Coagulopathy and haemorrhagic progression in traumatic brain injury: advances in mechanisms, diagnosis, and management

Traumatic brain injury: Symptoms to systems in the 21st century

Severe traumatic brain injury (TBI) is a devastating injury with a mortality of ∼ 25-30 %. Despite decades of high-quality research, no drug therapy has reduced mortality. Why is this so? We argue two contributing factors for the lack of effective drug therapies include the use of specific-pathogen free (SPF) animals for translational research and the flawed practice of single-nodal targeting for drug design. A revolution is required to better understand how the whole body responds to TBI, identify new markers of its progression, and discover new system-acting drugs to treat it. In this review, we present a brief history of TBI, discuss its system's pathophysiology and propose a new research strategy for the 21st century. TBI progression develops from injury signals radiating from the primary impact, which can cause local ischemia, hemorrhage, excitotoxicity, cellular depolarization, immune dysfunction, sympathetic hyperactivity, blood-brain barrier breach, coagulopathy and whole-body dysfunction. Metabolic reprograming of immune cells drives neuroinflammation and secondary injury processes. We propose if sympathetic hyperactivity and immune cell activation can be corrected early, cardiovascular function and endothelial-glycocalyx-mitochondrial coupling can be restored, and secondary injury minimized with improved patient outcomes. The therapeutic goal is to switch the injury phenotype to a healing phenotype by restoring homeostasis and maintaining sufficient tissue O2 delivery. We have been developing a small-volume fluid therapy comprising adenosine, lidocaine and magnesium (ALM) to treat TBI and have shown that it blunts the CNS-stress response, supports cardiovascular function and reduces secondary injury. Future research will investigate its suitability for human translation.

The role of coagulopathy and subdural hematoma thickness at admission in predicting the prognoses of patients with severe traumatic brain injury: a multicenter retrospective cohort study from China

BACKGROUND

Traumatic brain injury (TBI) is one of the diseases with high disability and mortality worldwide. Recent studies have shown that TBI-related factors may change the complex balance between bleeding and thrombosis, leading to coagulation disorders. The aim of this retrospective study was to investigate the prediction of coagulopathy and subdural hematoma thickness at admission using the Glasgow Outcome Scale (GOS) in patients with severe TBI at 6 months after discharge.

METHODS

In this retrospective cohort study, a total of 1006 patients with severe TBI in large medical centers in three different provinces of China from June 2015 to June 2021 were enrolled after the exclusion criteria, and 800 patients who met the enrollment criteria were included. A receiver operating characteristic (ROC) curve was used to determine the best cut-off values of platelet (PLT), international normalized ratio (INR), activated partial thromboplastin time (APTT), and subdural hematoma (SDH) thickness. The ROC curve, nomogram, calibration curve, and the decision curve were used to evaluate the predictive effect of the coagulopathy and Coagulopathy-SDH(X1) models on the prognoses of patients with severe TBI, and the importance of predictive indicators was ranked by machine learning.

RESULTS

Among the patients with severe TBI on admission, 576/800 (72%) had coagulopathy, 494/800 (61%) had SDH thickness ≥14.05 mm, and 385/800 (48%) had coagulopathy combined with SDH thickness ≥14.05 mm. Multivariate logistic regression analyses showed that age, pupil, brain herniation, WBC, CRP, SDH, coagulopathy, and X1 were independent prognostic factors for GOS after severe TBI. Compared with other single indicators, X1 as a predictor of the prognosis of severe TBI was more accurate. The GOS of patients with coagulopathy and thick SDH (X1, 1 point) at 6 months after discharge was significantly worse than that of patients with coagulopathy and thin SDH (X1, 2 points), patients without coagulopathy and thick SDH (X1, 3 point), and patients without coagulopathy and thin SDH (X1, 4 points). In the training group, the C-index based on the coagulopathy nomogram was 0.900. The C-index of the X1-based nomogram was 0.912. In the validation group, the C-index based on the coagulopathy nomogram was 0.858. The C-index of the X1-based nomogram was 0.877. Decision curve analysis also confirmed that the X1-based model had a higher clinical net benefit of GOS at 6 months after discharge than the coagulopathy-based model in most cases, both in the training and validation groups. In addition, compared with the calibration curve based on the coagulopathy model, the prediction of the X1 model-based calibration curve for the probability of GOS at 6 months after discharge showed better agreement with actual observations. Machine learning compared the importance of each independent influencing factor in the evaluation of GOS prediction after TBI, with results showing that the importance of X1 was better than that of coagulopathy alone.

CONCLUSION

Coagulopathy combined with SDH thickness could be used as a new, accurate, and objective clinical predictor, and X1, based on combining coagulopathy with SDH thickness could be used to improve the accuracy of GOS prediction in patients with TBI, 6 months after discharge.

Relationship between coagulopathy score and ICU mortality: Analysis of the MIMIC-IV database

Objective

Coagulopathy score has been applied as a new prognostic indicator for sepsis, heart failure and acute respiratory failure. However, its ability to forecast intensive care unit (ICU) mortality in patients with an acute cerebral hemorrhage (ICH) has not been assessed. The purpose of this study was to clarify the relationship between ICU mortality and early coagulation problem score.

Methods

Data from the Medical Information Mart for Intensive Care (MIMIC-IV) (v2.0) database were used in this retrospective cohort analysis. The association between the coagulation disorder score and ICU mortality was examined using multivariate logistic regression. Furthermore, the impact of additional variables on the results was investigated by a subgroup analysis.

Results

3174 patients (57.3 % male) were enrolled in total. The ICU mortality reached 18.2 %. After adjusting for potential confounders, the ICU mortality of patients rose with the increase of coagulation disorder score. The ROC curve revealed the predictive accuracy of coagulation dysfunction score to mortality in patients with ICU. The coagulation disorder score had a lower AUC value (0.601, P < 0.001) than the SAPSII(AUCs of 0.745[95 % CI, 0.730-0.761]) and the combined indicators(AUCs of 0.752[95 % CI, 0.737-0.767]), but larger than single indicators platelet, INR and APTT. In the subgroup analysis, most subgroups showed no significant interaction, but only age showed significant interaction in the adjusted model.

Conclusion

The coagulopathy score and ICU mortality were found to be strongly positively correlated in this study, and its ability to predict ICU mortality was better than that of a single measure (platelet, INR, or APTT), but worse than that of the SAPSII score, GCS system.

Untargeted blood serum proteomics identifies novel proteins related to neurological recovery after human spinal cord injury

BACKGROUND

The discovery of new prognostic biomarkers following spinal cord injury (SCI) is a rapidly growing field that could help uncover the underlying pathological mechanisms of SCI and aid in the development of new therapies. To date, this search has largely focused on the initial days after the lesion. However, during the subacute stage of SCI (weeks to months after the injury), there remains potential for sensorimotor recovery, and numerous secondary events develop in various organs. Additionally, the confounding effects of early interventions after the injury are less likely to interfere with the results.

METHODS

In this study, we conducted an untargeted proteomics analysis to identify biomarkers of recovery in blood serum samples during the subacute phase of SCI patients, comparing those with strong recovery to those with no recovery between 30 and 120 days. We analyzed the fraction of serum that is depleted of the most abundant proteins to unmask proteins that would otherwise go undetected. Linear models were used to identify peptides and proteins related to neurological recovery and we validated changes in some of these proteins using Enzyme-linked Immunosorbent Assay (ELISA).

RESULTS

Our findings reveal that differences in subacute recovery after SCI (from 30 to 120 days) are associated with an enrichment in proteins involved in inflammation, coagulation, and lipid metabolism. Technical validation using commercial ELISAs further confirms that high levels of SERPINE1 and ARHGAP35 are associated with strong neurological recovery, while high levels of CD300a and DEFA1 are associated with a lack of recovery.

CONCLUSIONS

Our study identifies new candidates for biomarkers of neurological recovery and for novel therapeutic targets after SCI.

Platelet Contribution and Endothelial Activation and Stress Index-Potential Mortality Predictors in Traumatic Brain Injury

Coagulopathy and traumatic brain injury (TBI) are complexly intertwined. In isolated TBI, coagulopathy may contribute to hemorrhagic lesion development, progression, or recurrence, as it may lead to a particular pattern of coagulopathy called TBI-induced coagulopathy (TBI-IC). We performed a retrospective and descriptive evaluation of 63 patients admitted to the Emergency Clinical Hospital Bucharest with the diagnosis of moderate/severe brain injury. In addition to demographic data, all included patients had a complete paraclinical evaluation that included rotational thromboelastometric (ROTEM) blood-clot analysis. The platelet component (PLTEM) and the endotheliopathy activation and stress index score (EASIX) were calculated. These parameters were presented comparatively according to survival at 30 days and helped define the two study groups: survivors and non-survivors at 30 days. The contribution of platelets to clot strength is derived from maximum clot elasticity (MCE) and maximum clot firmness (MCF). MCE is defined as (MCF × 100)/(100 - MCF), and PLTEM is defined as EXTEM MCE-FIBTEM MCE. EASIX is a novel biomarker recently studied in TBI patients, calculated according to the following formula: lactate dehydrogenase (U/L) × creatinine (mg/dL)/platelets (109 cells/L). Regarding the demographic data, there were no significant differences between the survivors and non-survivors. All ROTEM parameters related to clot amplitude (A5, A10, A20, MCF in EXTEM and FIBTEM channels) were higher in the group of patients who survived. Also, PLTEM was decreased in the group of deceased patients (89.71 ± 22.86 vs. 132.3 ± 16.56 p < 0.0001). The cut-off point determined with the ROC curve is 114.10, with a sensitivity of 94.74% and a specificity of 93.18%, for the detection of the negative prognosis (death at 30 days). The EASIX score was significantly higher in the patients who survived the traumatic event, with a median difference value of 1.15 (p < 0.0001). The ROC analysis of this biomarker highlights a cut-off point of 2.12, with a sensitivity of 88.64% and a specificity of 94.74% (AUC = 0.95, p < 0.0001), for the prediction of mortality. The comparative analysis of the two studied markers was performed using the Cox proportional hazard ratio and highlighted the greater influence that PLTEM has on survival time (b value = -0.05, p < 0.0001) compared to EASIX (b value = 0.49, p = 0.0026). The present retrospective study indicates the potential of the TBI-IC reflecting parameters PLTEM and EASIX as markers of mortality prognosis. Larger prospective studies are needed to confirm their combined prognostic value and use in decision-making and reduction in the burden of disease by adequate allocation of resources in a personalized and timely manner.

Traumatic Brain Injury as an Independent Predictor of Futility in the Early Resuscitation of Patients in Hemorrhagic Shock

This review explores the concept of futility timeouts and the use of traumatic brain injury (TBI) as an independent predictor of the futility of resuscitation efforts in severely bleeding trauma patients. The national blood supply shortage has been exacerbated by the lingering influence of the COVID-19 pandemic on the number of blood donors available, as well as by the adoption of balanced hemostatic resuscitation protocols (such as the increasing use of 1:1:1 packed red blood cells, plasma, and platelets) with and without early whole blood resuscitation. This has underscored the urgent need for reliable predictors of futile resuscitation (FR). As a result, clinical, radiologic, and laboratory bedside markers have emerged which can accurately predict FR in patients with severe trauma-induced hemorrhage, such as the Suspension of Transfusion and Other Procedures (STOP) criteria. However, the STOP criteria do not include markers for TBI severity or transfusion cut points despite these patients requiring large quantities of blood components in the STOP criteria validation cohort. Yet, guidelines for neuroprognosticating patients with TBI can require up to 72 h, which makes them less useful in the minutes and hours following initial presentation. We examine the impact of TBI on bleeding trauma patients, with a focus on those with coagulopathies associated with TBI. This review categorizes TBI into isolated TBI (iTBI), hemorrhagic isolated TBI (hiTBI), and polytraumatic TBI (ptTBI). Through an analysis of bedside parameters (such as the proposed STOP criteria), coagulation assays, markers for TBI severity, and transfusion cut points as markers of futilty, we suggest amendments to current guidelines and the development of more precise algorithms that incorporate prognostic indicators of severe TBI as an independent parameter for the early prediction of FR so as to optimize blood product allocation.

Early hypocoagulable state in traumatic brain injury patients: incidence, predisposing factors, and outcomes in a retrospective cohort study

Coagulopathy development in traumatic brain injury (TBI) is among the significant complications that can negatively affect the clinical course and outcome of TBI patients. Timely identification of this complication is of utmost importance in the acute clinical setting. We reviewed TBI patients admitted to our trauma center from 2015 to 2021. Demographic data, mechanism of injury, findings on admission, imaging studies, procedures during hospitalization, and functional outcomes were gathered. INR with a cutoff of 1.3, platelet count less than 100 × 10⁹/L, or partial thromboplastin time greater than 40s were utilized as the markers of coagulopathy. A total of 4002 patients were included. Coagulopathy occurred in 38.1% of the patients. Age of the patients (Odds Ratio (OR) = 0.993, 95% Confidence Interval (CI) = 0.986-0.999, p = 0.028), systolic blood pressure (OR = 0.993, 95% CI = 0.989-0.998, p = 0.005), fibrinogen level (OR = 0.998, 95% CI = 0.996-0.999, p < 0.001), and hemoglobin level (OR = 0.886, 95% CI = 0.839-0.936, p < 0.001) were independently associated with coagulopathy. Furthermore, coagulopathy was independently associated with higher mortality rates and longer ICU stays. Coagulopathy had the most substantial effect on mortality of TBI patients (OR = 2.6, 95% CI = 2.1-3.3, p < 0.001), compared to other admission clinical characteristics independently associated with mortality such as fixed pupillary light reflex (OR = 1.8, 95% CI = 1.5-2.4, p < 0.001), GCS (OR = 0.91, 95% CI = 0.88-0.94, p < 0.001), and hemoglobin level (OR = 0.93, 95% CI = 0.88-0.98, p = 0.004). Early coagulopathy in TBI patients can lead to higher mortality rates. Future studies are needed to prove that early detection and correction of coagulopathy and modifiable risk factors may help improve outcomes of TBI patients.

Traumatic Brain Injury in Patients under Anticoagulant Therapy: Review of Management in Emergency Department

The best management of patients who suffer from traumatic brain injury (TBI) while on oral anticoagulants is one of the most disputed problems of emergency services. Indeed, guidelines, clinical decision rules, and observational studies addressing this topic are scarce and conflicting. Moreover, relevant issues such as the specific treatment (and even definition) of mild TBI, rate of delayed intracranial injury, indications for neurosurgery, and anticoagulant modulation are largely empiric. We reviewed the most recent evidence on these topics and explored other clinically relevant aspects, such as the promising role of dosing brain biomarkers, the strategies to assess the extent of anticoagulation, and the indications of reversals and tranexamic acid administration, in cases of mild TBI or as a bridge to neurosurgery. The appropriate timing of anticoagulant resumption was also discussed. Finally, we obtained an insight into the economic burden of TBI in patients on oral anticoagulants, and future directions on the management of this subpopulation of TBI patients were proposed. In this article, at the end of each section, a "take home message" is stated.

Early postoperative acetylsalicylic acid administration does not increase the risk of postoperative intracranial bleeding in patients with spontaneous intracerebral hemorrhage

Administration of acetylsalicylic acid (ASA) at early stage after surgery for spontaneous intracerebral hemorrhage (SICH) may increase the risk of postoperative intracranial bleeding (PIB), because of potential inhibition of platelet function. This study aimed to investigate whether early ASA administration after surgery was related to increased risk of PIB. This retrospective study enrolled SICH patients receiving surgery from September 2019 to December 2022 in seven medical institution. Based on postoperative ASA administration, patients who continuously received ASA more than three days within seven days post-surgery were identified as ASA users, otherwise as non-ASA users. The primary outcome was symptomatic PIB events within seven days after surgery. Incidence of PIB was compared between ASA users and non-ASA users using survival analysis. This study included 744 appropriate patients from 794 SICH patients. PIB occurred in 42 patients. Survival analysis showed no statistical difference between ASA users and non-ASA users in incidence of PIB (P = 0.900). Multivariate Cox analysis demonstrated current smoker (hazard ratio [HR], 2.50, 95%CI, 1.33-4.71, P = 0.005), dyslipidemia (HR = 3.03; 95%CI, 1.31-6.99; P = 0.010) and pre-hemorrhagic antiplatelet therapy (HR = 3.05; 95% CI, 1.64-5.68; P < 0.001) were associated with PIB. Subgroup analysis manifested no significant difference in incidence of PIB between ASA users and non-ASA users after controlling the effect from factors of PIB (i.e., sex, age, current smoker, regular drinker, dyslipidemia, pre-hemorrhagic antiplatelet therapy and hematoma location). This study revealed that early ASA administration to SICH patients after surgery was not related to increased risk of PIB.

Settlement Is at the End-Common Trauma Scores Require a Critical Reassessment Due to the Possible Dynamics of Traumatic Brain Injuries in Patients' Clinical Course

Background: Scientific studies on severely injured patients commonly utilize the Abbreviated Injury Scale (AIS) and the Injury Severity Score (ISS) for injury assessment and to characterize trauma cohorts. However, due to potential deterioration (e.g., in the case of an increasing hemorrhage) during the clinical course, the assessment of injury severity in traumatic brain injury (TBI) can be challenging. Therefore, the aim of this study was to investigate whether and to what extent the worsening of TBI affects the AIS and ISS. Methods: We retrospectively evaluated 80 polytrauma patients admitted to the trauma room of our level I trauma center with computed-tomography-confirmed TBI. The initial AIS, ISS, and Trauma and Injury Severity Score (TRISS) values were reevaluated after follow-up imaging. Results: A total of 37.5% of the patients showed a significant increase in AIShead (3.7 vs. 4.1; p = 0.002) and the ISS (22.9 vs. 26.7, p = 0.0497). These changes resulted in an eight percent reduction in their TRISS-predicted survival probability (74.82% vs. 66.25%, p = 0.1835). Conclusions: The dynamic nature of intracranial hemorrhage complicates accurate injury severity assessment using the AIS and ISS, necessitating consideration in clinical studies and registries to prevent systematic bias in patient selection and subsequent data analysis.

Diagnostic Utility of Glial Fibrillary Acidic Protein Beyond 12 Hours After Traumatic Brain Injury: A TRACK-TBI Study

Blood levels of glial fibrillary acidic protein (GFAP) and ubiquitin carboxyl-terminal hydrolase-L1 (UCH-L1) within 12h of suspected traumatic brain injury (TBI) have been approved by the Food and Drug administration to aid in determining the need for a brain computed tomography (CT) scan. The current study aimed to determine whether this context of use can be expanded beyond 12h post-TBI in patients presenting with Glasgow Coma Scale (GCS) 13-15. The prospective, 18-center Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study enrolled TBI participants aged ≥17 years who presented to a United States Level 1 trauma center and received a clinically indicated brain CT scan within 24h post-injury, a blood draw within 24h and at 14 days for biomarker analysis. Data from participants with emergency department arrival GCS 13-15 and biomarker values at days 1 and 14 were extracted for the primary analysis. A subgroup of hospitalized participants with serial biomarkers at days 1, 3, 5, and 14 were analyzed, including plasma GFAP and UCH-L1, and serum neuron-specific enolase (NSE) and S100 calcium-binding protein B (S100B). The primary analysis compared biomarker values dichotomized by head CT results (CT+/CT-). Area under receiver-operating characteristic curve (AUC) was used to determine diagnostic accuracy. The overall cohort included 1142 participants with initial GCS 13-15, with mean age 39.8 years, 65% male, and 73% Caucasian. The GFAP provided good discrimination in the overall cohort at days 1 (AUC = 0.82) and 14 (AUC = 0.72), and in the hospitalized subgroup at days 1 (AUC = 0.84), 3 (AUC = 0.88), 5 (AUC = 0.82), and 14 (AUC = 0.74). The UCH-L1, NSE, and S100B did not perform well (AUC = 0.51-0.57 across time points). This study demonstrates the utility of GFAP to aid in decision-making for diagnostic brain CT imaging beyond the 12h time frame in patients with TBI who have a GCS 13-15.

EASIX is an effective marker in predicting mortality of traumatic brain injury patients

BACKGROUND

The Endothelial Activation and Stress Index (EASIX) is a novel marker of endothelial injury and correlates with survival of various patients. The endothelial dysfunction plays an important role on the pathophysiological process of traumatic brain injury (TBI). This study was designed to explore the prognostic value of EASIX on TBI patients.

METHODS

358 TBI patients hospitalized in the West China hospital between October 2018 and October 2022 were enrolled for this study. The EASIX was calculated based on the formula: lactate dehydrogenase (U/L) × creatinine (mg/dL)/platelets (109 cells/L). The univariate and multivariate logistic regression with forward method was performed to explore the association between EASIX and mortality. A prognostic model was developed combining significant risk factors in the multivariate logistic regression. The receiver operating characteristic (ROC) curve was used to compare the predictive accuracy of the EASIX and the developed model.

RESULTS

The 30-day mortality of enrolled 358 TBI patients was 51.1%. Non-survivors had higher EASIX than survivors (p < 0.001). The multivariate logistic regression confirmed seven risk factors for mortality of TBI including injury mechanism (p = 0.010), GCS (p < 0.001), glucose (p < 0.001), EASIX (p = 0.017), subdural hematoma (p = 0.012), coagulopathy (p = 0.001). The AUC of EASIX, SOFA, GCS was 0.747, 0.748 and 0.774, respectively. The AUC of developed predictive model was 0.874 with the sensitivity of 0.913 and specificity of 0.686.

CONCLUSIONS

The EASIX is a reliable marker for predicting mortality of TBI patients. The predictive model incorporating EASIX is helpful for clinicians to evaluate the mortality risk of TBI patients.

Extracellular vesicles in disorders of hemostasis following traumatic brain injury

Traumatic brain injury (TBI) is a global health priority. In addition to being the leading cause of trauma related death, TBI can result in long-term disability and loss of health. Disorders of haemostasis are common despite the absence of some of the traditional risk factors for coagulopathy following trauma. Similar to trauma induced coagulopathy, this manifests with a biphasic response consisting of an early hypocoagulable phase and delayed hypercoagulable state. This coagulopathy is clinically significant and associated with increased rates of haemorrhagic expansion, disability and death. The pathophysiology of TBI-induced coagulopathy is complex but there is biologic plausibility and emerging evidence to suggest that extracellular vesicles (EVs) have a role to play. TBI and damage to the blood brain barrier result in release of brain-derived EVs that contain tissue factor and phosphatidylserine on their surface. This provides a platform on which coagulation can occur. Preclinical animal models have shown that an early rapid release of EVs results in overwhelming activation of coagulation resulting in a consumptive coagulopathy. This phenomenon can be attenuated with administration of substances to promote EV clearance and block their effects. Small clinical studies have demonstrated elevated levels of procoagulant EVs in patients with TBI correlating with clinical outcome. EVs represent a promising opportunity for use as minimally invasive biomarkers and potential therapeutic targets for TBI patients. However, additional research is necessary to bridge the gap between their potential and practical application in clinical settings.

Review of Temperature Management in Traumatic Brain Injuries

Therapeutic hypothermia (TH) for severe traumatic brain injury has seen restricted application due to the outcomes of randomized controlled trials (RCTs) conducted since 2000. In contrast with earlier RCTs, recent trials have implemented active normothermia management in control groups, ensuring comparable intensities of non-temperature-related therapeutic interventions, such as neurointensive care. This change in approach may be a contributing factor to the inability to establish the efficacy of TH. Currently, an active temperature management method using temperature control devices is termed "targeted temperature management (TTM)". One of the goals of TTM for severe traumatic brain injury is the regulation of increased intracranial pressure, employing TTM as a methodology for intracranial pressure management. Additionally, fever in traumatic brain injury has been acknowledged as contributing to poor prognosis, underscoring the importance of proactively preventing fever. TTM is also employed for the preemptive prevention of fever in severe traumatic brain injury. As an integral component of current neurointensive care, it is crucial to precisely delineate the targets of TTM and to potentially apply them in the treatment of severe traumatic brain injury.

Brain-derived extracellular vesicles mediate systemic coagulopathy and inflammation after traumatic brain injury

Traumatic brain injury (TBI) can induce systemic coagulopathy and inflammation, thereby increasing the risk of mortality and disability. However, the mechanism causing systemic coagulopathy and inflammation following TBI remains unclear. In prior research, we discovered that brain-derived extracellular vesicles (BDEVs), originating from the injured brain, can activate the coagulation cascade and inflammatory cells. In this study, we primarily investigated how BDEVs affect systemic coagulopathy and inflammation in peripheral circulation. The results of cytokines and coagulation function indicated that BDEVs can lead to systemic coagulopathy and inflammation by influencing inflammatory factors and chemokines within 24 h. Furthermore, according to flow cytometry and blood cell counter results, we found that BDEVs induced changes in the blood count such as a reduced number of platelets and leukocytes and an increased percentage of neutrophils, macrophages, activated platelets, circulating platelet-EVs, and leukocyte-derived EVs. We also discovered that eliminating circulating BDEVs with lactadherin helped improve coagulopathy and inflammation, relieved blood cell dysfunction, and decreased the circulating platelet-EVs and leukocyte-derived EVs. Our research provides a novel viewpoint and potential mechanism of TBI-associated secondary damage.

Impact of early follow-up CT in the conservative management of traumatic brain injury on surgical decision making: A retrospective, single-center analysis with special respect to coagulopathy

INTRODUCTION

Initial management of traumatic brain injury (TBI) without immediate need for surgical therapy varies across centers. The additional value of routine repeat cranial computerized tomography (CT) to neurological monitoring is controversial. This retrospective study investigates the impact of routine follow-up CT after 6 h (CT6h) in initially conservatively managed TBI on surgical decision making. Furthermore, the impact of coagulopathy on lesion size and progression was examined.

METHODS

We reviewed charts of patients admitted to our clinic in the time between 1st January 2020 and 30th June 2022 for the ICD10 diagnosis S06.3 (traumatic brain contusion), S06.4 (epidural hematoma), S06.5 (subdural hematoma), and S06.6 (traumatic subarachnoid hemorrhage). Baseline characteristics as well as timing, reason, and consequences of first and second cranial CT, clinical course, lesion size at first and second CT as well as presence and type of coagulopathy (standard laboratory testing and prior medical history) were noted among others. Significance testing was carried out using Student's t-test. The significance level was set to p < 0.005.

RESULTS

A total of 213 patients were included, 78 were operated after first CT, 123 underwent clinical and imaging surveillance, and 12 patients were not treated. CT6h did not anticipate imminent neurological deterioration. Early secondary deteriorating patients (9/123, 7.3%) did so before 6 h after admission clustering between 3 and 4 h (6/9, 66.7%). CT6h changed surgical decision making in one case (1/114, < 1%). Nine out of 106 (8.5%) patients managed conservatively after CT6h showed a late secondary clinical deterioration or failure of conservative treatment, eight out of which had stable size of hemorrhage in CT6h. There was no significant difference in lesion size at first CT related to the presence of coagulopathy, antiplatelet agents, or anticoagulant drugs for SDH or contusions. In patients with radiological progression of SDH in combined brain injury (CBI), coagulopathy was associated with a higher increase of lesion size (diameter increase > 6 mm: 11.1% with vs. 2.8% without coagulopathy). This effect was not observed for contusions in CBI (volume increase > 6 ml: 17.4% with vs. 22.7% without coagulopathy).

CONCLUSION

Early routine follow-up CT does neither anticipate imminent neurological deterioration nor impact surgical decision making. A substantial number of patients with initially stable follow-up imaging need delayed surgery due to conservative treatment failure. If patients can be monitored clinically, surgical decision making depends on clinical status. Patients with coagulopathy do not present with larger lesions, but show a higher ratio of drastic increase in SDH in contrast to contusions.

An analysis of neutrophil-to-lymphocyte ratios and monocyte-to-lymphocyte ratios with six-month prognosis after cerebral contusions

Background and purpose

Neutrophil-to-lymphocyte ratio (NLR) and monocyte-to-lymphocyte ratio (MLR) have been identified as potential prognostic markers in various conditions, including cancer, cardiovascular disease, and stroke. This study aims to investigate the dynamic changes of NLR and MLR following cerebral contusion and their associations with six-month outcomes.

Methods

Retrospective data were collected from January 2016 to April 2020, including patients diagnosed with cerebral contusion and discharged from two teaching-oriented tertiary hospitals in Southern China. Patient demographics, clinical manifestations, laboratory test results (neutrophil, monocyte, and lymphocyte counts) obtained at admission, 24 hours, and one week after cerebral contusion, as well as outcomes, were analyzed. An unfavorable outcome was defined as a Glasgow Outcome Score (GOS) of 0-3 at six months. Logistic regression analysis was performed to identify independent predictors of prognosis, while receiver characteristic curve analysis was used to determine the optimal cutoff values for NLR and MLR.

Results

A total of 552 patients (mean age 47.40, SD 17.09) were included, with 73.19% being male. Higher NLR at one-week post-cerebral contusion (adjusted OR = 4.19, 95%CI, 1.16 - 15.16, P = 0.029) and higher MLR at admission and at 24 h (5.80, 1.40 - 24.02, P = 0.015; 9.06, 1.45 - 56.54, P = 0.018, respectively) were significantly associated with a 6-month unfavorable prognosis after adjustment for other risk factors by multiple logistic regression. The NLR at admission and 24 hours, as well as the MLR at one week, were not significant predictors for a 6-month unfavorable prognosis. Based on receiver operating characteristic curve analysis, the optimal thresholds of NLR at 1 week and MLR at admission after cerebral contusion that best discriminated a unfavorable outcome at 6-month were 6.39 (81.60% sensitivity and 70.73% specificity) and 0.76 (55.47% sensitivity and 78.26% specificity), respectively.

Conclusion

NLR measured one week after cerebral contusion and MLR measured at admission may serve as predictive markers for a 6-month unfavorable prognosis. These ratios hold potential as parameters for risk stratification in patients with cerebral contusion, complementing established biomarkers in diagnosis and treatment. However, further prospective studies with larger cohorts are needed to validate these findings.

Thromboelastometry-Based Prophylaxis for Venous Thromboembolism in the Acute Period Following Isolated Severe Traumatic Brain Injury

Objective

Traumatic brain injury (TBI) is an independent risk factor for venous thromboembolism (VTE). This study aimed to determine the optimal timing for initiating pharmacological thromboprophylaxis for VTE in patients with isolated severe TBI using rotational thromboelastometry (ROTEM).

Methods

This single-center observational study enrolled 115 patients aged 18-59 years with isolated severe TBI within the first 48 hours after injury.

Results

Using ROTEM data, we identified hypercoagulation due to an increase in clot density (MCF EXTEM >72), which was attributed to fibrinogen (MCF FIBTEM >25). From day 4, hypercoagulation occurred in 14.8% of the patients. By day 7, these changes were observed in 85.2% of patients. According to brain computed tomography findings, patients who received early VTE chemoprophylaxis on days 3-4 after severe TBI did not experience progression of hemorrhagic foci.

Conclusion

Our results emphasize the clinical significance of thromboelastometry in patients with isolated severe traumatic TBI. Anticoagulant prophylaxis started on 3-4 days after severe TBI was relatively safe, and most patients did not experience hemorrhagic foci progression. The data acquired in this study may enable the optimization of VTE chemoprophylactic approaches, thereby reducing the associated risks to patients.

Effect of low fibrinogen level on in-hospital mortality and 6-month functional outcome of TBI patients, a single center experience

In patients affected by traumatic brain injury (TBI), hypofibrinogenemia within the initial hours of trauma can be expected due to vascular and inflammatory changes. In this study, we aimed to evaluate the effect of hypofibrinogenemia on the in-hospital mortality and 6-month functional outcomes of TBI patients, admitted to Rajaee Hospital, a referral trauma center in Shiraz, Iran. This study included all TBI patients admitted to our center who had no prior history of coagulopathy or any systemic disease, were alive on arrival, and had not received any blood product before admission. On admission, hospitalization, imaging, and 6-month follow-up information of included patients were extracted from the TBI registry database. The baseline characteristics of patients with fibrinogen levels of less than 150 mg/dL were compared with the cases with higher levels. To assess the effect of low fibrinogen levels on in-hospital mortality, a uni- and multivariate was conducted between those who died in hospital and survivors. Based on the 6-month GOSE score of patients, those with GOSE < 4 (unfavorable outcome) were compared with those with a favorable outcome. A total of 3049 patients (84.3% male, 15.7% female), with a mean age of 39.25 ± 18.87, met the eligibility criteria of this study. 494 patients had fibrinogen levels < 150 mg/dl, who were mostly younger and had lower average GCS scores in comparison to cases with higher fibrinogen levels. By comparison of the patients who died during hospitalization and survivors, it was shown that fibrinogen < 150 mg/dl is among the prognostic factors for in-hospital mortality (OR:1.75, CI: 1.32:2.34, P-value < 0.001), while the comparison between patients with the favorable and unfavorable functional outcome at 6-month follow-up, was not in favor of prognostic effect of low fibrinogen level (OR: 0.80, CI: 0.58: 1.11, P-value: 0.19). Hypofibrinogenemia is associated with in-hospital mortality of TBI patients, along with known factors such as higher age and lower initial GCS score. However, it is not among the prognostic factors of midterm functional outcome.

Management of Antithrombotic Drugs in Patients with Isolated Traumatic Brain Injury: An Intersociety Consensus Document

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.

A decision tree model to help treatment decision-making for severe spontaneous intracerebral hemorrhage

BACKGROUND

Surgical treatment demonstrated a reduction in mortality among patients suffering from severe spontaneous intracerebral hemorrhage (SSICH). However, which SSICH patients could benefit from surgical treatment was unclear. This study aimed to establish and validate a decision tree (DT) model to help determine which SSICH patients could benefit from surgical treatment.

MATERIALS AND METHODS

SSICH patients from a prospective, multicenter cohort study were analyzed retrospectively. The primary outcome was the incidence of neurological poor outcome (modified Rankin scale as 4-6) on the 180th day posthemorrhage. Then, surgically-treated SSICH patients were set as the derivation cohort (from a referring hospital) and validation cohort (from multiple hospitals). A DT model to evaluate the risk of 180-day poor outcome was developed within the derivation cohort and validated within the validation cohort. The performance of clinicians in identifying patients with poor outcome before and after the help of the DT model was compared using the area under curve (AUC).

RESULTS

One thousand two hundred sixty SSICH patients were included in this study (middle age as 56, and 984 male patients). Surgically-treated patients had a lower incidence of 180-day poor outcome compared to conservatively-treated patients (147/794 vs. 128/466, P <0.001). Based on 794 surgically-treated patients, multivariate logistic analysis revealed the ischemic cerebro-cardiovascular disease history, renal dysfunction, dual antiplatelet therapy, hematoma volume, and Glasgow coma score at admission as poor outcome factors. The DT model, incorporating these above factors, was highly predictive of 180-day poor outcome within the derivation cohort (AUC, 0.94) and validation cohort (AUC, 0.92). Within 794 surgically-treated patients, the DT improved junior clinicians' performance to identify patients at risk for poor outcomes (AUC from 0.81 to 0.89, P <0.001).

CONCLUSIONS

This study provided a DT model for predicting the poor outcome of SSICH patients postsurgically, which may serve as a useful tool assisting clinicians in treatment decision-making for SSICH.

Astroglial Cells: Emerging Therapeutic Targets in the Management of Traumatic Brain Injury

Traumatic Brain Injury (TBI) represents a significant health concern, necessitating advanced therapeutic interventions. This detailed review explores the critical roles of astrocytes, key cellular constituents of the central nervous system (CNS), in both the pathophysiology and possible rehabilitation of TBI. Following injury, astrocytes exhibit reactive transformations, differentiating into pro-inflammatory (A1) and neuroprotective (A2) phenotypes. This paper elucidates the interactions of astrocytes with neurons, their role in neuroinflammation, and the potential for their therapeutic exploitation. Emphasized strategies encompass the utilization of endocannabinoid and calcium signaling pathways, hormone-based treatments like 17β-estradiol, biological therapies employing anti-HBGB1 monoclonal antibodies, gene therapy targeting Connexin 43, and the innovative technique of astrocyte transplantation as a means to repair damaged neural tissues.

"COAGULATION": a mnemonic device for treating coagulation disorders following traumatic brain injury-a narrative-based method in the intensive care unit

Introduction

Coagulopathy associated with isolated traumatic brain injury (C-iTBI) is a frequent complication associated with poor outcomes, primarily due to its role in the development or progression of haemorrhagic brain lesions. The independent risk factors for its onset are age, severity of traumatic brain injury (TBI), volume of fluids administered during resuscitation, and pre-injury use of antithrombotic drugs. Although the pathophysiology of C-iTBI has not been fully elucidated, two distinct stages have been identified: an initial hypocoagulable phase that begins within the first 24 h, dominated by platelet dysfunction and hyperfibrinolysis, followed by a hypercoagulable state that generally starts 72 h after the trauma. The aim of this study was to design an acronym as a mnemonic device to provide clinicians with an auxiliary tool in the treatment of this complication.

Methods

A narrative analysis was performed in which intensive care physicians were asked to list the key factors related to C-iTBI. The initial sample was comprised of 33 respondents. Respondents who were not physicians, not currently working in or with experience in coagulopathy were excluded. Interviews were conducted for a month until the sample was saturated. Each participant was asked a single question: Can you identify a factor associated with coagulopathy in patients with TBI? Factors identified by respondents were then submitted to a quality check based on published studies and proven evidence. Because all the factors identified had strong support in the literature, none was eliminated. An acronym was then developed to create the mnemonic device.

Results and conclusion

Eleven factors were identified: cerebral computed tomography, oral anticoagulant & antiplatelet use, arterial blood pressure (Hypotension), goal-directed haemostatic therapy, use fluids cautiously, low calcium levels, anaemia-transfusion, temperature, international normalised ratio (INR), oral antithrombotic reversal, normal acid-base status, forming the acronym "Coagulation." This acronym is a simple mnemonic device, easy to apply for anyone facing the challenge of treating patients of moderate or severe TBI on a daily basis.

Effect of antiplatelet and anticoagulant medication use on injury severity and mortality in patients with traumatic brain injury treated in the intensive care unit

BACKGROUND

Antiplatelet and anticoagulant medication are increasingly common and can increase the risks of morbidity and mortality in traumatic brain injury (TBI) patients. Our study aimed to quantify the association of antiplatelet or anticoagulant use in intensive care unit (ICU)-treated TBI patients with 1-year mortality and head CT findings.

METHOD

We conducted a retrospective, multicenter observational study using the Finnish Intensive Care Consortium database. We included adult TBI patients admitted to four university hospital ICUs during 2003-2013. The patients were followed up until the end of 2016. The national drug reimbursement database provided information on prescribed medication for our study. We used multivariable logistic regression models to assess the association between TBI severity, prescribed antiplatelet and anticoagulant medication, and their association with 1-year mortality.

RESULTS

Of 3031 patients, 128 (4%) had antiplatelet and 342 (11%) anticoagulant medication before their TBI. Clopidogrel (2%) and warfarin (9%) were the most common antiplatelets and anticoagulants. Three patients had direct oral anticoagulant (DOAC) medication. The median age was higher among antiplatelet/anticoagulant users than in non-users (70 years vs. 52 years, p < 0.001), and their head CT findings were more severe (median Helsinki CT score 3 vs. 2, p < 0.05). In multivariable analysis, antiplatelets (OR 1.62, 95% CI 1.02-2.58) and anticoagulants (OR 1.43, 95% CI 1.06-1.94) were independently associated with higher odds of 1-year mortality. In a sensitivity analysis including only patients over 70, antiplatelets (OR 2.28, 95% CI 1.16-4.22) and anticoagulants (1.50, 95% CI 0.97-2.32) were associated with an increased risk of 1-year mortality.

CONCLUSIONS

Both antiplatelet and anticoagulant use before TBI were risk factors in our study for 1-year mortality. Antiplatelet and anticoagulation medication users had a higher radiological intracranial injury burden than non-users defined by the Helsinki CT score. Further investigation on the effect of DOACs on mortality should be done in ICU-treated TBI patients.

Point-of-care, goal-directed management of bleeding in trauma patients

PURPOSE OF REVIEW

The purpose of this review is to consider the clinical value of point-of-care (POC) testing in coagulopathic trauma patients with traumatic brain injury (TBI) and trauma-induced coagulopathy (TIC).

RECENT FINDINGS

Patients suffering from severe TBI or TIC are at risk of developing pronounced haemostatic disorders. Standard coagulation tests (SCTs) are insufficient to reflect the complexity of these coagulopathies. Recent evidence has shown that viscoelastic tests (VETs) identify haemostatic disorders more rapidly and in more detail than SCTs. Moreover, VET results can guide coagulation therapy, allowing individualised treatment, which decreases transfusion requirements. However, the impact of VET on mortality remains uncertain. In contrast to VETs, the clinical impact of POC platelet function testing is still unproven.

SUMMARY

POC SCTs are not able to characterise the complexity of trauma-associated coagulopathy. VETs provide a rapid estimation of underlying haemostatic disorders, thereby providing guidance for haemostatic therapy, which impacts allogenic blood transfusion requirements. The value of POC platelet function testing to identify platelet dysfunction and guide platelet transfusion is still uncertain.

Hydrophobic Polystyrene-Modified Gelatin Enhances Fast Hemostasis and Tissue Regeneration in Traumatic Brain Injury

Hemostatic sealant is required to deal with blood loss, especially in the scenario of traumatic brain injury (TBI), which presents high rates of morbidity and disability. Hemostasis in surgery with traditional gelatin-based sealants often leads to blood loss and other issues in brain because of the hydrophilic gelatin swelling. Herein, hydrophobic effects on the hemostasis in TBI surgery are studied by tuning the chain length of polystyrene (PS) onto methylacrylated gelatin (Gel-MA). The hydrophobicity and hemostatic efficiency can be tuned by controlling the length of PS groups. The platelet activation of modified sealants Gel-MA-2P, Gel-MA-P, and Gel-MA-0.5P is as much as 17.5, 9.1, and 2.1 times higher than Gel-MA in vitro. The hemostatic time of Gel-MA-2P, Gel-MA-P, and Gel-MA-0.5P groups is 2.0-, 1.6-, and 1.1-folds faster than that in Gel-MA group in TBI mice. Increased formation of fibrins and platelet aggregation can also be observed in vitro by scanning electron microscopy. Animal's mortality is lowered by 46%, neurologic deficiency is reduced by 1.5 times, and brain edema is attenuated by 10%. Protein expression is further investigated to exhibit toxic iron-related processes caused by delayed hemostasis and activation of platelets via PI3K/PKC-α signaling. The hydrophobic Gel-MA has the potential in hemostatic TBI and promotes nervous system recovery in brain with the potentials in clinics.

Hypofibrinogenemia following injury in 186 children and adolescents: identification of the phenotype, current outcomes, and potential for intervention

Objectives

Recent studies evaluating fibrinogen replacement in trauma, along with newly available fibrinogen-based products, has led to an increase in debate on where products such as cryoprecipitate belong in our resuscitation strategies. We set out to define the phenotype and outcomes of those with hypofibrinogenemia and evaluate whether fibrinogen replacement should have a role in the initial administration of massive transfusion.

Methods

All patients <18 years of age presenting to our trauma center 11/17-4/21 were reviewed. We then evaluated all patients who received emergency-release and massive transfusion protocol (MTP) products. Patients were defined as hypofibrinogenemic (HYPOFIB) if admission fibrinogen <150 or rapid thrombelastography (r-TEG) angle <60 degrees. Our analysis sought to define risk factors for presenting with HYPOFIB, the impact on outcomes, and whether early replacement improved mortality.

Results

4169 patients were entered into the trauma registry, with 926 level 1 trauma activations, of which 186 patients received emergency-release blood products during this time; 1%, 3%, and 10% were HYPOFIB, respectively. Of the 186 patients of interest, 18 were HYPOFIB and 168 were non-HYPOFIB. The HYPOFIB patients were significantly younger, had lower field and arrival Glasgow Coma Scale, had higher head Abbreviated Injury Scale, arrived with worse global coagulopathy, and died from brain injury. Non-HYPOFIB patients were more likely to have (+)focused assessment for the sonography of trauma on arrival, sustained severe abdominal injuries, and die from hemorrhage. 12% of patients who received early cryoprecipitate (0-2 hours) had higher mortality by univariate analysis (55% vs 31%, p=0.045), but no difference on multivariate analysis (OR 0.36, 95% CI 0.07 to 1.81, p=0.221). Those receiving early cryoprecipitate who survived after pediatric intensive care unit (PICU) admission had lower PICU fibrinogen and r-TEG alpha-angle values.

Conclusion

In pediatric trauma, patients with hypofibrinogenemia on admission are most likely younger and to have sustained severe brain injury, with an associated mortality of over 80%. Given the absence of bleeding-related deaths in HYPOFIB patients, this study does not provide evidence for the empiric use of cryoprecipitate in the initial administration of a massive transfusion protocol.

Level of Evidence

Level III - Therapeutic/Care Management.

The prognostic value of an age-adjusted BIG score in adult patients with traumatic brain injury

Background

The base deficit, international normalized ratio, and Glasgow Coma Scale (BIG) score was previously developed to predict the outcomes of pediatric trauma patients. We designed this study to explore and improve the prognostic value of the BIG score in adult patients with traumatic brain injury (TBI).

Methods

Adult patients diagnosed with TBI in a public critical care database were included in this observational study. The BIG score was calculated based on the Glasgow Coma Scale (GCS), the international normalized ratio (INR), and the base deficit. Logistic regression analysis was performed to confirm the association between the BIG score and the outcome of included patients. Receiver operating characteristic (ROC) curves were drawn to evaluate the prognostic value of the BIG score and novel constructed models.

Results

In total, 1,034 TBI patients were included in this study with a mortality of 22.8%. Non-survivors had higher BIG scores than survivors (p < 0.001). The results of multivariable logistic regression analysis showed that age (p < 0.001), pulse oxygen saturation (SpO2) (p = 0.032), glucose (p = 0.015), hemoglobin (p = 0.047), BIG score (p < 0.001), subarachnoid hemorrhage (p = 0.013), and intracerebral hematoma (p = 0.001) were associated with in-hospital mortality of included patients. The AUC (area under the ROC curves) of the BIG score was 0.669, which was not as high as in previous pediatric trauma cohorts. However, combining the BIG score with age increased the AUC to 0.764. The prognostic model composed of significant factors including BIG had the highest AUC of 0.786.

Conclusion

The age-adjusted BIG score is superior to the original BIG score in predicting mortality of adult TBI patients. The prognostic model incorporating the BIG score is beneficial for clinicians, aiding them in making early triage and treatment decisions in adult TBI patients.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

Adolescent traumatic brain injury leads to incremental neural impairment in middle-aged mice: role of persistent oxidative stress and neuroinflammation

Background

Traumatic brain injury (TBI) increases the risk of mental disorders and neurodegenerative diseases in the chronic phase. However, there is limited neuropathological or molecular data on the long-term neural dysfunction and its potential mechanism following adolescent TBI.

Methods

A total of 160 male mice aged 8 weeks were used to mimic moderate TBI by controlled cortical impact. At 1, 3, 6 and 12 months post-injury (mpi), different neurological functions were evaluated by elevated plus maze, forced swimming test, sucrose preference test and Morris water maze. The levels of oxidative stress, antioxidant response, reactive astrocytes and microglia, and expression of inflammatory cytokines were subsequently assessed in the ipsilateral hippocampus, followed by neuronal apoptosis detection. Additionally, the morphological complexity of hippocampal astrocytes was evaluated by Sholl analysis.

Results

The adolescent mice exhibited persistent and incremental deficits in memory and anxiety-like behavior after TBI, which were sharply exacerbated at 12 mpi. Depression-like behaviors were observed in TBI mice at 6 mpi and 12 mpi. Compared with the age-matched control mice, apoptotic neurons were observed in the ipsilateral hippocampus during the chronic phase of TBI, which were accompanied by enhanced oxidative stress, and expression of inflammatory cytokines (IL-1β and TNF-α). Moreover, the reactive astrogliosis and microgliosis in the ipsilateral hippocampus were observed in the late phase of TBI, especially at 12 mpi.

Conclusion

Adolescent TBI leads to incremental cognitive dysfunction, and depression- and anxiety-like behaviors in middle-aged mice. The chronic persistent neuroinflammation and oxidative stress account for the neuronal loss and neural dysfunction in the ipsilateral hippocampus. Our results provide evidence for the pathogenesis of chronic neural damage following TBI and shed new light on the treatment of TBI-induced late-phase neurological dysfunction.

Association Between High-Level D-Dimer at Admission and Early Intubation in Patients With Moderate Traumatic Brain Injury

It is unclear who can benefit from tracheal intubation in the moderate (mTBI) traumatic brain injury (TBI) population. Given that mTBI patients are conscious, intubation can cause intense stress, possibly triggering neurological deterioration. Therefore, identifying potential risk factors for intubation in mTBI patients can serve as a valuable clinical warning. We sought to investigate whether elevated D-dimer is a possible risk factor for intubation in mTBI patients. Using the STROBE statement, adult patients with isolated TBI (Glasgow Coma Scale [GCS] score 9-13) treated at a high-volume neurotrauma center between January 2015 and December 2020 were reviewed. The demographics, clinical presentation, neuroimaging, and laboratory information were collected based on the patients' electronic medical record. D-dimer values were assessed from serum when patients were admitted to the hospital. The primary study end-point was that the mTBI patient was intubated within 72 h upon admission. A total of 557 patients with mTBI were finally included in this study. Of these, 85 (15.3%) patients were intubated. Multi-variate logistic regression analysis showed that high-level D-dimer (≥17.9mg/L) was significantly associated with early tracheal intubation in mTBI patients (odds ratio, 3.10 [1.16-8.25]; p = 0.024) after adjusting for age, sex, GCS scores, Marshall scores, and Injury Severity Scores. Sensitivity analysis showed that high-level D-dimer had a robust correlation with intubation in the different subgroups or after propensity score matching. High-level D-dimer on admission is an independent risk factor for early tracheal intubation in isolated mTBI patients.

Analysis of traumatic intracranial hemorrhage and delayed traumatic intracranial hemorrhage in patients with isolated head injury on anticoagulation and antiplatelet therapy

Objectives

Anticoagulants and antiplatelet (ACAP) agents are increasingly and frequently used, especially in the elderly. The present study was carried out to assess the prevalence of delayed traumatic intracranial hemorrhage (dtICH) after a normal result on an initial head computed tomography (CT) in adults who were taking ACAP medication.

Materials and Methods

The present retrospective included all adult patients who arrived in the emergency department between January 2017 and January 2021 with a history of fall from the patient's own height, while being on ACAP medication with an isolated head injury. The Institutional Review Board approved the study with a waiver of consent. The primary outcome measures were prevalence of dtICH in patients who had initial normal CT scan brain and were on ACAP medication.

Results

There were 2137 patients on ACAP medication, of which 1062 were male, and 1075 were of the female gender. The mean age of the patients was 82.1 years. About 8.2% had positive first CT scans (176/2137), while 0.023 (27/1149) had dtICH. The most common positive finding on the CT scan was subarachnoid hemorrhage followed by subdural hemorrhage. Male gender positively correlated with increased risk for first CT being positive (P = 0.033). Patient's with comorbidity of cirrhosis and chemotherapy had higher risk of dtICH (P = 0.47, 0.011).

Conclusion

There was a very low (0.023%) prevalence of dtICH. Dual therapy or Coumadin therapy made up the majority of tICH. Cirrhosis and chemotherapy were associated with the risk of a repeat CT scan being positive with an initial CT scan negative.

Cellular and molecular mechanisms in vascular repair after traumatic brain injury: a narrative review

Traumatic brain injury (TBI) disrupts normal brain function and is associated with high morbidity and fatality rates. TBI is characterized as mild, moderate or severe depending on its severity. The damage may be transient and limited to the dura matter, with only subtle changes in cerebral parenchyma, or life-threatening with obvious focal contusions, hematomas and edema. Blood vessels are often injured in TBI. Even in mild TBI, dysfunctional cerebral vascular repair may result in prolonged symptoms and poor outcomes. Various distinct types of cells participate in vascular repair after TBI. A better understanding of the cellular response and function in vascular repair can facilitate the development of new therapeutic strategies. In this review, we analyzed the mechanism of cerebrovascular impairment and the repercussions following various forms of TBI. We then discussed the role of distinct cell types in the repair of meningeal and parenchyma vasculature following TBI, including endothelial cells, endothelial progenitor cells, pericytes, glial cells (astrocytes and microglia), neurons, myeloid cells (macrophages and monocytes) and meningeal lymphatic endothelial cells. Finally, possible treatment techniques targeting these unique cell types for vascular repair after TBI are discussed.

Catechol-chitosan/carboxymethylated cotton-based Janus hemostatic patch for rapid hemostasis in coagulopathy

Uncontrolled bleeding is the leading cause of death, and the death risk of bleeding from coagulopathy is even higher. By infusing the relevant coagulation factors, bleeding in patients with coagulopathy can be clinically treated. However, there are not many emergency hemostatic products accessible for coagulopathy patients. In response, a Janus hemostatic patch (PCMC/CCS) with a two-layer structure of partly carboxymethylated cotton (PCMC) and catechol-grafted chitosan (CCS) was developed. Ultra-high blood absorption (4000 %) and excellent tissue adhesion (60 kPa) were both displayed by PCMC/CCS. The proteomic analysis revealed that PCMC/CCS has significantly contributed to the creative generation of FV, FIX, and FX, as well as to the substantial enrichment of FVII and FXIII, re-paving the initially blocked coagulation pathway of coagulopathy to promote hemostasis. The in vivo bleeding model of coagulopathy demonstrated that PCMC/CCS was substantially more effective than gauze and commercial gelatin sponge at achieving hemostasis in just 1 min. The study provides one of the first investigations on procoagulant mechanisms in anticoagulant blood conditions. Rapid hemostasis in coagulopathy will be significantly affected by the results of this experiment.

Associations Between Core Temperature Disorders and Outcomes of Pediatric Intensive Care Unit Patients

BACKGROUND

The few studies of associations between fever and outcomes in pediatric intensive care unit (PICU) patients have conflicting findings. Associations between hypothermia and patient outcomes have not been studied.

OBJECTIVE

To investigate the incidence and characteristics of fever and hypothermia and their associations with adverse outcomes among PICU patients.

METHODS

Patients consecutively admitted to 2 PICUs in a 2-year period were prospectively studied. Core temperature was mainly measured by rectal or axillary thermometry. Fever and hypothermia were defined as core temperatures of greater than 38.0 °C and less than 36.0 °C, respectively. Prolonged mechanical ventilation, prolonged PICU stay, and PICU mortality were the adverse patient outcomes studied. Associations between patient outcomes and core temperature disorders were evaluated with univariate comparisons and multivariate analyses.

RESULTS

Of 545 patients enrolled, fever occurred in 299 (54.9%) and hypothermia occurred in 161 (29.5%). Both temperature disorders were independently associated with prolonged mechanical ventilation and prolonged PICU stay (P < .001) but not with PICU mortality. Late onset of fever (P < .001) and hypothermia (P = .009) were independently associated with prolonged mechanical ventilation, fever magnitude and duration (both P < .001) were independently associated with prolonged PICU stay, and fever magnitude (P < .001) and infectious cause of hypothermia (P= .01) were independently associated with higher PICU mortality.

CONCLUSIONS

These findings provide evidence that the manifestation and characteristics of fever and hypothermia are independent predictors of adverse outcomes in PICU patients.

Roles and therapeutic potential of different extracellular vesicle subtypes on traumatic brain injury

Traumatic brain injury (TBI) is a leading cause of injury-related disability and death around the world, but the clinical stratification, diagnosis, and treatment of complex TBI are limited. Due to their unique properties, extracellular vesicles (EVs) are emerging candidates for being biomarkers of traumatic brain injury as well as serving as potential therapeutic targets. However, the effects of different extracellular vesicle subtypes on the pathophysiology of traumatic brain injury are very different, or potentially even opposite. Before extracellular vesicles can be used as targets for TBI therapy, it is necessary to classify different extracellular vesicle subtypes according to their functions to clarify different strategies for EV-based TBI therapy. The purpose of this review is to discuss contradictory effects of different EV subtypes on TBI, and to propose treatment ideas based on different EV subtypes to maximize their benefits for the recovery of TBI patients. Video Abstract.

Effect of Injury Patterns on the Development of Complications and Trauma-Induced Mortality in Patients Suffering Multiple Trauma

Patients that suffer from severe multiple trauma are highly vulnerable to the development of complications that influence their outcomes. Therefore, this study aimed to evaluate the risk factors that can facilitate an early recognition of adult patients at risk. The inclusion criteria were as follows: admission to a level 1 trauma center, injury severity score (ISS) ≥ 16 (severe injury was defined by an abbreviated injury score (AIS) ≥ 3) and ≥18 years of age. Injury- and patient-associated factors were correlated with the development of four complication clusters (surgery-related, infection, thromboembolic events and organ failure) and three mortality time points (immediate (6 h after admission), early (>6 h-72 h) and late (>72 h) mortality). Statistical analysis was performed using a Chi-square, Mann-Whitney U test, Cox hazard regression analysis and binominal logistic regression analysis. In total, 383 patients with a median ISS of 24 (interquartile range (IQR) 17-27) were included. The overall mortality rate (27.4%) peaked in the early mortality group. Lactate on admission significantly correlated with immediate and early mortality. Late mortality was significantly influenced by severe head injuries in patients with a moderate ISS (ISS 16-24). In patients with a high ISS (≥25), late mortality was influenced by a higher ISS, older age and higher rates of organ failure. Complications were observed in 47.5% of all patients, with infections being seen most often. The development of complications was significantly influenced by severe extremity injuries, the duration of mechanical ventilation and length of ICU stay. Infection remains the predominant posttraumatic complication. While immediate and early mortality is mainly influenced by the severity of the initial trauma, the rates of severe head injuries influence late mortality in moderate trauma severity, while organ failure remains a relevant factor in patients with a high injury severity.

Age, admission platelet count, and mortality in severe isolated traumatic brain injury: A retrospective cohort study

BACKGROUND

We asked whether patients >50 years of age with acute traumatic brain injury (TBI) present with lower platelet counts and whether lower platelet counts are independently associated with mortality.

METHODS

We combined trauma registry and laboratory data on a retrospective cohort of all patients ≥18 years of age admitted to our Level 1 US regional trauma center 2015-2021 with severe (Head Abbreviated Injury Score [AIS] ≥3), isolated (all other AIS <3) TBI who had a first platelet count within 1 h of arrival. Age and platelet count were assessed continuously and as groups (age 18-50 vs. >50, platelet normals, and at conventional transfusion thresholds). Outcomes such as mean admission platelet counts and in-hospital mortality were assessed categorically and with logistic regression.

RESULTS

Of 44,056 patients, 1298 (3%, median age: 52 [IQR 33,68], 76.1% male) met all inclusion criteria with no differences between younger and older age groups for (ISS; 18 [14,26] vs. 17 [14,26], p = .22), New ISS (NISS; 29 [19,50] vs. 28 [17,50], p = .36), or AIS-Head (4 [3,5] vs. 4 [3,5]; p = .87). Patients aged >50 had lower admission platelet counts (219,000 ± 93,000 vs. 242,000 ± 76,000/μL; p < .001) and greater in-hospital mortality (24.5% vs. 15.6%, p < .001) than those 18-50. In multivariable regression, firearms injuries (OR9.08), increasing age (OR1.004), NISS (OR1.007), and AIS-Head (OR1.05), and decreasing admission platelet counts (OR0.998) were independently associated with mortality (p < .001-.041). Platelet transfusion in the first 4 h of care was more frequent among older patients (p < .001).

CONCLUSIONS

Older patients with TBI had lower admission platelet counts, which were independently associated with greater mortality.

Machine Learning to Predict Three Types of Outcomes After Traumatic Brain Injury Using Data at Admission: A Multi-Center Study for Development and Validation

The difficulty of accurately identifying patients who would benefit from promising treatments makes it challenging to prove the efficacy of novel treatments for traumatic brain injury (TBI). Although machine learning is being increasingly applied to this task, existing binary outcome prediction models are insufficient for the effective stratification of TBI patients. The aim of this study was to develop an accurate 3-class outcome prediction model to enable appropriate patient stratification. To this end, retrospective balanced data of 1200 blunt TBI patients admitted to six Japanese hospitals from January 2018 onwards (200 consecutive cases at each institution) were used for model training and validation. We incorporated 21 predictors obtained in the emergency department, including age, sex, six clinical findings, four laboratory parameters, eight computed tomography findings, and an emergency craniotomy. We developed two machine learning models (XGBoost and dense neural network) and logistic regression models to predict 3-class outcomes based on the Glasgow Outcome Scale-Extended (GOSE) at discharge. The prediction models were developed using a training dataset with n = 1000, and their prediction performances were evaluated over two validation rounds on a validation dataset (n = 80) and a test dataset (n = 120) using the bootstrap method. Of the 1200 patients in aggregate, the median patient age was 71 years, 199 (16.7%) exhibited severe TBI, and emergency craniotomy was performed on 104 patients (8.7%). The median length of stay was 13.0 days. The 3-class outcomes were good recovery/moderate disability for 709 patients (59.1%), severe disability/vegetative state in 416 patients (34.7%), and death in 75 patients (6.2%). XGBoost model performed well with 69.5% sensitivity, 82.5% accuracy, and an area under the receiver operating characteristic curve of 0.901 in the final validation. In terms of the receiver operating characteristic curve analysis, the XGBoost outperformed the neural network-based and logistic regression models slightly. In particular, XGBoost outperformed the logistic regression model significantly in predicting severe disability/vegetative state. Although each model predicted favorable outcomes accurately, they tended to miss the mortality prediction. The proposed machine learning model was demonstrated to be capable of accurate prediction of in-hospital outcomes following TBI, even with the three GOSE-based categories. As a result, it is expected to be more impactful in the development of appropriate patient stratification methods in future TBI studies than conventional binary prognostic models. Further, outcomes were predicted based on only clinical data obtained from the emergency department. However, developing a robust model with consistent performance in diverse scenarios remains challenging, and further efforts are needed to improve generalization performance.

Dynamic Changes of Hemostasis in Patients with Traumatic Brain Injury Undergoing Craniotomy: Association with in-Hospital Mortality

BACKGROUND

Traumatic brain injury (TBI) induces complex systemic hemostatic alterations associated with secondary brain damage and death. We specifically investigated perioperative changes of hemostasis in patients with isolated TBI undergoing major neurosurgery and searched for their influence on outcome.

METHODS

Serial analysis (four time points, T0-T3) of conventional coagulation assay and rotational thromboelastometry data acquired during 72 h from admission of 68 patients who underwent craniotomy to remove hematoma and/or to decompress the brain was performed. The primary outcome was in-hospital mortality. Secondary outcomes were the prevalence of hypocoagulation and increased clotting activity, coagulation parameters between survivors and nonsurvivors, and cutoff values of coagulation parameters predictive of mortality.

RESULTS

Overall mortality was 22%. The prevalence of hypocoagulation according to rotational thromboelastometry decreased from 35.8% (T0) to 15.9% (T3). Lower fibrinogen levels, hyperfibrinolysis and fibrinolysis shutdown in the early period (T0-T1) following TBI were associated with higher mortality. Optimal cutoff values were identified: fibrin polymerization thromboelastometry (FIBTEM) clot amplitude at 10 min after clotting time ≤ 13 mm at T0 and FIBTEM clot amplitude at 10 min after clotting time ≤ 16.5 mm at T1 increased the odds of death by 6.0 (95% confidence interval [CI] 1.54-23.13, p = 0.010) and 9.7 (95% CI 2.06-45.36, p = 0.004), respectively. FIBTEM maximum clot firmness ≤ 14.5 mm at T0 and FIBTEM maximum clot firmness ≤ 18.5 mm at T1 increased the odds of death by 6.3 (95% CI 1.56-25.69, p = 0.010) and 9.1 (95% CI 1.88-44.39, p = 0.006). Fibrinogen < 3 g/L on postoperative day 1 (T1) was associated with a 9.5-fold increase of in-hospital mortality (95% CI 1.72-52.98, p = 0.01). Increased clotting activity was not associated with mortality.

CONCLUSIONS

Rotational thromboelastometry adds important information for identifying patients with TBI at increased risk of death. Early fibrinogen-related coagulation disorders are associated with mortality of patients with TBI undergoing major neurosurgical procedures. Maintenance of higher fibrinogen levels might be necessary for neurosurgical patients with acute TBI.

Efficacy of Serum Antithrombin III Test in Patients With Severe Traumatic Brain Injury

Objective

Immune reactions following traumatic brain injury (TBI) cause many complications, including intravascular dissemination. Antithrombin III (AT-III) plays an important role in suppressing abnormal clot formation and ensuring hemostasis. Therefore, we investigated the efficacy of serum AT-III in patients with severe TBI.

Methods

This retrospective study included 224 patients with severe TBI who visited a single regional trauma center between 2018 and 2020. AT-III levels were measured immediately after the TBI diagnosis. AT-III deficiency was defined as an AT-III serum level <70%. Patient characteristics, injury severity, and procedures were also investigated. Patient outcomes included Glasgow Outcome Scale scores at discharge and mortality.

Results

AT-III levels were significantly lower in the AT-III deficient group (n=89; 48.27% ± 1.91%) than in the AT-III sufficient group (n = 135, 78.90% ± 1.52%) (p < 0.001). Mortality occurred in 72 of the 224 patients (33.04%), indicating that there were significantly more patients in the AT-III-deficient group (45/89, 50.6%) than in the AT-III-sufficient group (27/135, 20%). Significant risk factors for mortality included the Glasgow Coma Scale score (P = 0.003), pupil dilatation (P = 0.031), disseminated intravascular coagulopathy (P = 0.012), serum AT-III level (P = 0.033), and procedures including barbiturate coma therapy (P = 0.010). Serum AT-III levels were significantly correlated with Glasgow Outcome Scale scores at discharge (correlation coefficient = 0.455, p < 0.001).

Conclusion

Patients with AT-III deficiency after severe TBI may require more intensive care during treatment, because AT-III levels reflect injury severity and correlate with mortality.

The establishment and validation of a prediction model for traumatic intracranial injury patients: a reliable nomogram

Objective

Traumatic brain injury (TBI) leads to death and disability. This study developed an effective prognostic nomogram for assessing the risk factors for TBI mortality.

Method

Data were extracted from an online database called "Multiparameter Intelligent Monitoring in Intensive Care IV" (MIMIC IV). The ICD code obtained data from 2,551 TBI persons (first ICU stay, >18 years old) from this database. R divided samples into 7:3 training and testing cohorts. The univariate analysis determined whether the two cohorts differed statistically in baseline data. This research used forward stepwise logistic regression after independent prognostic factors for these TBI patients. The optimal variables were selected for the model by the optimal subset method. The optimal feature subsets in pattern recognition improved the model prediction, and the minimum BIC forest of the high-dimensional mixed graph model achieved a better prediction effect. A nomogram-labeled TBI-IHM model containing these risk factors was made by nomology in State software. Least Squares OLS was used to build linear models, and then the Receiver Operating Characteristic (ROC) curve was plotted. The TBI-IHM nomogram model's validity was determined by receiver operating characteristic curves (AUCs), correction curve, Hosmer-Lemeshow test, integrated discrimination improvement (IDI), net reclassification improvement (NRI), and decision-curve analysis (DCA).

Result

The eight features with a minimal BIC model were mannitol use, mechanical ventilation, vasopressor use, international normalized ratio, urea nitrogen, respiratory rate, and cerebrovascular disease. The proposed nomogram (TBI-IHM model) was the best mortality prediction model, with better discrimination and superior model fitting for severely ill TBI patients staying in ICU. The model's receiver operating characteristic curve (ROC) was the best compared to the seven other models. It might be clinically helpful for doctors to make clinical decisions.

Conclusion

The proposed nomogram (TBI-IHM model) has significant potential as a clinical utility in predicting mortality in TBI patients.

Association between plasma metal elements and platelet dysfunction in trauma-induced coagulopathy rat model

BACKGROUND

Disorders of metal elements and platelet dysfunction are common in patients with trauma-induced coagulopathy (TIC).

AIM

The aim of this study was to explore the potential role of plasma metal elements in platelet dysfunction in TIC.

METHODS

Thirty Sprague-Dawley rats were divided into control, hemorrhage shock (HS) and multiple injury (MI) groups. At timepoints of 0.5 and 3 h after trauma and being documented as _{HS 0.5 h}, HS_3 h, _{MI 0.5 h} or MI_3 h, blood samples were harvested for inductively coupled plasma mass spectrometer, conventional coagulation function and thromboelastograph.

RESULTS

The plasma zinc (Zn), vanadium (V) and cadmium (Ca) decreased initially in HS _0.5 h and recovered slightly in HS_3 h, whereas their plasma concentrations continued to decrease from beginning till MI_3 h (p < 0.05). In HS, plasma Ca, V and nickel were negatively correlated to the time taken to reach the initial formation (R), whereas R was positively correlated to plasms Zn, V, Ca and selenium in MI (p < 0.05). In MI, plasma Ca was positively correlated to maximum amplitude, and plasma V was positively correlated to platelet count (p < 0.05).

CONCLUSION

The plasma concentrations of Zn, V and Ca appeared to contribute to platelet dysfunction in _{HS 0.5 h}, HS_3 h, _{MI 0.5 h} and MI_3 h, which were trauma type sensitive.

Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Mild Traumatic Brain Injury: Approved by ACEP Board of Directors, February 1, 2023 Clinical Policy Endorsed by the Emergency Nurses Association (April 5, 2023)

This 2023 Clinical Policy from the American College of Emergency Physicians is an update of the 2008 “Clinical Policy: Neuroimaging and Decisionmaking in Adult Mild Traumatic Brain Injury in the Acute Setting.” A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following questions: 1) In the adult emergency department patient presenting with minor head injury, are there clinical decision tools to identify patients who do not require a head computed tomography? 2) In the adult emergency department patient presenting with minor head injury, a normal baseline neurologic examination, and taking an anticoagulant or antiplatelet medication, is discharge safe after a single head computed tomography? and 3) In the adult emergency department patient diagnosed with mild traumatic brain injury or concussion, are there clinical decision tools or factors to identify patients requiring follow-up care for postconcussive syndrome or to identify patients with delayed sequelae after emergency department discharge? Evidence was graded and recommendations were made based on the strength of the available data. Widespread and consistent implementation of evidence-based clinical recommendations is warranted to improve patient care.

Acute Haemostatic Depletion and Failure in Patients with Traumatic Brain Injury (TBI): Pathophysiological and Clinical Considerations

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.

Dynamic predictors of in-hospital and 3-year mortality after traumatic brain injury: A retrospective cohort study

BACKGROUND

Mortality risks after Traumatic Brain Injury (TBI) are understudied in critical illness. We sought to identify risks of mortality in critically ill patients with TBI using time-varying covariates.

METHODS

This single-center, six-year (2006-2012), retrospective cohort study measured demographics, injury characteristics, and daily data of acute TBI patients in the Intensive Care Unit (ICU). Time-varying Cox proportional hazards models assessed in-hospital and 3-year mortality.

RESULTS

Post-TBI ICU patients (n = 2664) experienced 20% in-hospital mortality (n = 529) and 27% (n = 706) 3-year mortality. Glasgow Coma Scale motor subscore (hazard ratio (HR) 0.58, p < 0.001), pupil reactivity (HR 3.17, p < 0.001), minimum glucose (HR 1.44, p < 0.001), mSOFA score (HR 1.81, p < 0.001), coma (HR 2.26, p < 0.001), and benzodiazepines (HR 1.38, p < 0.001) were associated with in-hospital mortality. At three years, public insurance (HR 1.78, p = 0.011) and discharge disposition (HR 4.48, p < 0.001) were associated with death.

CONCLUSIONS

Time-varying characteristics influenced in-hospital mortality post-TBI. Socioeconomic factors primarily affect three-year mortality.

Neutrophil extracellular traps contribute to coagulopathy after traumatic brain injury

Coagulopathy contributes to the majority of deaths and disabilities associated with traumatic brain injury (TBI). Whether neutrophil extracellular traps (NETs) contribute to an abnormal coagulation state in the acute phase of TBI remains unknown. Our objectives were to demonstrate the definitive role of NETs in coagulopathy in TBI. We detected NET markers in 128 TBI patients and 34 healthy individuals. Neutrophil-platelet aggregates were detected in blood samples from TBI patients and healthy individuals using flow cytometry and staining for CD41 and CD66b. Endothelial cells were incubated with isolated NETs and we detected the expression of vascular endothelial cadherin, syndecan-1, thrombomodulin, von Willebrand factor, phosphatidylserine, and tissue factor. In addition, we established a TBI mouse model to determine the potential role of NETs in TBI-associated coagulopathy. NET generation was mediated by high mobility group box 1 (HMGB1) from activated platelets and contributed to procoagulant activity in TBI. Furthermore, coculture experiments indicated that NETs damaged the endothelial barrier and caused these cells to assume a procoagulant phenotype. Moreover, the administration of DNase I before or after brain trauma markedly reduced coagulopathy and improved the survival and clinical outcome of mice with TBI.