We demonstrate how the complement system interacts with the coagulation cascade by activating the intrinsic coagulation pathway and by bypassing the initial cascade and directly producing thrombin as well. This crosstalk also effects platelets, where evidence points to a relationship with the complement system on multiple levels, with complement anaphylatoxins being able to induce disproportionate platelet activation and adhesion. The complement system also stimulates thrombosis by inhibiting fibrinolysis and stimulating endothelial cells to release prothrombotic microparticles. These interactions see clinical relevance in several disorders where a deficiency in complement regulation seems to result in a prothrombotic clinical presentation. Finally, based on these observations, we present the outline of an observational cohort study that is currently under preparation and aimed at assessing how complement influences coagulation in patients with isolated TBI.
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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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Martin G, Shah D, Elson N, Boudreau R, Hanseman D, Pritts TA, Makley AT, Foreman B, Goodman MD. Relationship of Coagulopathy and Platelet Dysfunction to Transfusion Needs After Traumatic Brain Injury. Neurocrit Care 2019; 28:330-337. [PMID: 29313313 DOI: 10.1007/s12028-017-0485-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Coagulopathy and platelet dysfunction commonly develop after traumatic brain injury (TBI). Thromboelastography (TEG) and platelet function assays (PFAs) are often performed at the time of admission; however, their roles in assessing post-TBI coagulopathy have not been investigated. We hypothesized that compared to blunt TBI, penetrating TBI would (1) demonstrate greater coagulopathy by TEG, (2) be associated with abnormal PFA results, and (3) require more blood product transfusions. METHODS We performed a retrospective study of patients admitted to the neuroscience intensive care unit of a level 1 trauma center from 2013 to 2015 with head Abbreviated Injury Scale ≥3. Patients were compared by mechanism of injury (blunt vs. penetrating). Admission demographics, injury characteristics, and laboratory parameters were evaluated. VerifyNow® Aspirin and P2Y12 tests were used for platelet function analysis. RESULTS Five hundred and thirty-four patients were included in the analysis. There were no differences between groups in platelet count or international normalized ratio; however, patients with penetrating TBI were more coagulopathic by TEG, with all of the TEG parameters being significantly different except for R time. Patients with penetrating head trauma were not more likely than their blunt counterparts to have abnormal PFA results, and PFA results did not correlate with any TEG parameter in either group. The penetrating cohort received more units of blood products in the first 4 and 24 h than the blunt cohort. CONCLUSIONS Patients presenting with penetrating TBI demonstrated increased coagulopathy compared to those with blunt TBI as measured by TEG and need for transfusion. PFA results did not correlate with TEG findings in this population.
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Affiliation(s)
- Grace Martin
- Division of Trauma/Critical Care, Department of Surgery, College of Medicine, University of Cincinnati, 231 Albert Sabin Way, ML 0558, Cincinnati, OH, 45267, USA
| | - Dhavan Shah
- Division of Trauma/Critical Care, Department of Surgery, College of Medicine, University of Cincinnati, 231 Albert Sabin Way, ML 0558, Cincinnati, OH, 45267, USA
| | - Nora Elson
- Division of Trauma/Critical Care, Department of Surgery, College of Medicine, University of Cincinnati, 231 Albert Sabin Way, ML 0558, Cincinnati, OH, 45267, USA
| | - Ryan Boudreau
- Division of Trauma/Critical Care, Department of Surgery, College of Medicine, University of Cincinnati, 231 Albert Sabin Way, ML 0558, Cincinnati, OH, 45267, USA
| | - Dennis Hanseman
- Division of Trauma/Critical Care, Department of Surgery, College of Medicine, University of Cincinnati, 231 Albert Sabin Way, ML 0558, Cincinnati, OH, 45267, USA
| | - Timothy A Pritts
- Division of Trauma/Critical Care, Department of Surgery, College of Medicine, University of Cincinnati, 231 Albert Sabin Way, ML 0558, Cincinnati, OH, 45267, USA
| | - Amy T Makley
- Division of Trauma/Critical Care, Department of Surgery, College of Medicine, University of Cincinnati, 231 Albert Sabin Way, ML 0558, Cincinnati, OH, 45267, USA
| | - Brandon Foreman
- Division of Neurocritical Care, Department of Neurology, College of Medicine, University of Cincinnati, 231 Albert Sabin Way, ML 0558, Cincinnati, OH, 45267, USA
| | - Michael D Goodman
- Division of Trauma/Critical Care, Department of Surgery, College of Medicine, University of Cincinnati, 231 Albert Sabin Way, ML 0558, Cincinnati, OH, 45267, USA.
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Ho KM, Rao S, Honeybul S, Zellweger R, Wibrow B, Lipman J, Holley A, Kop A, Geelhoed E, Corcoran T, Misur P, Edibam C, Baker RI, Chamberlain J, Forsdyke C, Rogers FB. A Multicenter Trial of Vena Cava Filters in Severely Injured Patients. N Engl J Med 2019; 381:328-337. [PMID: 31259488 DOI: 10.1056/nejmoa1806515] [Citation(s) in RCA: 102] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Whether early placement of an inferior vena cava filter reduces the risk of pulmonary embolism or death in severely injured patients who have a contraindication to prophylactic anticoagulation is not known. METHODS In this multicenter, randomized, controlled trial, we assigned 240 severely injured patients (Injury Severity Score >15 [scores range from 0 to 75, with higher scores indicating more severe injury]) who had a contraindication to anticoagulant agents to have a vena cava filter placed within the first 72 hours after admission for the injury or to have no filter placed. The primary end point was a composite of symptomatic pulmonary embolism or death from any cause at 90 days after enrollment; a secondary end point was symptomatic pulmonary embolism between day 8 and day 90 in the subgroup of patients who survived at least 7 days and did not receive prophylactic anticoagulation within 7 days after injury. All patients underwent ultrasonography of the legs at 2 weeks; patients also underwent mandatory computed tomographic pulmonary angiography when prespecified criteria were met. RESULTS The median age of the patients was 39 years, and the median Injury Severity Score was 27. Early placement of a vena cava filter did not result in a significantly lower incidence of symptomatic pulmonary embolism or death than no placement of a filter (13.9% in the vena cava filter group and 14.4% in the control group; hazard ratio, 0.99; 95% confidence interval [CI], 0.51 to 1.94; P = 0.98). Among the 46 patients in the vena cava filter group and the 34 patients in the control group who did not receive prophylactic anticoagulation within 7 days after injury, pulmonary embolism developed in none of those in the vena cava filter group and in 5 (14.7%) in the control group, including 1 patient who died (relative risk of pulmonary embolism, 0; 95% CI, 0.00 to 0.55). An entrapped thrombus was found in the filter in 6 patients. CONCLUSIONS Early prophylactic placement of a vena cava filter after major trauma did not result in a lower incidence of symptomatic pulmonary embolism or death at 90 days than no placement of a filter. (Funded by the Medical Research Foundation of Royal Perth Hospital and others; Australian New Zealand Clinical Trials Registry number, ACTRN12614000963628.).
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Affiliation(s)
- Kwok M Ho
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Sudhakar Rao
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Stephen Honeybul
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Rene Zellweger
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Bradley Wibrow
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Jeffrey Lipman
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Anthony Holley
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Alan Kop
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Elizabeth Geelhoed
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Tomas Corcoran
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Philip Misur
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Cyrus Edibam
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Ross I Baker
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Jenny Chamberlain
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Claire Forsdyke
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Frederick B Rogers
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
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Very High Blood Alcohol Concentration and Fatal Hemorrhage in Acute Subdural Hematoma. World Neurosurg 2019; 130:454-458. [PMID: 31252079 DOI: 10.1016/j.wneu.2019.06.124] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 06/14/2019] [Accepted: 06/15/2019] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Alcohol intoxication is often present concurrently with traumatic brain injury (TBI). Recent studies have looked at the effect alcohol has on TBI and on coagulopathy. Typically, cases reviewed in the current literature report only on the effects of modest alcohol intoxication. CASE DESCRIPTION A 43-year-old male presented to the trauma center after a fall, with rapidly deteriorating mental status. Computed tomography of the head demonstrated a 1.9-cm acute subdural hematoma. Of note, classical coagulation studies were normal, but blood ethanol level was high, 436 mg/dL. Postoperatively, the patient suffered an intracerebral hemorrhage requiring emergent return to the operating room, where a large volume of unclotted blood and clinical coagulopathy was encountered. DISCUSSION We review the literature pertaining to coagulopathy in the context of TBI and ethanol intoxication. This case is a cautionary tale of a phenomenon of unmeasured coagulopathy in the face of severe alcohol intoxication manifested by intraoperative coagulopathy with new postoperative hemorrhage. Although routine preoperative testing indicated normal clotting function, a thromboelastogram demonstrated delayed clot formation. The protective effects of alcohol are well described; however, we believe that there is a population of patients with severe acute intoxication who have coagulopathy that may go undetected by routine preoperative screening. CONCLUSIONS Caution should be exercised when taking care of patients with very high levels of alcohol because physiologic derangements may be unpredictable. Additional research is needed for patients with very high levels of alcohol intoxication and the effect it may have on coagulation.
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PENG Q, ZHAO J, WANG P, HUANG C, CHEN B, SONG J, XU G. Expressions of plasma cystatin C, D-dimer and hypersensitive C-reactive protein in patients with intracranial progressive hemorrhagic injury after craniocerebral injury, and their clinical significance. ARQUIVOS DE NEURO-PSIQUIATRIA 2019; 77:381-386. [PMID: 31314839 DOI: 10.1590/0004-282x20190057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 01/20/2019] [Indexed: 11/22/2022]
Abstract
ABSTRACT Objective To investigate the expressions of plasma cystatin C (Cys-C), D-dimer (D-D) and hypersensitive C-reactive protein (hs-CRP) in patients with intracranial progressive hemorrhagic injury (IPHI) after craniocerebral injury, and their clinical significance. Methods Forty-two IPHI patients and 20 healthy participants (control) were enrolled. The severity and outcome of IPHI were determined according to the Glasgow Coma Scale and Glasgow Outcome Scale, and the plasma Cys-C, hs-CRP and D-D levels were measured. Results The plasma Cys-C, D-D and hs-CRP levels in the IPHI group were significantly higher than those in the control group (p < 0.01). There were significant differences of plasma Cys-C, D-D and hs-CRP levels among different IPHI patients according to the Glasgow Coma Scale and according to the Glasgow Outcome Scale (all p < 0.05). In the IPHI patients, the plasma Cys-C, D-D and hs-CRP levels were positively correlated with each other (p < 0.001). Conclusion The increase of plasma Cys-C, D-D and hs-CRP levels may be involved in IPHI after craniocerebral injury. The early detection of these indexes may help to understand the severity and outcome of IPHI.
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Affiliation(s)
- Qibin PENG
- Southern Medical University, China; Hainan Provincial People’s Hospital, China
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Effects of platelet-sparing leukocyte reduction and agitation methods on in vitro measures of hemostatic function in cold-stored whole blood. J Trauma Acute Care Surg 2019; 84:S104-S114. [PMID: 29554042 DOI: 10.1097/ta.0000000000001870] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Agitation of platelet units stored at room temperature is performed routinely to maintain platelet function, and leukoreduction of blood products is the standard of care in many countries to reduce immune consequences of transfusion. The effect of agitation and leukoreduction on whole blood stored at 4°C requires investigation, as reductions in hemostatic capacity of whole blood may reduce its efficacy in treating trauma-induced coagulopathy and platelet dysfunction. We hypothesize that agitation of whole blood will not affect hemostatic function and that leukoreduction will reduce hemostatic function of whole blood. METHODS In this in vitro randomized controlled study, 21 units of leukoreduced and 20 nonleukoreduced whole blood units were each randomly assigned into four agitation groups. Hemostatic parameters were measured using viscoelastic assays (rotational thromboelastometry-Extrinsic Screening Test (ROTEM-EXTEM) and thromboelastography (TEG) platelet mapping), impedance aggregometry (agonists-adenosine phosphate, arachidonic acid, thrombin receptor activating peptide, and collagen), and a thrombin generation assay from these whole blood units before and after filtration and on 0, 5, 10, and 15 days of storage at 4°C. RESULTS Leukoreduction compared to nonleukoreduction reduced platelet concentration on Day 0. Viscoelastic measures and thrombin generation parameters revealed significant reduction in hemostatic function between the leukoreduced units and the nonleukoreduced units at a few time points. Leukoreduced units consistently demonstrated reduced platelet aggregation compared to the nonleukoreduced units. Agitation methods did not significantly affect any of the hemostatic parameters examined. CONCLUSIONS Leukoreduction of whole blood with a platelet-sparing filter caused a moderate but significant reduction in some measures of whole blood hemostatic function most evident early in storage. The benefits of leukoreduction should be weighed against the potential reduced hemostatic function of leukoreduced units. Agitation of whole blood is not required to maintain hemostatic function. LEVEL OF EVIDENCE In vitro randomized controlled trial, level 1.
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Chan DYC, Tsang ACO, Li LF, Cheng KKF, Tsang FCP, Taw BBT, Pu JKS, Ho WWS, Lui WM, Leung GKK. Improving Survival with Tranexamic Acid in Cerebral Contusions or Traumatic Subarachnoid Hemorrhage: Univariate and Multivariate Analysis of Independent Factors Associated with Lower Mortality. World Neurosurg 2019; 125:e665-e670. [PMID: 30721773 DOI: 10.1016/j.wneu.2019.01.145] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Revised: 01/23/2019] [Accepted: 01/24/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Fall with head injury is a pervasive challenge, especially in the aging population. Contributing factors for mortality include the development of cerebral contusions and delayed traumatic intracerebral hematoma. Currently, there is no established specific treatment for these conditions. OBJECT This study aimed to investigate the impact of independent factors on the mortality rate of traumatic brain injury with contusions or traumatic subarachnoid hemorrhage. METHODS Data were collected from consecutive patients admitted for cerebral contusions or traumatic subarachnoid hemorrhage at an academic trauma center from 2010 to 2016. The primary outcome was the 30-day mortality rate. Independent factors for analysis included patient factors and treatment modalities. Univariate and multivariate analyses were conducted to identify independent factors related to mortality. Secondary outcomes included thromboembolic complication rates associated with the use of tranexamic acid. RESULTS In total, 651 consecutive patients were identified. For the patient factors, low Glasgow Coma Scale on admission, history of renal impairment, and use of warfarin were identified as independent factors associated with higher mortality from univariate and multivariate analyses. For the treatment modalities, univariate analysis identified tranexamic acid as an independent factor associated with lower mortality (P = 0.021). Thromboembolic events were comparable in patients with or without tranexamic acid. CONCLUSION Tranexamic acid was identified by univariate analysis as an independent factor associated with lower mortality in cerebral contusions or traumatic subarachnoid hemorrhage. Further prospective studies are needed to validate this finding.
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Affiliation(s)
- David Yuen Chung Chan
- Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong
| | - Anderson Chun On Tsang
- Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong
| | - Lai Fung Li
- Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong
| | - Kevin King Fai Cheng
- Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong
| | - Frederick Chun Pong Tsang
- Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong
| | - Benedict Beng Teck Taw
- Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong
| | - Jenny Kan Suen Pu
- Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong
| | - Wilson Wai Shing Ho
- Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong
| | - Wai Man Lui
- Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong
| | - Gilberto Ka Kit Leung
- Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong.
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Shpiner AC, Bugaev N, Riesenburger R, Ng I, Breeze JL, Arabian SS, Rabinovici R. The profile of blunt traumatic supratentorial cranial bleed types. J Clin Neurosci 2018; 59:79-83. [PMID: 30420206 DOI: 10.1016/j.jocn.2018.10.149] [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: 05/13/2018] [Accepted: 10/29/2018] [Indexed: 01/05/2023]
Abstract
The characteristics of blunt traumatic supratentorial cranial bleed (STCB) types have not been directly compared. The National Trauma Data Bank (NTDB) 2014 was queried for adults with an isolated single STCB n = 57,278. Patients were grouped by STCB categories: subdural (SDH), subarachnoid (SAH), epidural (EDH), intraparenchymal (IPH), and intraventricular hemorrhage (IVH). Frequency, demographics, clinical characteristics, procedures, and outcomes were compared among groups. SDH was the most common STCB (53%) and occurred mostly in elderly patients after a fall (78%), 30% underwent craniotomy and their mortality was 7%. SAH occurred in 32% of patients and carried the lowest mortality (3%). SAH were least likely to have a severe brain injury (7%), and had the lowest Injury Severity Score (ISS, median 8) and complication rate (1%), as well as the shortest hospital length of stay (HLOS, 4.6 ± 6.4 days). EDH was uncommon (2%), occurred in younger patients (median 35 years), and had the highest percentage of traffic related injuries (28%). While EDH patients presented with the poorest neurological status (16% Glasgow Coma Scale ≤ 8, ISS median 18) and were operated on more than any other STCB type (51%), their mortality was lower (4%) and they had the highest discharge to home rate (71%). IVH was the least common (2%), but most lethal (9%) STCB type. These patients had the highest HLOS and intensive care unit LOS, and the lowest craniotomy rate (21%). STCB types have different clinical course, and outcomes. Understanding these differences can be useful in managing patients with STB.
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Affiliation(s)
- Aaron C Shpiner
- Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA 02111, United States.
| | - Nikolay Bugaev
- Division of Trauma & Acute Care Surgery, Tufts Medical Center, Tufts University School of Medicine, 800 Washington St, #4488, Boston, MA 02111, United States.
| | - Ron Riesenburger
- Department of Neurosurgery, Tufts Medical Center, Tufts University School of Medicine, 800 Washington St, #8484, Boston, MA 02111, United States.
| | - Isaac Ng
- Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA 02111, United States.
| | - Janis L Breeze
- Tufts Clinical and Translational Science Institute, Tufts University and Institute for Clinical Research and Health Policy Studies, Kneeland St, Boston, MA 02111, United States.
| | - Sandra S Arabian
- Division of Trauma & Acute Care Surgery, Tufts Medical Center, Tufts University School of Medicine, 800 Washington St, #4488, Boston, MA 02111, United States.
| | - Reuven Rabinovici
- Division of Trauma & Acute Care Surgery, Tufts Medical Center, Tufts University School of Medicine, 800 Washington St, #4488, Boston, MA 02111, United States.
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Carnevale JA, Segar DJ, Powers AY, Shah M, Doberstein C, Drapcho B, Morrison JF, Williams JR, Collins S, Monteiro K, Asaad WF. Blossoming contusions: identifying factors contributing to the expansion of traumatic intracerebral hemorrhage. J Neurosurg 2018; 129:1305-1316. [PMID: 29303442 DOI: 10.3171/2017.7.jns17988] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Accepted: 07/06/2017] [Indexed: 11/06/2022]
Abstract
Here, the authors examined the factors involved in the volumetric progression of traumatic brain contusions. The variables significant in this progression are identified, and the expansion rate of a brain bleed can now effectively be predicted given the presenting characteristics of the patient.
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Affiliation(s)
- Joseph A Carnevale
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - David J Segar
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
- 2Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Andrew Y Powers
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Meghal Shah
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | | | - Benjamin Drapcho
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - John F Morrison
- 3Department of Neurosurgery, University at Buffalo, New York
| | - John R Williams
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
- 5Department of Neurological Surgery, University of Washington, Seattle, Washington; and
| | | | - Kristina Monteiro
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Wael F Asaad
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
- 7Norman Prince Neurosciences Institute, Rhode Island Hospital, Providence, Rhode Island
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Guillotte AR, Herbert JP, Madsen R, Hammer RD, Litofsky NS. Effects of platelet dysfunction and platelet transfusion on outcomes in traumatic brain injury patients. Brain Inj 2018; 32:1849-1857. [PMID: 30346865 DOI: 10.1080/02699052.2018.1536805] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Platelet inhibition in traumatic brain injury (TBI) may be due to injury or antiplatelet medication use pre-injury. This study aims to identify factors associated with increased platelet arachidonic acid (AA) and adenosine diphosphate (ADP) inhibition and determine if platelet transfusion reduces platelet dysfunction and affects outcome. METHODS Prospective thromboelastography (TEG) assays were collected on adult patients with TBI with intracranial injuries detected by computed tomography (CT). Outcomes included in-hospital mortality, and CT lesion expansion. RESULTS Of 153 patients, ADP inhibition was increased in moderate and severe TBI compared to mild TBI (p = 0.0011). P2Y12 inhibiting medications had increased ADP inhibition (p = 0.0077). Admission ADP inhibition was not associated with in-hospital mortality (p = 0.24) or CT lesion expansion (p = 0.94). Mean reduction of ADP inhibition from platelet transfusion (-15.1%) relative to no transfusion (+ 11.7%) was not statistically different (p = 0.0472). CONCLUSIONS Mild TBI results in less ADP inhibition compared to moderate and severe TBI, suggesting a dose response relationship between TBI severity and degree of platelet dysfunction. Further, study is warranted to determine efficacy and parameters for platelet transfusion in patients with TBI.
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Affiliation(s)
- Andrew R Guillotte
- a Division of Neurological Surgery , University of Missouri School of Medicine , Columbia , MO , USA
| | - Joseph P Herbert
- a Division of Neurological Surgery , University of Missouri School of Medicine , Columbia , MO , USA
| | - Richard Madsen
- b Biostatistics and Research Design , University of Missouri School of Medicine , Columbia , MO , USA
| | - Richard D Hammer
- c Department of Pathology and Anatomical Sciences , University of Missouri School of Medicine , Columbia , MO USA
| | - N Scott Litofsky
- a Division of Neurological Surgery , University of Missouri School of Medicine , Columbia , MO , USA
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The profile of blunt traumatic infratentorial cranial bleed types. J Clin Neurosci 2018; 60:58-62. [PMID: 30342807 DOI: 10.1016/j.jocn.2018.10.035] [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: 05/13/2018] [Accepted: 10/05/2018] [Indexed: 11/20/2022]
Abstract
Infratentorial traumatic intracranial bleeds (ICBs) are rare and the distribution of subtypes is unknown. To characterize this distribution the National Trauma Data Bank (NTDB) 2014 was queried for adults with single type infratentorial ICB, n = 1,821: subdural hemorrhage (SDH), subarachnoid hemorrhage (SAH), epidural hemorrhage (EDH), and intraparenchymal hemorrhage (IPH). Comparisons were made between the groups with statistical significance determined using chi squared and t-tests. SDH occurred in 29% of patients, mostly in elderly on anti-coagulants (13%) after a fall (77%), 42% of them underwent craniotomy, their mortality was the lowest (4%). SAH was the most common (56%) occurring mostly from traffic related injuries (27%). Furthermore, 9% of them had a severe head injury Glasgow Coma Scale ≤8 (GCS), but had the lowest Injury Severity Score (ISS, median 8) as well as a short hospital length of stay, 5.1 ± 6.2 days. These patients were most likely to be discharged to home (64%). They had the lowest mortality (4%). EDH was the least common ICB (5%), occurred in younger patients (median age 49 years), and it had the highest percentage of associated injuries (13%). EDH patients presented with the poorest neurological status (26% GCS ≤8, ISS median 25) and were operated on more than any other ICB type (55%). EDH was the highest mortality (9%) ICB type and had a low discharge to home rate (58%). IPH was uncommon (10%). Infratentorial bleeds types have different clinical courses, and outcomes. Understanding these differences can be useful in managing these patients.
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Chen GR, Yao PS, Liu CB, Shang-Guan HC, Zheng SF, Yu LH, Lin YX, Lin ZY, Kang DZ. Risk factors of acute coagulation dysfunction after aneurysmal subarachnoid hemorrhage. Chin Neurosurg J 2018; 4:28. [PMID: 32922889 PMCID: PMC7398250 DOI: 10.1186/s41016-018-0135-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Accepted: 09/06/2018] [Indexed: 12/20/2022] Open
Abstract
Background Although coagulopathy have been proved to be a contributor to a poor outcome of aneurysmal subarachnoid hemorrhage (aSAH), the risk factors for triggering coagulation abnormalities have not been studied after aneurysm clipping. Methods We investigated risk factors of coagulopathy and analyzed the relationship between acute coagulopathy and outcome after aneurysm clipping. The clinical data of 137 patients with ruptured CA admitted to our institution was collected and retrospectively reviewed. Patient demographic data (age, sex), smoking, alcohol use, hypertension, diabetes, Hunt-Hess grade, Fisher grade, operation time, intraoperative total infusion volume, intraoperative blood loss, intraoperative transfusion, intraoperative hemostatic drug treatment, calcium reduction (preoperative free calcium concentration–postoperative free calcium concentration) were recorded. Coagulation was assessed within 24 h. Postoperative hemorrhage and infarction, deep venous thrombosis (DVT), and mortality were analyzed. Results Coagulopathy was detected in a total of 51 cases (group I), while not in 86 cases (group II). Univariable analysis demonstrated that age, smoking, alcohol use, intraoperative total infusion volume, intraoperative blood loss, intraoperative transfusion, and calcium reduction (≥ 1.2 mg/dl) were related to coagulopathy. Non-conditional logistic regression analysis showed that age [OR, 1.037 (95% CI, 1.001–1.074); p = 0.045] and calcium reduction (≥ 1.2 mg/dl) [OR, 5.509 (95% CI, 1.900–15.971); p = 0.002] were considered as the risk factors for coagulopathy. Hunt-Hess grade [OR, 2.641 (95% CI, 1.079–6.331); p = 0.033] and operation time [OR, 0.107 (95% CI, 1.012–0.928); p = 0.043] were considered as the risk factors for hypocoagulopathy. There were 6 cases (11.7%) with cerebral infarction in group I, while 6 cases (6.98%) in group II (χ2 = 0.918, p = 0.338). There were 4 cases (7.84%) with rebleeding in group I, while 5 cases (5.81%) in group II (χ2 = 0.215, p = 0.643). The mortality was 9.80% (5/51) in group I, while 1.16% (1/86) in group II (χ2 = 5.708, p = 0.017). DVT was not detected in all cases. Conclusions In conclusion, age (≥ 65 years) and calcium reduction (≥ 1.2 mg/dl) were considered as the risk factors for coagulopathy and have been proved to be associated with higher mortality after aneurysm clipping.
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Affiliation(s)
- Guo-Rong Chen
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, NO. 20 Chazhong Road, Taijiang District, Fuzhou City, 350004 Fujian China
| | - Pei-Sen Yao
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, NO. 20 Chazhong Road, Taijiang District, Fuzhou City, 350004 Fujian China
| | - Chu-Bin Liu
- Department of Neurosurgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou City, 362000 Fujian China
| | - Huang-Cheng Shang-Guan
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, NO. 20 Chazhong Road, Taijiang District, Fuzhou City, 350004 Fujian China
| | - Shu-Fa Zheng
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, NO. 20 Chazhong Road, Taijiang District, Fuzhou City, 350004 Fujian China
| | - Liang-Hong Yu
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, NO. 20 Chazhong Road, Taijiang District, Fuzhou City, 350004 Fujian China
| | - Yuan-Xiang Lin
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, NO. 20 Chazhong Road, Taijiang District, Fuzhou City, 350004 Fujian China
| | - Zhang-Ya Lin
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, NO. 20 Chazhong Road, Taijiang District, Fuzhou City, 350004 Fujian China
| | - De-Zhi Kang
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, NO. 20 Chazhong Road, Taijiang District, Fuzhou City, 350004 Fujian China
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Roberts I, Belli A, Brenner A, Chaudhri R, Fawole B, Harris T, Jooma R, Mahmood A, Shokunbi T, Shakur H. Tranexamic acid for significant traumatic brain injury (The CRASH-3 trial): Statistical analysis plan for an international, randomised, double-blind, placebo-controlled trial. Wellcome Open Res 2018; 3:86. [PMID: 30175246 PMCID: PMC6081978 DOI: 10.12688/wellcomeopenres.14700.2] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2018] [Indexed: 12/21/2022] Open
Abstract
International Standard Randomised Controlled Trials registry ( ISRCTN15088122) 19/07/2011, and ClinicalTrials.gov ( NCT01402882) 25/07/2011.
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Affiliation(s)
- Ian Roberts
- Clinical Trials Unit, LSHTM, London, WC1E 7HT, UK
| | - Antonio Belli
- The National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, UK
| | - Amy Brenner
- Clinical Trials Unit, LSHTM, London, WC1E 7HT, UK
| | - Rizwana Chaudhri
- RMC-LSHTM Research Collaboration Centre (RLRCC), Holy Family Hospital, Rawalpindi, Pakistan
| | - Bukola Fawole
- COMUI-LSHTM Research Collaboration Centre (CLRCC), University College Hospital, Ibadan, Nigeria
| | - Tim Harris
- Barts Health and Queen Mary University, London, UK
| | | | - Abda Mahmood
- Clinical Trials Unit, LSHTM, London, WC1E 7HT, UK
| | - Temitayo Shokunbi
- COMUI-LSHTM Research Collaboration Centre (CLRCC), University College Hospital, Ibadan, Nigeria
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Factors associated with the progression of conservatively managed acute traumatic subdural hemorrhage. J Crit Care 2018; 48:243-250. [PMID: 30245365 DOI: 10.1016/j.jcrc.2018.09.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 08/28/2018] [Accepted: 09/12/2018] [Indexed: 11/21/2022]
Abstract
PURPOSE Traumatic subdural hemorrhage (SDH) is associated with high mortality, yet many patients are not managed surgically. We sought to understand what factors might be associated with SDH enlargement to contribute to the triage of these conservatively managed patients. MATERIALS AND METHODS A consecutive series of 117 patients admitted to our institution's level 1 trauma center for SDH between January 1, 2010 and December 31, 2010 were evaluated. Volumetric measurement of SDHs was performed on initial and follow-up head computed tomography (CT) scans with recording of initial midline shift and classification by location. Multimodel analysis quantified associations with change in SDH volume. RESULTS Systolic blood pressure, presence of subarachnoid hemorrhage, and initial SDH volume demonstrated positive associations with change in SDH volume, while initial midline shift and transfusion of platelets demonstrated negative associations. Initial convexity SDH volume demonstrated positive association with change in convexity SDH volume, while initial midline shift and transfusion of platelets demonstrated negative associations. Anticoagulant/antiplatelet use demonstrated positive association with change in tentorial SDH volume, while time between CT scans demonstrated negative association. CONCLUSIONS Platelet transfusion, anticoagulation, and hypertension have significant associations with expansion in non-surgical cases of SDH. Monitoring these factors may assist triaging these patients.
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Roberts I, Belli A, Brenner A, Chaudhri R, Fawole B, Harris T, Jooma R, Mahmood A, Shokunbi T, Shakur H. Tranexamic acid for significant traumatic brain injury (The CRASH-3 trial): Statistical analysis plan for an international, randomised, double-blind, placebo-controlled trial. Wellcome Open Res 2018; 3:86. [DOI: 10.12688/wellcomeopenres.14700.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2018] [Indexed: 12/22/2022] Open
Abstract
Background: Worldwide, traumatic brain injury (TBI) kills or hospitalises over 10 million people each year. Early intracranial bleeding is common after TBI, increasing the risk of death and disability. Tranexamic acid reduces blood loss in surgery and death due to bleeding in trauma patients with extra-cranial injury. Early administration of tranexamic acid in TBI patients might limit intracranial bleeding, reducing death and disability. The CRASH-3 trial aims to provide reliable evidence on the effect of tranexamic acid on death and disability in TBI patients. We will randomly allocate about 13,000 TBI patients to an intravenous infusion of tranexamic acid or matching placebo in addition to usual care. This paper presents a protocol update (version 2.1) and statistical analysis plan for the CRASH-3 trial. Results: The primary outcome is head injury death in hospital within 28 days of injury for patients treated within 3 hours of injury (deaths in patients treated after 3 hours will also be reported). Because there are strong scientific reasons to expect that tranexamic acid will be most effective in patients treated immediately after injury and less effective with increasing delay, the effect in patients treated within one hour of injury is of particular interest. Secondary outcomes are all-cause and cause-specific mortality, vascular occlusive events (myocardial infarction, pulmonary embolism, deep vein thrombosis, stroke), disability based on the Disability Rating Scale and measures suggested by patient representatives, seizures, neurosurgical intervention, neurosurgical blood loss, days in intensive care and adverse events. Sub-group analyses will examine the effect of tranexamic acid on head injury death stratified by time to treatment, severity of TBI and baseline risk. Conclusion: The CRASH-3 trial will provide reliable evidence of the effectiveness and safety of tranexamic acid in patients with acute TBI. Registration: International Standard Randomised Controlled Trials registry (ISRCTN15088122) 19/07/2011, and ClinicalTrials.gov (NCT01402882) 25/07/2011.
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Kumar A, Alvarado A, Shah K, Arnold PM. Necessity of Repeat Computed Tomography Imaging in Isolated Mild Traumatic Subarachnoid Hemorrhage. World Neurosurg 2018; 113:399-403. [DOI: 10.1016/j.wneu.2018.02.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 02/02/2018] [Indexed: 10/18/2022]
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