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Levy M, Arfi Levy E, Marianayagam NJ, Frolov V, Maimon S, Salomon O. Distinctive patterns of sequential platelet counts following blunt traumatic brain injury predict outcomes. Brain Inj 2024; 38:818-826. [PMID: 38679938 DOI: 10.1080/02699052.2024.2347571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 04/22/2024] [Indexed: 05/01/2024]
Abstract
OBJECTIVE To determine the role of platelet counts in the context of the decision to treat patients with non-compounded, non-surgically-treated blunt traumatic brain injury (NCNS-bTBI) with anticoagulants/antiaggregants. METHODS A retrospective analysis of 141 anticoagulants/antiaggregants-naïve patients with NCNS-bTBI. Changes in PT-INR and prolonged aPTT were examined and correlated with Marshall and Rotterdam scores, clinical and neuroradiological outcomes. RESULTS Three groups of platelet counts were identified. Group 1 (83% of patients) had normal platelet counts (150,000-450,000 platelets/mm3) from admission to discharge. Group 2 (13%) developed transient thrombocytopenia (<150,000 platelets/mm3) 2-3 days post-trauma. Group 3 (4%) developed extreme thrombocytosis > 1,000,000/mm3 platelets 6-9 days post-trauma. Neither acute coagulopathy of trauma nor progressive hemorrhagic insults followed NCNS-bTBI. Moreover, while patients with thrombocytosis/extreme thrombocytosis presented with a worse Glasgow coma score (GCS) on admission (8.8 ± 2.9 vs. 13 ± 2, p < 0.01) and had longer hospitalization (13.5 ± 10.4 vs. 4.5 ± 2.1 days), their improvement at discharge was the highest (delta GCS, 4 ± 2.8 vs. 1.2 ± 2.1, p = 0.05). Traumatic subarachnoid hemorrhage was associated with isolated thrombocytosis and 'best improvement.' No thromboembolic or hemorrhagic complications occurred. CONCLUSION NCNS-bTBI, thrombocytosis was correlated with better outcomes and was not associated with an increased risk for developing thromboembolism or hemorrhage, precluding the immediate need for any additional antiaggregates.
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Affiliation(s)
- Mikael Levy
- Department of Neurosurgery, Rabin Medical Center, Tel Aviv, Israel
- Functional Neurosurgery Unit, Assuta Medical Centers, Tel Aviv, Israel
| | - Esther Arfi Levy
- Department of Pediatric Cardiac Surgery, Schneider Medical Center, Petach Tikva, Israel
| | | | - Vladimir Frolov
- Interventional Neuroradiology Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Shimon Maimon
- Interventional Neuroradiology Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Ophira Salomon
- Thrombosis and Hemostasis Unit, Sheba Medical Center, Ramat Gan, Israel
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Zoghi S, Ansari A, Azad TD, Niakan A, Kouhpayeh SA, Taheri R, Khalili H. Early hypocoagulable state in traumatic brain injury patients: incidence, predisposing factors, and outcomes in a retrospective cohort study. Neurosurg Rev 2024; 47:297. [PMID: 38922506 DOI: 10.1007/s10143-024-02523-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 04/12/2024] [Accepted: 06/15/2024] [Indexed: 06/27/2024]
Abstract
Coagulopathy development in traumatic brain injury (TBI) is among the significant complications that can negatively affect the clinical course and outcome of TBI patients. Timely identification of this complication is of utmost importance in the acute clinical setting. We reviewed TBI patients admitted to our trauma center from 2015 to 2021. Demographic data, mechanism of injury, findings on admission, imaging studies, procedures during hospitalization, and functional outcomes were gathered. INR with a cutoff of 1.3, platelet count less than 100 × 10⁹/L, or partial thromboplastin time greater than 40s were utilized as the markers of coagulopathy. A total of 4002 patients were included. Coagulopathy occurred in 38.1% of the patients. Age of the patients (Odds Ratio (OR) = 0.993, 95% Confidence Interval (CI) = 0.986-0.999, p = 0.028), systolic blood pressure (OR = 0.993, 95% CI = 0.989-0.998, p = 0.005), fibrinogen level (OR = 0.998, 95% CI = 0.996-0.999, p < 0.001), and hemoglobin level (OR = 0.886, 95% CI = 0.839-0.936, p < 0.001) were independently associated with coagulopathy. Furthermore, coagulopathy was independently associated with higher mortality rates and longer ICU stays. Coagulopathy had the most substantial effect on mortality of TBI patients (OR = 2.6, 95% CI = 2.1-3.3, p < 0.001), compared to other admission clinical characteristics independently associated with mortality such as fixed pupillary light reflex (OR = 1.8, 95% CI = 1.5-2.4, p < 0.001), GCS (OR = 0.91, 95% CI = 0.88-0.94, p < 0.001), and hemoglobin level (OR = 0.93, 95% CI = 0.88-0.98, p = 0.004). Early coagulopathy in TBI patients can lead to higher mortality rates. Future studies are needed to prove that early detection and correction of coagulopathy and modifiable risk factors may help improve outcomes of TBI patients.
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Affiliation(s)
- Sina Zoghi
- Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ali Ansari
- Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Tej D Azad
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amin Niakan
- Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Reza Taheri
- Shiraz Neuroscience Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
- School of Medicine, Fasa University of Medical Sciences, Fasa, Iran.
| | - Hosseinali Khalili
- Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
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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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Jing X, Wang X, Zhuang H, Fang X, Xu H. Multiple Machine Learning Approaches Based on Postoperative Prediction of Pulmonary Complications in Patients With Emergency Cerebral Hemorrhage Surgery. Front Surg 2022; 8:797872. [PMID: 35127804 PMCID: PMC8812295 DOI: 10.3389/fsurg.2021.797872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 12/01/2021] [Indexed: 11/26/2022] Open
Abstract
Objective This study aimed to create a prediction model of postoperative pulmonary complications for the patients with emergency cerebral hemorrhage surgery. Methods Patients with hemorrhage surgery who underwent cerebral hemorrhage surgery were included and divided into two groups: patients with or without pulmonary complications. Patient characteristics, previous history, laboratory tests, and interventions were collected. Univariate and multivariate logistic regressions were used to predict postoperative pulmonary infection. Multiple machine learning approaches have been used to compare their importance in predicting factors, namely K-nearest neighbor (KNN), stochastic gradient descent (SGD), support vector classification (SVC), random forest (RF), and logistics regression (LR), as they are the most successful and widely used models for clinical data. Results Three hundred and fifty four patients with emergency cerebral hemorrhage surgery between January 1, 2017 and December 31, 2020 were included in the study. 53.7% (190/354) of the patients developed postoperative pulmonary complications (PPC). Stepwise logistic regression analysis revealed four independent predictive factors associated with pulmonary complications, including current smoker, lymphocyte count, clotting time, and ASA score. In addition, the RF model had an ideal predictive performance. Conclusions According to our result, current smoker, lymphocyte count, clotting time, and ASA score were independent risks of pulmonary complications. Machine learning approaches can also provide more evidence in the prediction of pulmonary complications.
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Affiliation(s)
- Xiaolei Jing
- Division of Life Sciences and Medicine, Department of Neurosurgery, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Xueqi Wang
- Division of Life Sciences and Medicine, Department of Neurosurgery, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Hongxia Zhuang
- Division of Life Sciences and Medicine, Department of Neurosurgery, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Xiang Fang
- Division of Life Sciences and Medicine, Department of Neurology, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Hao Xu
- Division of Life Sciences and Medicine, Department of Neurosurgery, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
- *Correspondence: Hao Xu
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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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Matsuoka A, Miike T, Miyazaki M, Goto T, Sasaki A, Yamazaki H, Komaki M, Higuchi M, Mori K, Shinada K, Nakayama K, Sakurai R, Asahi M, Futami A, Yoshitake K, Narumi S, Koba M, Koami H, Kawaguchi A, Murakawa TH, Monji A, Sakamoto Y. Development of a delirium predictive model for adult trauma patients in an emergency and critical care center: a retrospective study. Trauma Surg Acute Care Open 2021; 6:e000827. [PMID: 34901468 PMCID: PMC8634003 DOI: 10.1136/tsaco-2021-000827] [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: 08/31/2021] [Accepted: 11/02/2021] [Indexed: 11/10/2022] Open
Abstract
Background Delirium has been shown to prolong the length of intensive care unit stay, hospitalization, and duration of ventilatory control, in addition to increasing the use of sedatives and increasing the medical costs. Although there have been a number of reports referring to risk factors for the development of delirium, no model has been developed to predict delirium in trauma patients at the time of admission. This study aimed to create a scoring system that predicts delirium in trauma patients. Methods In this single-center, retrospective, observational study, trauma patients aged 18 years and older requiring hospitalization more than 48 hours were included and divided into the development and validation cohorts. Univariate analysis was performed in the development cohort to identify factors significantly associated with prediction of delirium. The final scoring system for predicting delirium was developed using multivariate analysis and internal validation was performed. Results Of the 308 patients in the development cohort, 91 developed delirium. Clinical Frailty Score, fibrin/fibrinogen degradation products, low body mass index, lactate level, and Glasgow Coma Scale score were independently associated with the development of delirium. We developed a scoring system using these factors and calculated the delirium predictive score, which had an area under the curve of 0.85. In the validation cohort, 46 of 206 patients developed delirium. The area under the curve for the validation cohort was 0.86, and the calibration plot analysis revealed the scoring system was well calibrated in the validation cohort. Discussion This scoring system for predicting delirium in trauma patients consists of only five risk factors. Delirium prediction at the time of admission may be useful in clinical practice. Level of evidence Prognostic and epidemiological, level III.
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Affiliation(s)
- Ayaka Matsuoka
- Emergency and Critical Care Medicine, Saga University Hospital, Saga City, Japan
| | - Toru Miike
- Emergency and Critical Care Medicine, Saga University Hospital, Saga City, Japan
| | - Mariko Miyazaki
- Emergency and Critical Care Medicine, Saga University Hospital, Saga City, Japan
| | - Taku Goto
- Emergency and Critical Care Medicine, Saga University Hospital, Saga City, Japan
| | - Akira Sasaki
- Emergency and Critical Care Medicine, Saga University Hospital, Saga City, Japan
| | - Hirotaka Yamazaki
- Emergency and Critical Care Medicine, Saga University Hospital, Saga City, Japan
| | - Moe Komaki
- Emergency and Critical Care Medicine, Saga University Hospital, Saga City, Japan
| | - Masahiro Higuchi
- Emergency and Critical Care Medicine, Saga University Hospital, Saga City, Japan
| | - Kosuke Mori
- Emergency and Critical Care Medicine, Saga University Hospital, Saga City, Japan
| | - Kota Shinada
- Emergency and Critical Care Medicine, Saga University Hospital, Saga City, Japan
| | - Kento Nakayama
- Emergency and Critical Care Medicine, Saga University Hospital, Saga City, Japan
| | - Ryota Sakurai
- Emergency and Critical Care Medicine, Saga University Hospital, Saga City, Japan
| | - Miho Asahi
- Emergency and Critical Care Medicine, Saga University Hospital, Saga City, Japan
| | - Akiko Futami
- Emergency and Critical Care Medicine, Saga University Hospital, Saga City, Japan
| | - Kunimasa Yoshitake
- Emergency and Critical Care Medicine, Saga University Hospital, Saga City, Japan
| | - Shougo Narumi
- Emergency and Critical Care Medicine, Saga University Hospital, Saga City, Japan
| | - Mayuko Koba
- Emergency and Critical Care Medicine, Saga University Hospital, Saga City, Japan
| | - Hiroyuki Koami
- Emergency and Critical Care Medicine, Saga University Hospital, Saga City, Japan
| | - Atsushi Kawaguchi
- Education and Research Center for Community Medicine, Saga University, Saga, Japan
| | | | - Akira Monji
- Psychiatry, Faculty of Medicine, Saga University Hospital, Saga City, Japan
| | - Yuichirou Sakamoto
- Emergency and Critical Care Medicine, Saga University Hospital, Saga City, Japan
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Chen P, Mei J, Cheng W, Jiang X, Lin S, Wei X, Qian R, Niu C. Application of multimodal MRI and radiologic features for stereotactic brain biopsy: insights from a series of 208 patients. Br J Neurosurg 2021; 35:611-618. [PMID: 34002649 DOI: 10.1080/02688697.2021.1926922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES We reviewed our institutional experience during a 10-year period for improvement of safety and efficacy of stereotactic biopsy procedures. METHODS We performed a retrospective review of inpatient summaries, stereotactic worksheets and radiologic investigations of 208 consecutive patients, who underwent MRI-guided stereotactic biopsies between March 2010 and March 2020. RESULTS The overall diagnostic yield was 96.2%. CT-confirmed intracranial hemorrhage occurred in 17 patients (8.2%), and the overall mortality rate was 0.5%. Combined MRS and PWI helped target selection in 27 cases (13.0%), the diagnostic yield was 100%. The results of the regression analysis revealed that non-diagnostic biopsy specimen significantly correlated with the cystic trait (p<.01) and edema of lesions (p<.05). Enhancement (p<.01) is shown to be an important factor for obtaining a diagnostic biopsy. Furthermore, the edema trait of lesions (p<.01) showed the important factors of hemorrhage. CONCLUSIONS The radiological features of lesions and use of the most suitable MRI sequences during biopsy planning are recommended ways to improve the diagnostic yield and safety of this technique.
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Affiliation(s)
- Peng Chen
- Department of Neurosurgery, Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China.,Anhui Provincial Key Laboratory of Brain Function and Brain Disease, Hefei, China
| | - Jiaming Mei
- Department of Neurosurgery, Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Wei Cheng
- Department of Neurosurgery, Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Xiaofeng Jiang
- Department of Neurosurgery, Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Shiying Lin
- Department of Neurosurgery, Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China.,Anhui Provincial Stereotactic Neurosurgical Institute, Hefei, China
| | - Xiangpin Wei
- Department of Neurosurgery, Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China.,Anhui Provincial Stereotactic Neurosurgical Institute, Hefei, China
| | - Ruobing Qian
- Department of Neurosurgery, Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China.,Anhui Provincial Stereotactic Neurosurgical Institute, Hefei, China
| | - Chaoshi Niu
- Department of Neurosurgery, Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China.,Anhui Provincial Key Laboratory of Brain Function and Brain Disease, Hefei, China.,Anhui Provincial Stereotactic Neurosurgical Institute, Hefei, China
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Krishna G, Aggarwal V, Singh I. Prospective Analysis of Coagulopathy Associated with Isolated Traumatic Brain Injury and Clinical Outcome. INDIAN JOURNAL OF NEUROSURGERY 2021. [DOI: 10.1055/s-0041-1728989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Abstract
Introduction Traumatic brain injury (TBI) affects the coagulation pathway in a distinct way than does extracranial trauma. The extent of coagulation abnormalities varies from bleeding diathesis to disseminated thrombosis.
Design Prospective study.
Methods The study included 50 patients of isolated TBI with cohorts of moderate (MHI) and severe head injury (SHI). Coagulopathy was graded according to the values of parameters in single laboratory. The incidence of coagulopathy according to the severity of TBI and correlation with disseminated intravascular coagulation (DIC) score, platelets, prothrombin time (PT), activated partial thromboplastin time (APTT), D-dimer, and fibrinogen was observed. The comparison was also made between expired and discharged patients within each group. It also compared coagulation derailments with clinical presentation (Glasgow Coma Scale [GCS]) and outcome (Glasgow Outcome Scale [GOS]).
Results Road traffic accident was the primary (72%) mode of injury. Fifty-two percent had MHI and rest had SHI. Eighty-four percent of cases were managed conservatively. The mean GCS was 12.23 and 5.75 in MHI and SHI, respectively. Sixty-two percent of MHI and 96% of the patients with SHI had coagulation abnormalities. On statistical analysis, DIC score (p < 0.001) strongly correlated with the severity of head injury and GOS. PT and APTT were also significantly associated with the severity of TBI. In patients with moderate TBI, D-dimer and platelet counts showed association with clinical outcome. Fibrinogen levels did not show any statistical significance. The mean platelet counts remained normal in both the groups of TBI. The mean GOS was 1.54 and 4.62 in SHI and MHI, respectively.
Conclusion Coagulopathy is common in isolated TBI. The basic laboratory parameters are reliable predictors of coagulation abnormalities in TBI. Coagulopathy is directly associated with the severity of TBI, GCS, and poor outcome.
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Affiliation(s)
- Gopal Krishna
- Department of Neurosurgery, Pt. B.D. Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Varun Aggarwal
- Department of Neurosurgery, Pt. B.D. Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Ishwar Singh
- Department of Neurosurgery, Pt. B.D. Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India
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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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10
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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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11
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Hanko M, Grendár M, Snopko P, Opšenák R, Šutovský J, Benčo M, Soršák J, Zeleňák K, Kolarovszki B. Random Forest-Based Prediction of Outcome and Mortality in Patients with Traumatic Brain Injury Undergoing Primary Decompressive Craniectomy. World Neurosurg 2021; 148:e450-e458. [PMID: 33444843 DOI: 10.1016/j.wneu.2021.01.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 01/01/2021] [Accepted: 01/02/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Various prognostic models are used to predict mortality and functional outcome in patients after traumatic brain injury with a trend to incorporate machine learning protocols. None of these models is focused exactly on the subgroup of patients indicated for decompressive craniectomy. Evidence regarding efficiency of this surgery is still incomplete, especially in patients undergoing primary decompressive craniectomy with evacuation of traumatic mass lesions. METHODS In a prospective study with a 6-month follow-up period, we assessed postoperative outcome and mortality of 40 patients who underwent primary decompressive craniectomy for traumatic brain injuries during 2018-2019. The results were analyzed in relation to a wide spectrum of preoperatively available demographic, clinical, radiographic, and laboratory data. Random forest algorithms were trained for prediction of both mortality and unfavorable outcome, with their accuracy quantified by area under the receiver operating curves (AUCs) for out-of-bag samples. RESULTS At the end of the follow-up period, we observed mortality of 57.5%. Favorable outcome (Glasgow Outcome Scale [GOS] score 4-5) was achieved by 30% of our patients. Random forest-based prediction models constructed for 6-month mortality and outcome reached a moderate predictive ability, with AUC = 0.811 and AUC = 0.873, respectively. Random forest models trained on handpicked variables showed slightly decreased AUC = 0.787 for 6-month mortality and AUC = 0.846 for 6-month outcome and increased out-of-bag error rates. CONCLUSIONS Random forest algorithms show promising results in prediction of postoperative outcome and mortality in patients undergoing primary decompressive craniectomy. The best performance was achieved by Classification Random forest for 6-month outcome.
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Affiliation(s)
- Martin Hanko
- Clinic of Neurosurgery, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava and University Hospital in Martin, Martin, Slovak Republic.
| | - Marián Grendár
- Bioinformatic Center, Biomedical Center Martin (BioMed), Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Pavol Snopko
- Clinic of Neurosurgery, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava and University Hospital in Martin, Martin, Slovak Republic
| | - René Opšenák
- Clinic of Neurosurgery, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava and University Hospital in Martin, Martin, Slovak Republic
| | - Juraj Šutovský
- Clinic of Neurosurgery, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava and University Hospital in Martin, Martin, Slovak Republic
| | - Martin Benčo
- Clinic of Neurosurgery, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava and University Hospital in Martin, Martin, Slovak Republic
| | - Jakub Soršák
- Clinic of Radiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava and University Hospital in Martin, Martin, Slovak Republic
| | - Kamil Zeleňák
- Clinic of Radiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava and University Hospital in Martin, Martin, Slovak Republic
| | - Branislav Kolarovszki
- Clinic of Neurosurgery, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava and University Hospital in Martin, Martin, Slovak Republic
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12
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Abstract
Management of acute neurologic disorders in the emergency department is multimodal and may require the use of medications to decrease morbidity and mortality secondary to neurologic injury. Clinicians should form an individualized treatment approach with regard to various patient specific factors. This review article focuses on the pharmacotherapy for common neurologic emergencies that present to the emergency department, including traumatic brain injury, central nervous system infections, status epilepticus, hypertensive emergencies, spinal cord injury, and neurogenic shock.
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Affiliation(s)
- Kyle M DeWitt
- Emergency Medicine, Department of Pharmacy, The University of Vermont Medical Center, 111 Colchester Avenue, Mailstop 272 BA1, Burlington, VT 05401, USA.
| | - Blake A Porter
- Emergency Medicine, Department of Pharmacy, The University of Vermont Medical Center, 111 Colchester Avenue, Mailstop 272 BA1, Burlington, VT 05401, USA. https://twitter.com/RxEmergency
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13
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Baldon IV, Amorim AC, Santana LM, Solla DJ, Kolias A, Hutchinson P, Paiva WS, Rosa-Júnior M. The extravasation of contrast as a predictor of cerebral hemorrhagic contusion expansion, poor neurological outcome and mortality after traumatic brain injury: A systematic review and meta-analysis. PLoS One 2020; 15:e0235561. [PMID: 32634141 PMCID: PMC7340282 DOI: 10.1371/journal.pone.0235561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 06/17/2020] [Indexed: 01/14/2023] Open
Abstract
Background The active extravasation of contrast on CT angiography (CTA) in primary intracerebral hemorrhages (ICH) is recognized as a predictive factor for ICH expansion, unfavorable outcomes and mortality. However, few studies have been conducted on the setting of traumatic brain injury (TBI). Purpose To perform a literature systematic review and meta-analysis of the association of contrast extravasation on cerebral hemorrhagic contusion expansion, neurological outcomes and mortality. Data sources The PubMed, Cochrane Library, Medline, Scielo, VHL and IBECS databases up to September 21, 2019, were searched for eligible studies. Study selection A total of 505 individual titles and abstracts were identified and screened. A total of 36 were selected for full text analysis, out of which 4 fulfilled all inclusion and exclusion criteria. Data analysis All 4 studies yielded point estimates suggestive of higher risk for hematoma expansion with contrast extravasation and the summary RR was 5.75 (95%CI 2.74–10.47, p<0.001). Contrast extravasation was also associated with worse neurological outcomes (RR 3.25, 95%CI 2.24–4.73, p<0.001) and higher mortality (RR 2.77, 95%CI 1.03–7.47, p = 0.04). Data synthesis This study is a Systematic Review and Meta-Analysis revealed the extravasation of contrast is a useful imaging sign to predict hematoma expansion, worse neurological outcomes and higher mortality. Limitations Only four articles were selected. Conclusions The extravasation of contrast in the setting of TBI is a useful imaging sign to predict hematoma expansion, worse neurological outcomes and higher mortality.
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Affiliation(s)
- Isabella Vargas Baldon
- Department of Radiology, Hospital Universitário Cassiano Antônio de Moraes da Universidade Federal do Espírito Santo – HUCAM/UFES/EBSERH, Vitória, State of Espírito Santo, Brazil
| | - Andre Candeas Amorim
- Department of Radiology, Hospital Universitário Cassiano Antônio de Moraes da Universidade Federal do Espírito Santo – HUCAM/UFES/EBSERH, Vitória, State of Espírito Santo, Brazil
| | - Larissa Marques Santana
- Department of Radiology, Hospital Universitário Cassiano Antônio de Moraes da Universidade Federal do Espírito Santo – HUCAM/UFES/EBSERH, Vitória, State of Espírito Santo, Brazil
| | - Davi J. Solla
- Department of Neurology, Division of Neurosurgery, Hospital das Clínicas of the University of São Paulo, São Paulo, Brazil
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Angelos Kolias
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s, Hospital and University of Cambridge, Cambridge, United Kingdom
| | - Peter Hutchinson
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s, Hospital and University of Cambridge, Cambridge, United Kingdom
| | - Wellingson S. Paiva
- Department of Neurology, Division of Neurosurgery, Hospital das Clínicas of the University of São Paulo, São Paulo, Brazil
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Marcos Rosa-Júnior
- Department of Neuroradiology, Hospital Universitário Cassiano Antônio de Moraes da Universidade Federal do Espírito Santo – HUCAM/UFES/EBSERH, Vitória, State of Espírito Santo, Brazil
- * E-mail:
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14
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Sakakura K, Ikeda G, Nakai Y, Watanabe N, Uemura K, Zaboronok A, Ishikawa E, Matsumura A. High fibrin/fibrinogen degradation product value as a risk factor for progressive remote traumatic intracranial haemorrhage following neurosurgery. Br J Neurosurg 2020; 35:749-752. [PMID: 32530358 DOI: 10.1080/02688697.2020.1775788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Introduction: Remote traumatic intracranial haemorrhage (RTIH) may develop after neurosurgery. Recognition of the risk factors for RTIH before surgery might be of great value. The purpose of this study was to verify if the fibrin/fibrinogen degradation product (FDP) value may be a risk factor for RTIH.Methods: This was a retrospective study of the data of 56 patients with traumatic intracranial hematomas shown on initial computed tomography (CT) who were treated with craniotomy or decompressive craniectomy and underwent a follow-up CT at a single centre over a period of approximately 10.5 years. We divided the patients into 2 groups: those who developed RTIH (Positive: P-group) and those who did not (Negative: N-group). We compared the 2 groups in terms of not only the laboratory data before surgery, but also patient age, sex, antiplatelet/antithrombotic medications received, cause of injury, and GCS score on arrival.Results: RTIH was observed in 22 patients (P-group, 39.3%). The FDP value was the only significant risk factor identified in this study (p = 0.00076). The cut-off value was estimated on the basis of the area under the receiver operating characteristic (ROC) curve. The cut-off FDP value was 120 µg/mL (63.6% sensitivity and 85.3% specificity).Conclusions: FDP levels over 120 µg/mL were determined to be a risk factor for progressive RTIH after neurosurgery. We suggest the FDP level be checked before surgery for traumatic intracranial haemorrhage and follow-up CT be done as soon as possible after the surgery if the serum FDP level is over 120 µg/mL.
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Affiliation(s)
- Kazuki Sakakura
- Department of Neurosurgery, Tsukuba Medical Center Hospital, Tsukuba, Japan.,Department of Neurosurgery, University of Tsukuba, Tsukuba, Japan
| | - Go Ikeda
- Department of Neurosurgery, Tsukuba Medical Center Hospital, Tsukuba, Japan
| | - Yasunobu Nakai
- Department of Neurosurgery, Tsukuba Medical Center Hospital, Tsukuba, Japan
| | - Noriyuki Watanabe
- Department of Neurosurgery, Tsukuba Medical Center Hospital, Tsukuba, Japan.,Department of Neurosurgery, University of Tsukuba, Tsukuba, Japan
| | - Kazuya Uemura
- Department of Neurosurgery, Tsukuba Medical Center Hospital, Tsukuba, Japan
| | | | - Eiichi Ishikawa
- Department of Neurosurgery, University of Tsukuba, Tsukuba, Japan
| | - Akira Matsumura
- Department of Neurosurgery, University of Tsukuba, Tsukuba, Japan
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15
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Zhou D, Li Z, Wu L, Shi G, Zhou J. Thrombocytopenia and platelet course on hospital mortality in neurological intensive care unit: a retrospective observational study from large database. BMC Neurol 2020; 20:220. [PMID: 32473647 PMCID: PMC7260747 DOI: 10.1186/s12883-020-01794-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 05/19/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Thrombocytopenia (TP) has been shown to be an independent predictor of mortality in the intensive care unit (ICU) patients. Studies are lacking in the neurological ICU (NICU) population. The aim was to evaluate the incidence of TP in NICU and the relationship between TP and outcomes. METHODS We conducted a retrospective multicenter study of prospectively collected data of all patients admitted to the NICU between 2014 and 2015 from a large database (eICU Collaborative Research Database). The main exposure was TP at admission and TP developed during NICU stay. Multivariable logistic regression and Cox proportional hazard models were used to evaluate the relationship of TP at admission and platelet course with hospital mortality. The primary outcome was hospital mortality. RESULTS 7450 patients in NICU from 17 hospitals were included. Hospital mortality was 9%. TP at admission was present in 20% of patients, TP developed during NICU stay was present in 13.2% of patients. TP at admission was not associated with hospital mortality after adjusting for confounders (OR 1.14 [95% CI 0.92-1.41, p = 0.237]). Hospital mortality of continuous TP during NICU stay was 15% while hospital mortality of recovery from TP at admission was 6% (p < 0.001). Patients with TP developed during NICU stay had higher odds ratio for hospital mortality (OR 1.65 [95% CI 1.3-2.09, p < 0.001]). CONCLUSIONS Thrombocytopenia is common in NICU and patients who have thrombocytopenia not resolving have increased mortality. Patients' recovery from thrombocytopenia may predict a good prognosis.
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Affiliation(s)
- Dawei Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhimin Li
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Lei Wu
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guangzhi Shi
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
| | - Jianxin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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16
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Mathieu F, Zeiler FA, Whitehouse DP, Das T, Ercole A, Smielewski P, Hutchinson PJ, Czosnyka M, Newcombe VFJ, Menon DK. Relationship Between Measures of Cerebrovascular Reactivity and Intracranial Lesion Progression in Acute TBI Patients: an Exploratory Analysis. Neurocrit Care 2020; 32:373-382. [PMID: 31797278 PMCID: PMC7082305 DOI: 10.1007/s12028-019-00885-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Failure of cerebral autoregulation and progression of intracranial lesion have both been shown to contribute to poor outcome in patients with acute traumatic brain injury (TBI), but the interplay between the two phenomena has not been investigated. Preliminary evidence leads us to hypothesize that brain tissue adjacent to primary injury foci may be more vulnerable to large fluctuations in blood flow in the absence of intact autoregulatory mechanisms. The goal of this study was therefore to assess the influence of cerebrovascular reactivity measures on radiological lesion expansion in a cohort of patients with acute TBI. METHODS We conducted a retrospective cohort analysis on 50 TBI patients who had undergone high-frequency multimodal intracranial monitoring and for which at least two brain computed tomography (CT) scans had been performed in the acute phase of injury. We first performed univariate analyses on the full cohort to identify non-neurophysiological factors (i.e., initial lesion volume, timing of scan, coagulopathy) associated with traumatic lesion growth in this population. In a subset analysis of 23 patients who had intracranial recording data covering the period between the initial and repeat CT scan, we then correlated changes in serial volumetric lesion measurements with cerebrovascular reactivity metrics derived from the pressure reactivity index (PRx), pulse amplitude index (PAx), and RAC (correlation coefficient between the pulse amplitude of intracranial pressure and cerebral perfusion pressure). Using multivariate methods, these results were subsequently adjusted for the non-neurophysiological confounders identified in the univariate analyses. RESULTS We observed significant positive linear associations between the degree of cerebrovascular reactivity impairment and progression of pericontusional edema. The strongest correlations were observed between edema progression and the following indices of cerebrovascular reactivity between sequential scans: % time PRx > 0.25 (r = 0.69, p = 0.002) and % time PAx > 0.25 (r = 0.64, p = 0.006). These associations remained significant after adjusting for initial lesion volume and mean cerebral perfusion pressure. In contrast, progression of the hemorrhagic core and extra-axial hemorrhage volume did not appear to be strongly influenced by autoregulatory status. CONCLUSIONS Our preliminary findings suggest a possible link between autoregulatory failure and traumatic edema progression, which warrants re-evaluation in larger-scale prospective studies.
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Affiliation(s)
- François Mathieu
- Division of Neurosurgery, University of Toronto, Toronto, Canada.
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Hills Road, Box 93, Cambridge, CB2 0QQ, UK.
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.
| | - Frederick A Zeiler
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Hills Road, Box 93, Cambridge, CB2 0QQ, UK
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Department of Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Daniel P Whitehouse
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Hills Road, Box 93, Cambridge, CB2 0QQ, UK
| | - Tilak Das
- Department of Radiology, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Addenbrooke's Hospital, Hills Road, Box 218, Cambridge, CB2 0QQ, UK
| | - Ari Ercole
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Hills Road, Box 93, Cambridge, CB2 0QQ, UK
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Peter J Hutchinson
- Brain Physics LaboratoryDivision of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Hills Road, Box 167, Cambridge, CB2 0QQ, UK
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
- Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - Virginia F J Newcombe
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Hills Road, Box 93, Cambridge, CB2 0QQ, UK
| | - David K Menon
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Hills Road, Box 93, Cambridge, CB2 0QQ, UK
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17
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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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18
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Cepeda S, Castaño-León AM, Munarriz PM, Paredes I, Panero I, Eiriz C, Gómez PA, Lagares A. Effect of decompressive craniectomy in the postoperative expansion of traumatic intracerebral hemorrhage: a propensity score-based analysis. J Neurosurg 2019; 132:1623-1635. [PMID: 31026834 DOI: 10.3171/2019.2.jns182025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 02/04/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Traumatic intracerebral hemorrhage (TICH) represents approximately 13%-48% of the lesions after a traumatic brain injury (TBI), and hemorrhagic progression (HP) occurs in 38%-63% of cases. In previous studies, decompressive craniectomy (DC) has been characterized as a risk factor in the HP of TICH; however, few studies have focused exclusively on this relationship. The object of the present study was to analyze the relationship between DC and the growth of TICH and to reveal any correlation with the size of the craniectomy, degree of cerebral parenchymal herniation (CPH), or volumetric expansion of the TICH. METHODS The authors retrospectively analyzed the records of 497 adult patients who had been consecutively admitted after suffering a severe or moderate closed TBI. An inclusion criterion was presentation with one or more TICHs on the initial or control CT. Demographic, clinical, radiological, and treatment variables were assessed for associations. RESULTS Two hundred three patients presenting with 401 individual TICHs met the selection criteria. TICH growth was observed in 281 cases (70.1%). Eighty-two cases (20.4%) underwent craniectomy without TICH evacuation. In the craniectomy group, HP was observed in 71 cases (86.6%); in the noncraniectomy group (319 cases), HP occurred in 210 cases (65.8%). The difference in the incidence of HP between the two groups was statistically significant (OR 3.41, p < 0.01). The mean area of the craniectomy was 104.94 ± 27.5 cm2, and the mean CPH distance through the craniectomy was 17.85 ± 11.1 mm. The mean increase in the TICH volume was greater in the groups with a craniectomy area > 115 cm2 and CPH > 25 mm (16.12 and 14.47 cm3, respectively, p = 0.01 and 0.02). After calculating the propensity score (PS), the authors followed three statistical methods-matching, stratification, and inverse probability treatment weighting (IPTW)-thereby obtaining an adequate balance of the covariates. A statistically significant relationship was found between HP and craniectomy (OR 2.77, p = 0.004). This correlation was confirmed with the three methodologies based on the PS with odds greater than 2. CONCLUSIONS DC is a risk factor for the growth of TICH, and there is also an association between the size of the DC and the magnitude of the volume increase in the TICH.
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Affiliation(s)
- Santiago Cepeda
- 1Department of Neurosurgery, University Hospital Río Hortega, Valladolid.,3University Complutense, Madrid, Spain
| | - Ana María Castaño-León
- 2Department of Neurosurgery, University Hospital 12 de Octubre, Instituto de Investigación i+12, Madrid; and.,3University Complutense, Madrid, Spain
| | - Pablo M Munarriz
- 2Department of Neurosurgery, University Hospital 12 de Octubre, Instituto de Investigación i+12, Madrid; and.,3University Complutense, Madrid, Spain
| | - Igor Paredes
- 2Department of Neurosurgery, University Hospital 12 de Octubre, Instituto de Investigación i+12, Madrid; and.,3University Complutense, Madrid, Spain
| | - Irene Panero
- 2Department of Neurosurgery, University Hospital 12 de Octubre, Instituto de Investigación i+12, Madrid; and.,3University Complutense, Madrid, Spain
| | - Carla Eiriz
- 2Department of Neurosurgery, University Hospital 12 de Octubre, Instituto de Investigación i+12, Madrid; and.,3University Complutense, Madrid, Spain
| | - Pedro A Gómez
- 2Department of Neurosurgery, University Hospital 12 de Octubre, Instituto de Investigación i+12, Madrid; and.,3University Complutense, Madrid, Spain
| | - Alfonso Lagares
- 2Department of Neurosurgery, University Hospital 12 de Octubre, Instituto de Investigación i+12, Madrid; and.,3University Complutense, Madrid, Spain
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19
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Bae IS, Chun HJ, Yi HJ, Bak KH, Choi KS, Kim DW. Modified Glasgow Coma Scale Using Serum Factors as a Prognostic Model in Traumatic Brain Injury. World Neurosurg 2019; 126:e959-e964. [PMID: 30876987 DOI: 10.1016/j.wneu.2019.02.197] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 02/19/2019] [Accepted: 02/20/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a major cause of death and disability. This study evaluated a possible relationship between serum factors at admission and the outcome of TBI. We propose a statistically validated scale for patients with TBI that combines serum factors and the Glasgow Coma Scale (GCS). METHODS Between May 2011 and July 2016, 219 patients underwent decompressive craniectomy for TBI. We assessed laboratory data on admission, and correlations with GSC and Glasgow Outcome Scale were investigated. The modified GCS was developed from a multivariable logistic regression model, which was validated with the backward stepwise method. RESULTS Of 219 patients with TBI enrolled in our study, 175 were men (79.9%) and 44 were women (20.1%) with a mean age of 49.1 ± 11.5 years. Initial serum values of hemoglobin, platelets, prothrombin time, and lactate dehydrogenase were associated with in-hospital mortality. The factor score was derived by adding the following points: hemoglobin (≥13.0 g/dL = 0, <13.0 g/dL = 1), platelets (≥150 × 103/mm3 = 0, <150 × 103/mm3 = 1), prothrombin time (<13.2 seconds = 0, ≥13.2 seconds = 1), and lactate dehydrogenase (<271 U/L = 0, ≥271 U/L = 1). The modified GCS score (GCS score [range, 6-15] - FS [range, 0-4]) was calculated. CONCLUSIONS The modified GCS score using serum factors extended the information provided about patient outcomes to be comparable to more complex methods. The modified GCS score may be useful to predict in-hospital mortality in patients with TBI.
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Affiliation(s)
- In-Suk Bae
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, South Korea
| | - Hyoung-Joon Chun
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, South Korea.
| | - Hyeong-Joong Yi
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, South Korea
| | - Koang-Hum Bak
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, South Korea
| | - Kyu-Sun Choi
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, South Korea
| | - Dong-Won Kim
- Department of Anesthesiology and Pain Medicine, Hanyang University Medical Center, Seoul, South Korea
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20
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Nakae R, Yokobori S, Yokota H. Coagulopathy and Brain Injury. Neurocrit Care 2019. [DOI: 10.1007/978-981-13-7272-8_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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21
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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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Beynon C, Wei S, Radbruch A, Capper D, Unterberg AW, Kiening KL. Preoperative assessment of haemostasis in patients undergoing stereotactic brain biopsy. J Clin Neurosci 2018; 53:112-116. [PMID: 29685415 DOI: 10.1016/j.jocn.2018.04.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 04/09/2018] [Indexed: 11/26/2022]
Abstract
Parenchymal hemorrhage is considered a major risk factor for perioperative morbidity in patients undergoing stereotactic brain biopsy. Studies on patients undergoing surgical procedures have suggested that evaluation of prothrombin time (PT) and activated partial thromboplastin time (aPTT) is of limited value with regard to prevention of haemorrhagic complications. However, this issue has not yet been addressed in patients undergoing stereotactic biopsy of intracranial lesions. We retrospectively analysed the medical records of 159 consecutive patients undergoing stereotactic biopsy of supratentorial intracranial lesions during a three-year period. Laboratory values (PT, aPTT, platelet count) were reviewed as well as clinical characteristics, modalities of surgical treatment, histopathological results and the postoperative course of patients. The overall diagnostic yield was 93.7%. Histopathological examination revealed glioma (WHO°I: 5, WHO°II: 25, WHO°III: 23, WHO°IV: 65), lymphoma (n = 14), inflammation (n = 8) and other entities (n = 6). Surgery-associated neurological deficits occurred in 7 patients (4.4%) and completely resolved in 6 of these patients. CT-confirmed intracranial hemorrhage occurred in 2 patients (1.3%) and in both cases, histopathological examination revealed glioblastoma. Results of hemostatic parameters (PT: 99 ± 13%, aPTT: 24 ± 3s, platelet count: 274 ± 87 103/μL) were within normal range values in all patients and did not correlate with postsurgical morbidity. Standard assessment of haemostasis seems to be of limited value in patients with intracranial lesions undergoing stereotactic biopsy. Further studies regarding the intratumoural vasculature's impact on the risk of biopsy-related bleeding are necessary.
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Affiliation(s)
| | - Shilai Wei
- Department of Neurosurgery, Heidelberg University Hospital, Germany
| | - Alexander Radbruch
- Department of Neuroradiology, Heidelberg University Hospital, Germany; Department of Diagnostic and Interventional Radiology and Neuroradiology, Essen University Hospital, Germany
| | - David Capper
- Institute of Neuropathology, Heidelberg University Hospital, Germany
| | | | - Karl L Kiening
- Department of Neurosurgery, Heidelberg University Hospital, Germany; Division of Stereotactic Neurosurgery, Department of Neurosurgery, Heidelberg University Hospital, Germany
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Yuan Q, Yu J, Wu X, Sun YR, Li ZQ, Du ZY, Wu XH, Hu J. Prognostic value of coagulation tests for in-hospital mortality in patients with traumatic brain injury. Scand J Trauma Resusc Emerg Med 2018; 26:3. [PMID: 29304855 PMCID: PMC5756421 DOI: 10.1186/s13049-017-0471-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 12/27/2017] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Coagulopathy is commonly observed after traumatic brain injury (TBI). However, it is not known whether using the standard independent predictors in conjunction with coagulation tests would improve their prognostic value. We determined the incidence of TBI-associated coagulopathy in patients with isolated TBI (iTBI), evaluated the prognostic value of coagulation tests for in-hospital mortality, and tested their predictive power for in-hospital mortality in patients with iTBI. METHODS We conducted a retrospective, observational database study on 2319 consecutive patients with iTBI who attended the Huashan Hospital Department of the Neurosurgery Neurotrauma Center at Fudan University in China between December 2004 and June 2015. Two models based on the admission characteristics were developed: model A included predictors such as age, Glasgow Coma Scale (GCS) score, pupil reactivity, type of injury, and hemoglobin and glucose levels, while model B included the predictors from model A as well as coagulation test results. A total of 1643 patients enrolled between December 2004 and December 2011 were used to derive the prognostic models, and 676 patients enrolled between January 2012 and June 2015 were used to validate the models. RESULTS Overall, 18.6% (n = 432) of the patients developed coagulopathy after iTBI. The prevalence of acute traumatic coagulopathy is associated with the severity of brain injury. The percentage of platelet count <100 × 109/L, international normalized ratio (INR) > 1.25, the prothrombin time (PT) > 14 s, activated partial thromboplastin time (APTT) > 36 s, D-dimer >5 mg/L and fibrinogen (FIB) < 1.5 g/L was also closely related to the severity of brain injury, significance being found among three groups. Age, pupillary reactivity, GCS score, epidural hematoma (EDH), and glucose levels were independent prognostic factors for in-hospital mortality in model A, whereas age, pupillary reactivity, GCS score, EDH, glucose levels, INR >1.25, and APTT >36 s exhibited strong prognostic effects in model B. Discrimination and calibration were good for the development group in both prediction models. However, the external validation test showed that calibration was better in model B than in model A for patients from the validation population (Hosmer-Lemeshow test, p = 0.152 vs. p = 0.046, respectively). CONCLUSIONS Coagulation tests can improve the predictive power of the standard model for in-hospital mortality after TBI.
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Affiliation(s)
- Qiang Yuan
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040, People's Republic of China
| | - Jian Yu
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040, People's Republic of China
| | - Xing Wu
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040, People's Republic of China
| | - Yi-Rui Sun
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040, People's Republic of China
| | - Zhi-Qi Li
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040, People's Republic of China
| | - Zhuo-Ying Du
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040, People's Republic of China
| | - Xue-Hai Wu
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040, People's Republic of China
| | - Jin Hu
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040, People's Republic of China.
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Derivation of a Predictive Score for Hemorrhagic Progression of Cerebral Contusions in Moderate and Severe Traumatic Brain Injury. Neurocrit Care 2017; 26:80-86. [PMID: 27473209 DOI: 10.1007/s12028-016-0303-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUNDS After traumatic brain injury (TBI), hemorrhagic progression of contusions (HPCs) occurs frequently. However, there is no established predictive score to identify high-risk patients for HPC. METHODS Consecutive patients who were hospitalized (2008-2013) with non-penetrating moderate or severe TBI were studied. The primary outcome was HPC, defined by both a relative increase in contusion volume by ≥30 % and an absolute increase by ≥10 mL on serial imaging. Logistic regression models were created to identify independent risk factors for HPC. The HPC Score was then derived based on the final model. RESULTS Among a total of 286 eligible patients, 61 (21 %) patients developed HPC. On univariate analyses, HPC was associated with older age, higher initial blood pressure, antiplatelet medications, anticoagulants, subarachnoid hemorrhage (SAH) subdural hematoma (SDH), skull fracture, frontal contusion, larger contusion volume, and shorter interval from injury to initial CT. In the final model, SAH (OR 6.33, 95 % CI, 1.80-22.23), SDH (OR 3.46, 95 % CI, 1.39-8.63), and skull fracture (OR 2.67, 95 % CI, 1.28-5.58) were associated with HPC. Based on these factors, the HPC Score was derived (SAH = 2 points, SDH = 1 point, and skull fracture = 1 point). This score had an area under the receiver operating curve of 0.77. Patients with a score of 0-2 had a 4.0 % incidence of HPC, while patients with a score of 3-4 had a 34.6 % incidence of HPC. CONCLUSIONS A simple HPC Score was developed for early risk stratification of HPC in patients with moderate or severe TBI.
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Hu GW, Lang HL, Guo H, Wu L, Zhang P, Kuang W, Zhu XG. A risk score based on admission characteristics to predict progressive hemorrhagic injury from traumatic brain injury in children. Eur J Pediatr 2017; 176:689-696. [PMID: 28343321 DOI: 10.1007/s00431-017-2897-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 03/14/2017] [Accepted: 03/21/2017] [Indexed: 10/19/2022]
Abstract
UNLABELLED Traumatic brain injury (TBI) is one of the leading causes of death and disability in children, and progressive hemorrhagic injury (PHI) post TBI is associated with poor outcomes. Therefore, the objective of this study was to develop and validate a prognostic model that uses the information available at admission to determine the likelihood of PHI occurrence after TBI in children. The identified demographic data, cause of injury, clinical predictors on admission, computed tomography scan characteristics, and routine laboratory parameters were collected and used to develop a PHI prognostic model with logistic regression analysis, and the prediction model was validated in 68 children. Eight independent prognostic factors were identified: lower Glasgow coma scale score (3 ~ 8) (6 points), intra-axial bleeding/brain contusion (4 points), midline shift ≥5 mm (9 points), platelets <100 × 109/L (11 points), prothrombin time >14 s (6 points), international normalized ratio >1.25 (7 points), D-dimer ≥5 mg/L (14 points), and glucose ≧10 mmol/L (11 points). We calculated risk scores for each child and defined three risk groups: low risk (0-16 points), intermediate risk (17-36 points), and high risk (37-68 points). In the development cohort, the PHI rates after TBI for the low-, intermediate-, and high-risk groups were 10.1, 47.9, and 84.2%, respectively. In the validation cohort, the corresponding PHI rates were 10.9, 47.5, and 85.4%, respectively. The C-statistic for the point system was 0.873 (p = 0.586 by the Hosmer-Lemeshow test) in the development cohort and 0.877 (p = 0.524 by the Hosmer-Lemeshow test) in the validation cohort. CONCLUSION Using admission predictors, we developed a relatively simple risk score that accurately predicted the risk of PHI after TBI in children. What is Known: • TBI is one of the leading causes of death and disability in children, and PHI post TBI is associated with poor outcomes. •Prediction of patients at low risk of PHI could help reduce treatment costs, whereas identification of patients at high risk of PHI could direct early medical intervention to improve outcomes. What is New: • This study firstly developed a risk score system by assessing the admission information that could provide an earlier prediction of the occurrence of PHI after acute TBI in children.
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Affiliation(s)
- Guo-Wen Hu
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Hai-Li Lang
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Hua Guo
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Lei Wu
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Pei Zhang
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Wei Kuang
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Xin-Gen Zhu
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China.
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Wan X, Fan T, Wang S, Zhang S, Liu S, Yang H, Shu K, Lei T. Progressive hemorrhagic injury in patients with traumatic intracerebral hemorrhage: characteristics, risk factors and impact on management. Acta Neurochir (Wien) 2017; 159:227-235. [PMID: 27943076 DOI: 10.1007/s00701-016-3043-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 11/24/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Progressive hemorrhagic injury (PHI) is a common occurrence in clinical practice; however, how PHI affects clinical management remains unclear. We attempt to evaluate the characteristics and risk factors of PHI and also investigate how PHI influences clinical management in traumatic intracerebral hemorrhage (TICH) patients. METHODS This retrospective study included a cohort of 181 patients with TICH who initially underwent conservative treatment and they were dichotomized into a PHI group and a non-PHI group. Clinical data were reviewed for comparison. Multivariate logistic regression analysis was applied to identify predictors of PHI and delayed operation. RESULTS Overall, 68 patients (37.6%) experienced PHI and 27 (14.9%) patients required delayed surgery. In the PHI group, 17 patients needed late operation; in the non-PHI group, 10 patients received decompressive craniectomy. Compared to patients with non-PHI, the PHI group was more likely to require late operation (P = 0.005, 25.0 vs 8.8%), which took place within 48 h (P = 0.01, 70.6 vs 30%). Multivariate logistic regression identified past medical history of hypertension (odds ratio [OR] = 4.56; 95% confidence interval [CI] = 2.04-10.45), elevated international normalized ratio (INR) (OR = 20.93; 95% CI 7.72-71.73) and linear bone fracture (OR = 2.11; 95% CI = 1.15-3.91) as independent risk factors for PHI. Hematoma volume of initial CT scan >5 mL (OR = 3.80; 95% CI = 1.79-8.44), linear bone fracture (OR = 3.21; 95% CI = 1.47-7.53) and PHI (OR = 3.49; 95% CI = 1.63-7.77) were found to be independently associated with delayed operation. CONCLUSIONS Past medical history of hypertension, elevated INR and linear bone fracture were predictors for PHI. Additionally, the latter was strongly predictive of delayed operation in the studied cohort.
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Affiliation(s)
- Xueyan Wan
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Ting Fan
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Sheng Wang
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China.
| | - Suojun Zhang
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Shengwen Liu
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Hongkuan Yang
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Kai Shu
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Ting Lei
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
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27
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Zeiler FA, Trickey K, Hornby L, Shemie SD, Lo BWY, Teitelbaum J. Mechanism of death after early decompressive craniectomy in traumatic brain injury. TRAUMA-ENGLAND 2016. [DOI: 10.1177/1460408616683208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Decompressive craniectomy in devastating traumatic brain injury is controversial. The impact of decompressive craniectomy on mechanism of death is unclear in the literature to date. Our goal was to determine the mechanism of death between those receiving early decompressive craniectomy and those managed medically. Methods We performed an institutional retrospective review, from June 2003 to June 2013, of adult patients with devastating blunt traumatic brain injury undergoing early decompressive craniectomy who subsequently died. We compared this group to a retrospectively matched group based on: age, pre-hospital KPS, Marshall diffuse computed tomography grades, Injury Severity Scores, and admission laboratory values. Results Forty patients were analyzed; 20 with decompressive craniectomy and 20 without. The two groups were similar based on admission demographics, with the only statistically significant difference being platelet levels. Upon analysis, through both univariate and multivariate regression analysis, the mechanism of death was significantly different (p = 0.003; OR: 0.07 (0.01–0.41) and p = 0.04; OR: 0.08 (0.01–0.87)) with the decompressive craniectomy and non-decompressive craniectomy groups displaying neurological death rates of 10.0% versus 60.0%, respectively, with all other patients in both groups dying secondary to circulatory arrest after withdrawal of life-sustaining therapy. Time to death was significantly longer in the decompressive craniectomy group (2.83 vs. 9.21 days, respectively) (p = 0.01; OR: 0.65 (0.46–0.91). Conclusions Progression to neurological death appears to be more common in those devastating blunt traumatic brain injury patients treated medically compared to those undergoing early decompressive craniectomy. Given the implications of end-of-life care and societal implications, the mechanism of death determination and organ donation should be reported as relevant outcomes in devastating traumatic brain injury studies.
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Affiliation(s)
- FA Zeiler
- Section of Neurosurgery, Department of Surgery, University of Manitoba, Winnipeg, Canada
- Clinician Investigator Program, University of Manitoba, Winnipeg, Canada
- Department of Anesthesia, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - K Trickey
- Department of Neurosciences, Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - L Hornby
- Division of Pediatric Critical Care, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - SD Shemie
- Division of Critical Care, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - BWY Lo
- Department of Neurosciences, Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - J Teitelbaum
- Section of Neurocritical Care, Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
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Yuan Q, Sun YR, Wu X, Yu J, Li ZQ, Du ZY, Wu XH, Zhou LF, Hu J. Coagulopathy in Traumatic Brain Injury and Its Correlation with Progressive Hemorrhagic Injury: A Systematic Review and Meta-Analysis. J Neurotrauma 2016; 33:1279-91. [PMID: 26850305 DOI: 10.1089/neu.2015.4205] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
- Qiang Yuan
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, PR China
| | - Yi-rui Sun
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, PR China
| | - Xing Wu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, PR China
| | - Jian Yu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, PR China
| | - Zhi-qi Li
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, PR China
| | - Zhuo-ying Du
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, PR China
| | - Xue-hai Wu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, PR China
| | - Liang-fu Zhou
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, PR China
| | - Jin Hu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, PR China
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29
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Dasenbrock HH, Devine CA, Liu KX, Gormley WB, Claus EB, Smith TR, Dunn IF. Thrombocytopenia and craniotomy for tumor: A National Surgical Quality Improvement Program analysis. Cancer 2016; 122:1708-17. [DOI: 10.1002/cncr.29984] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 01/13/2016] [Accepted: 02/10/2016] [Indexed: 11/07/2022]
Affiliation(s)
- Hormuzdiyar H. Dasenbrock
- Department of Neurosurgery; Brigham and Women's Hospital, Harvard Medical School; Boston Massachusetts
| | - Christopher A. Devine
- Department of Neurosurgery; Brigham and Women's Hospital, Harvard Medical School; Boston Massachusetts
| | - Kevin X. Liu
- Department of Neurosurgery; Brigham and Women's Hospital, Harvard Medical School; Boston Massachusetts
| | - William B. Gormley
- Department of Neurosurgery; Brigham and Women's Hospital, Harvard Medical School; Boston Massachusetts
| | - Elizabeth B. Claus
- Department of Neurosurgery; Brigham and Women's Hospital, Harvard Medical School; Boston Massachusetts
| | - Timothy R. Smith
- Department of Neurosurgery; Brigham and Women's Hospital, Harvard Medical School; Boston Massachusetts
| | - Ian F. Dunn
- Department of Neurosurgery; Brigham and Women's Hospital, Harvard Medical School; Boston Massachusetts
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Daley MJ, Enright Z, Nguyen J, Ali S, Clark A, Aydelotte JD, Teixeira PG, Coopwood TB, Brown CVR. Adenosine diphosphate platelet dysfunction on thromboelastogram is independently associated with increased morality in traumatic brain injury. Eur J Trauma Emerg Surg 2016; 43:105-111. [PMID: 26888580 DOI: 10.1007/s00068-016-0643-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 02/01/2016] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this study is to determine if adenosine diphosphate (ADP) platelet dysfunction on thromboelastogram (TEG) is associated with increased in-hospital mortality in patients with head trauma. The hypothesis is that ADP dysfunction is associated with increased mortality. METHODS This retrospective review evaluated trauma patients admitted to a level 1 trauma center from February 2011 to October 2013 who received a TEG. Patients were included if the TEG was drawn within the first 24 h of admission and the head abbreviated injury score was greater than or equal to three. Patients were categorized as severe ADP dysfunction if the degree of ADP inhibition on TEG exceeded 60 %. RESULTS A total of 90 patients were included (no ADP dysfunction n = 37; ADP dysfunction n = 53). Initial Glasgow Coma Scale [GCS (12 ± 4 vs. 11 ± 5; p = 0.26)] and use of pre-injury antiplatelet agents (30 vs. 28 %; p = 0.88) were similar. Patients with ADP dysfunction on TEG had a higher in-hospital mortality rate (8 vs. 32 %; p < 0.01). ADP dysfunction was independently associated with in-hospital mortality upon fixed logistic regression (OR 6.2; 95 % CI 1.2-33) while controlling for age, gender, hypotension, pre-injury antiplatelet agents, GCS and Injury Severity Score. CONCLUSION ADP dysfunction on TEG is associated with increased mortality in patients with traumatic brain injury.
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Affiliation(s)
- M J Daley
- Department of Pharmaceutical Services, University Medical Center Brackenridge, 601 E 15th St, Austin, TX, 78701, USA.
- College of Pharmacy, University of Texas, Austin, TX, USA.
| | - Z Enright
- Department of Pharmaceutical Services, University Medical Center Brackenridge, 601 E 15th St, Austin, TX, 78701, USA
- College of Pharmacy, University of Texas, Austin, TX, USA
| | - J Nguyen
- Department of Pharmaceutical Services, University Medical Center Brackenridge, 601 E 15th St, Austin, TX, 78701, USA
- College of Pharmacy, University of Texas, Austin, TX, USA
| | - S Ali
- Department of Trauma Services, University Medical Center Brackenridge, 601 E 15th St, Austin, TX, 78701, USA
| | - A Clark
- Department of Trauma Services, University Medical Center Brackenridge, 601 E 15th St, Austin, TX, 78701, USA
| | - J D Aydelotte
- Department of Trauma Services, University Medical Center Brackenridge, 601 E 15th St, Austin, TX, 78701, USA
- Dell Medical School, University of Texas, Austin, TX, USA
| | - P G Teixeira
- Department of Trauma Services, University Medical Center Brackenridge, 601 E 15th St, Austin, TX, 78701, USA
- Dell Medical School, University of Texas, Austin, TX, USA
| | - T B Coopwood
- Department of Trauma Services, University Medical Center Brackenridge, 601 E 15th St, Austin, TX, 78701, USA
- Dell Medical School, University of Texas, Austin, TX, USA
| | - C V R Brown
- Department of Trauma Services, University Medical Center Brackenridge, 601 E 15th St, Austin, TX, 78701, USA
- Dell Medical School, University of Texas, Austin, TX, USA
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Abstract
BACKGROUND The presence of coagulopathy is common after severe trauma. The aim of this study was to identify whether isolated severe traumatic brain injury (TBI) is an independent risk factor for coagulopathy. METHODS Prospective observational cohort of adult patients admitted to a Level I Trauma Center within 6 h of injury. Patients were categorized according to the abbreviated injury scale (AIS): Group 1-isolated severe TBI (AIS head ≥ 3 + AIS non-head < 3); Group 2-severe multisystem trauma associated with severe TBI (AIS head ≥ 3 + AIS non-head ≥ 3); Group 3-severe multisystem trauma without TBI (AIS head < 3 + AIS non-head ≥ 3). Primary outcome was the development of coagulopathy. Secondary outcome was in-hospital mortality. RESULTS Three hundred and forty five patients were included (Group 1 = 48 patients, Group 2 = 137, and Group 3 = 160). Group 1 patients had the lowest incidence of coagulopathy and disseminated intravascular coagulopathy, and in general presented with better coagulation profile measured by either classic coagulation tests, thromboelastography or clotting factors. Isolated severe TBI was not an independent risk factor for the development of coagulopathy (OR 1.06; 0.35-3.22 CI, p = 0.92), however, isolated severe TBI patients who developed coagulopathy had higher mortality rates than isolated severe TBI patients without coagulopathy (66 vs. 16.6 %, p < 0.05). The presence of coagulopathy (OR 5.61; 2.65-11.86 CI, p < 0.0001) and isolated severe TBI (OR 11.51; 3.9-34.2 CI, p < 0.0001) were independent risk factors for in-hospital mortality. CONCLUSION Isolated severe TBI is not an independent risk factor for the development of coagulopathy. However, severe TBI patients who develop coagulopathy have extremely high mortality rates.
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32
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Gupta G, Wadhwa C, Garg R, Dhaiya RS, Kaushal RK. Impact of Coagulation Profile on Outcome of Head Injury. J Clin Diagn Res 2016; 10:PC04-6. [PMID: 26894120 PMCID: PMC4740648 DOI: 10.7860/jcdr/2016/14638.7029] [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: 05/28/2015] [Accepted: 09/25/2015] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Worldwide, head injury is recognized as a major public health problem. Head injury patients often develop consumptive coagulopathy in the absence of other trauma or haemorrhages. The release of tissue factor from the damaged brain is postulated as the cause of coagulopathy. AIM To know the impact of coagulation profile derangements and their effect on the outcome of head injury patients. MATERIALS AND METHODS Fifty patients in the age group of 20-70 years admitted with isolated head injury were taken. Samples of complete haemogram (CBC), prothrombin time (PTI), partial thromboplastin time (PTK), D-Dimers and fibrinogen were taken within 24 hour of admission. Coagulopathy was defined as platelet counts < 100,000 cells/mm(2) and PTI >15 seconds or a DIC score more than 4. The outcome in each group was measured according to Glasgow outcome score. Coagulation abnormalities were analysed. RESULTS In case of severe head injury, p-values in patients who died with regard to DIC score, Prothrombin time and APTT were found to be significant (p< 0.05). For D-Dimers, fibrinogen and platelets counts the p-value was not significant. In case of moderate head injury, p-values in patients who died with regard to DIC score, platelet count, Prothrombin time, D-Dimer and APTT were found to be significant (0.05). For fibrinogen level it was insignificant. The mean DIC score and mean GOS in the severe head injury patients was significant (p<0.001). CONCLUSION Patients with isolated head injury are at risk of development of coagulation abnormalities, which is associated with poor outcome. Based on our results we also emphasize the importance of early diagnosis of coagulation abnormalities in isolated head injury patients.
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Affiliation(s)
- Gulzar Gupta
- Associate Professor, Department of Neurosurgery, Dayanand Medical College & Hospital, Ludhiana, Punjab, India
| | - Chetan Wadhwa
- Senior Resident, Department of Neurosurgery, Dayanand Medical College & Hospital, Ludhiana, Punjab, India
| | - Rajveer Garg
- Senior Resident, Department of Neurosurgery, Dayanand Medical College & Hospital, Ludhiana Punjab, India
| | - Ranbir S Dhaiya
- Ex Professor, Department of Surgery, PGIMS, Rohtak, Haryana, India
| | - Rakesh K Kaushal
- Professor and Head, Department of Neurosurgery, Dayanand Medical College & Hospital, Ludhiana, Punjab, India
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Ryu JI, Kim CH, Kim JM, Cheong JH. Assessment of the Clinical and the Radiological Prognostic Factors that Determine the Management of a Delayed, Traumatic, Intraparenchymal Hemorrhage (DTIPH). JOURNAL OF TRAUMA AND INJURY 2015. [DOI: 10.20408/jti.2015.28.4.223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Je Il Ryu
- Department of Neurosurgery, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Republic of Korea
| | - Choong Hyun Kim
- Department of Neurosurgery, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Republic of Korea
| | - Jae Min Kim
- Department of Neurosurgery, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Republic of Korea
| | - Jin Hwan Cheong
- Department of Neurosurgery, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Republic of Korea
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Cepeda S, Gómez PA, Castaño-Leon AM, Munarriz PM, Paredes I, Lagares A. Contrecoup Traumatic Intracerebral Hemorrhage: A Geometric Study of the Impact Site and Association with Hemorrhagic Progression. J Neurotrauma 2015; 33:1034-46. [PMID: 26391755 DOI: 10.1089/neu.2015.4153] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Traumatic intracerebral hemorrhage (TICH) represents 13-48% of the lesions after a traumatic brain injury (TBI). The frequency of TICH-hemorrhagic progression (TICH-HP) is estimated to be approximately 38-63%. The relationship between the impact site and TICH location has been described in many autopsy-based series. This association, however, has not been consistently demonstrated since the introduction of computed tomography (CT) for studying TBI. This study aimed to determine the association between the impact site and TICH location in patients with moderate and severe TBI. We also analyzed the associations between the TICH location, the impact site, the production mechanism (coup or contrecoup), and hemorrhagic progression. We retrospectively analyzed the records of 408 patients after a moderate or severe TBI between January 2010 and November 2014. We identified 177 patients with a total of 369 TICHs. We found a statistically significant association between frontal TICHs and impact sites located on the anterior area of the head (OR 5.8, p < 0.001). The temporal TICH location was significantly associated with impact sites located on the posterior head area (OR 4.9, p < 0.001). Anterior and lateral TICHs were associated with impact sites located at less than 90 degrees (coup) (OR 1.64, p = 0.03) and more than 90 degrees (contrecoup), respectively. Factors independently associated with TICH-HP obtained through logistic regression included an initial volume of <1 cc, cisternal compression, falls, acute subdural hematoma, multiple TICHs, and contrecoup TICHs. We demonstrated a significant association between the TICH location and impact site. The contrecoup represents a risk factor independently associated with hemorrhagic progression.
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Affiliation(s)
- Santiago Cepeda
- Department of Neurosurgery, Hospital 12 de Octubre, Universidad Complutense de Madrid , Madrid, Spain
| | - Pedro A Gómez
- Department of Neurosurgery, Hospital 12 de Octubre, Universidad Complutense de Madrid , Madrid, Spain
| | - Ana María Castaño-Leon
- Department of Neurosurgery, Hospital 12 de Octubre, Universidad Complutense de Madrid , Madrid, Spain
| | - Pablo M Munarriz
- Department of Neurosurgery, Hospital 12 de Octubre, Universidad Complutense de Madrid , Madrid, Spain
| | - Igor Paredes
- Department of Neurosurgery, Hospital 12 de Octubre, Universidad Complutense de Madrid , Madrid, Spain
| | - Alfonso Lagares
- Department of Neurosurgery, Hospital 12 de Octubre, Universidad Complutense de Madrid , Madrid, Spain
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Batchelor JS. A meta-analysis to determine the effect of coagulopathy on intracranial haematoma progression in adult patients with isolated blunt head trauma. TRAUMA-ENGLAND 2015. [DOI: 10.1177/1460408614568830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Coagulopathy following isolated traumatic brain injury is a well-recognised complication especially in patients with severe head injury. Intracranial haematoma progression is a major adverse factor affecting outcome in patients with traumatic brain injury. Coagulopathy is an important risk factor for haematoma progression. The aim of this meta-analysis was to determine the magnitude of effect of coagulopathy on intracranial haematoma progression in patients with isolated traumatic brain injury. Studies comparing patients with traumatic brain injury, coagulopathy and haematoma progression to patients with traumatic brain injury, haematoma progression and no coagulopathy were identified. The search was performed using Medline via the PubMed interface; no limits were placed on the language. In total 12 studies were identified as being suitable for the meta-analysis. Significant heterogeneity was present between the studies as demonstrated by an I2 = 80.185. The fixed effects model was considered to be the preferred model and this produced a pooled odds ratio of 6.897 (95% confidence interval: 5.495–8.655). The results of this meta-analysis show that traumatic brain injury-induced coagulopathy is a significant factor in haematoma progression in patients with isolated traumatic brain injury.
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Affiliation(s)
- John S Batchelor
- Department of Emergency Medicine, Central Manchester Foundation Trust, Manchester, UK
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Coagulation Parameters and Risk of Progressive Hemorrhagic Injury after Traumatic Brain Injury: A Systematic Review and Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2015; 2015:261825. [PMID: 26457298 PMCID: PMC4589576 DOI: 10.1155/2015/261825] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 07/03/2015] [Accepted: 07/29/2015] [Indexed: 11/18/2022]
Abstract
Intracranial hemorrhage (ICH) after traumatic brain injury (TBI) commonly increases in size and coagulopathy has been implicated in such progression. Our aim is to perform a meta-analysis to assess their relationship. Cochrane library, PubMed, and EMBASE were searched for literatures. Pooled effect sizes and 95% confidential intervals (CIs) were calculated using random-effects model. We included six studies, involving 1700 participants with 540 progressive hemorrhagic injuries (PHIs). Our findings indicate that PT, D-dimer level, and INR value are positively associated with the risk of PHI. Higher level of PLT and Fg seemed to suggest a lower risk of PHI. Among these parameters, higher D-dimer level and INR value would possess more powerful strength in predicting PHI.
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Kim DY, O'Leary M, Nguyen A, Kaji A, Bricker S, Neville A, Bongard F, Putnam B, Plurad D. The Effect of Platelet and Desmopressin Administration on Early Radiographic Progression of Traumatic Intracranial Hemorrhage. J Neurotrauma 2015; 32:1815-21. [PMID: 25604812 DOI: 10.1089/neu.2014.3728] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Limited data exist regarding the use of hemostatic adjuncts on the progression of traumatic intracranial hemorrhage (tICH). The objective of this study was to examine the impact of platelet transfusion and desmopressin (DDAVP) administration on hemorrhage progression following tICH. We hypothesized that platelet and DDAVP administration would not result in decreased early hemorrhagic progression. We performed a three-year retrospective analysis of a Level 1 trauma center database to identify all adult patents with blunt tICH. The primary outcome was early (≤4 hours) radiographic hemorrhagic progression. Secondary outcomes included mortality, frequency of operative interventions, and complications. Multiple logistic regression analysis was performed to identify predictors for hemorrhage progression and mortality. A propensity score analysis also was performed to minimize differences and improve comparability between patients who received platelets and DDAVP and those who did not. Of 408 patients with tICH meeting the inclusion criteria, 126 received platelets and DDAVP (P/D [+]) and 282 did not (P/D [-]). Overall, 37% of patients demonstrated early radiographic hemorrhage progression. On univariate analysis, there was no difference in the incidence of hemorrhage progression between groups (43.7% [P/D (+)] vs. 34.2% [P/D (-)]; p = 0.07). On multivariate analyses, platelet and DDAVP administration was not associated with either a decreased risk of hemorrhage progression (odds ratio [OR] = 1.40, confidence interval [CI] = 0.80-2.40; p = 0.2) or mortality (OR = 1.50, CI = 0.60-4.30; p = 0.4). The administration of platelets and DDAVP is not associated with a decreased risk for early radiographic hemorrhage progression in patients with tICH. Further prospective study of these potentially hemostatic adjuncts in patients with tICH is potentially warranted.
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Affiliation(s)
- Dennis Yong Kim
- 1 Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center , Torrance, California
| | - Michael O'Leary
- 2 Department of Surgery, Harbor-UCLA Medical Center , Torrance, California
| | - Andrew Nguyen
- 2 Department of Surgery, Harbor-UCLA Medical Center , Torrance, California
| | - Amy Kaji
- 3 Department of Emergency Medicine, Harbor-UCLA Medical Center , Torrance, California
| | - Scott Bricker
- 1 Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center , Torrance, California
| | - Angela Neville
- 1 Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center , Torrance, California
| | - Fred Bongard
- 1 Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center , Torrance, California
| | - Brant Putnam
- 1 Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center , Torrance, California
| | - David Plurad
- 1 Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center , Torrance, California
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Hochstadter E, Stewart TC, Alharfi IM, Ranger A, Fraser DD. Subarachnoid hemorrhage prevalence and its association with short-term outcome in pediatric severe traumatic brain injury. Neurocrit Care 2015; 21:505-13. [PMID: 24798696 DOI: 10.1007/s12028-014-9986-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Subarachnoid hemorrhage (SAH) is an independent prognostic indicator of outcome in adult severe traumatic brain injury (sTBI). There is a paucity of investigations on SAH in pediatric sTBI. The goal of this study was to determine in pediatric sTBI patients SAH prevalence, associated factors, and its relationship to short-term outcome. METHODS We retrospectively analyzed 171 sTBI patients (pre-sedation GCS ≤8 and head MAIS ≥4) who underwent CT head imaging within the first 24 h of hospital admission. Data were analyzed with both univariate and multivariate techniques. RESULTS SAH was found in 42 % of sTBI patients (n = 71/171), and it was more frequently associated with skull fractures, cerebral edema, diffuse axonal injury, contusion, and intraventricular hemorrhage (p < 0.05). Patients with SAH had higher Injury Severity Scores (p = 0.032) and a greater frequency of fixed pupil(s) on admission (p = 0.001). There were no significant differences in etiologies between sTBI patients with and without SAH. Worse disposition occurred in sTBI patients with SAH, including increased mortality (p = 0.009), increased episodes of central diabetes insipidus (p = 0.002), greater infection rates (p = 0.002), and fewer ventilator-free days (p = 0.001). In sTBI survivors, SAH was associated with increased lengths of stay (p < 0.001) and a higher level of care required on discharge (p = 0.004). Despite evidence that SAH is linked to poorer outcomes on univariate analyses, multivariate analysis failed to demonstrate an independent association between SAH and mortality (p = 0.969). CONCLUSION SAH was present in almost half of pediatric sTBI patients, and it was indicative of TBI severity and a higher level of care on discharge. SAH in pediatric patients was not independently associated with increased risk of mortality.
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Cepeda S, Gómez PA, Castaño-Leon AM, Martínez-Pérez R, Munarriz PM, Lagares A. Traumatic Intracerebral Hemorrhage: Risk Factors Associated with Progression. J Neurotrauma 2015; 32:1246-53. [PMID: 25752340 DOI: 10.1089/neu.2014.3808] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The increase in the volume of a traumatic intracerebral hemorrhage (TICH) is a widely studied phenomenon that has a direct impact on the prognosis of patients. The objective of this study was to identify the risk factors associated with the progression of TICH. We retrospectively analyzed the records of 1970 adult patients >15 years of age who were consecutively admitted after sustaining a closed severe traumatic brain injury (TBI) between January 1987 and November 2013 at a single center. Beginning in 2007, patients with moderate TBIs were also included. A total of 782 patients exhibited one or more TICH on the initial CT scan, and met the selection criteria. The main outcome variable was the presence or absence of progression of the TICH. Univariate and multivariate statistical analyses were performed. Factors independently associated with the growth of TICH obtained through logistic regression included the following: an initial volume <5 cc (odds ratio [OR] 2.42, p<0.001), cisternal compression (OR 1.95, p<0.001), decompressive craniectomy (OR 2.18, p<0.001), age (mean 37.67 vs. 42.95 years; OR 1.01, p<0.001), falls as mechanism of trauma (OR 1.72, p=0.001), multiple TICHs (OR 1.56, p=0.007), and hypoxia (OR 1.56, p=0.02). TICH progression occurred with a frequency of 63% in our study. We showed that there was a correlation between TICH growth and some variables, such as multiple TICHs, a lower initial volume, acute subdural hematoma, cisternal compression, older patient age, hypoxia, falls, and decompressive craniectomy.
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Affiliation(s)
- Santiago Cepeda
- Department of Neurosurgery, Hospital 12 de Octubre, Universidad Complutense de Madrid , Madrid, Spain
| | - Pedro A Gómez
- Department of Neurosurgery, Hospital 12 de Octubre, Universidad Complutense de Madrid , Madrid, Spain
| | - Ana María Castaño-Leon
- Department of Neurosurgery, Hospital 12 de Octubre, Universidad Complutense de Madrid , Madrid, Spain
| | - Rafael Martínez-Pérez
- Department of Neurosurgery, Hospital 12 de Octubre, Universidad Complutense de Madrid , Madrid, Spain
| | - Pablo M Munarriz
- Department of Neurosurgery, Hospital 12 de Octubre, Universidad Complutense de Madrid , Madrid, Spain
| | - Alfonso Lagares
- Department of Neurosurgery, Hospital 12 de Octubre, Universidad Complutense de Madrid , Madrid, Spain
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Sharda P, Haspani S, Idris Z. Factors prognosticating the outcome of decompressive craniectomy in severe traumatic brain injury: A Malaysian experience. Asian J Neurosurg 2015; 9:203-12. [PMID: 25685217 PMCID: PMC4323964 DOI: 10.4103/1793-5482.146605] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objective: The objective of this prospective cohort study was to analyse the characteristics of severe Traumatic Brain Injury (TBI) in a regional trauma centre Hospital Kuala Lumpur (HKL) along with its impact of various prognostic factors post Decompressive Craniectomy (DC). Materials and Methods: Duration of the study was of 13 months in HKL. 110 consecutive patients undergoing DC and remained in our centre were recruited. They were then analysed categorically with standard analytical software. Results: Age group have highest range between 12-30 category with male preponderance. Common mechanism of injury was motor vehicle accident involving motorcyclist. Univariate analysis showed statistically significant in referral area (P = 0.006). In clinical evaluation statistically significant was the motor score (P = 0.040), pupillary state (P = 0.010), blood pressure stability (P = 0.013) and evidence of Diabetes Insipidus (P < 0.001). In biochemical status the significant statistics included evidence of coagulopathy (P < 0.001), evidence of acidosis (P = 0.003) and evidence of hypoxia (P = 0.030). In Radiological sector, significant univariate analysis proved in location of the subdural clot (P < 0.010), location of the contusion (P = 0.045), site of existence of both type of clots (P = 0.031) and the evidence of edema (P = 0.041). The timing of injury was noted to be significant as well (P = 0.061). In the post operative care was, there were significance in the overall stability in intensive care (P < 0.001), the stability of blood pressure, cerebral perfusion pressure, pulse rates and oxygen saturation (all P < 0.001)seen individually, post operative ICP monitoring in the immediate (P = 0.002), within 24 hours (P < 0.001) and within 24-48 hours (P < 0.001) period, along with post operative pupillary size (P < 0.001) and motor score (P < 0.001). Post operatively, radiologically significant statistics included evidence of midline shift post operatively in the CT scan (P < 0.001). Multivariate logistic regression with stepwise likelihood ratio (LR) method concluded that hypoxia post operatively (P = 0.152), the unmaintained Cerebral Perfusion Pressure (CPP) (P = 0.007) and unstable blood pressure (BP) (P = <0.001). Poor outcome noted 10.2 times higher in post operative hypoxia [OR10.184; 95% CI: 0.424, 244.495]. Odds of having poor outcome if CPP unmaintained was 13.8 times higher [OR: 13.754; CI: 2.050, 92.301]. Highest predictor of poor outcome was the unstable BP, 32 times higher [OR 31.600; CI: 4.530, 220440]. Conclusion: Our series represent both urban and rural population, noted to be the largest series in severe TBI in this region. Severe head injury accounts for significant proportion of neurosurgical admissions, resources with its impact on socio-economic concerns to a growing population like Malaysia. This study concludes that the predictors of outcome in severe TBI post DC were postoperative hypoxia, unmaintained cerebral perfusion pressure and unstable blood pressure as independent predictors of poor outcome. Key words: Decompressive craniectomy, prognostication of decompressive craniectomy, prognostication of severe head injury, prognostication of traumatic brain injury, severe head injury, severe traumatic brain injury, traumatic brain injury.
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Affiliation(s)
- Priya Sharda
- Department of Neurosurgery, Hospital Kuala Lumpur, Jalan Pahang, Kuala Lumpur, Malaysia
| | - Saffari Haspani
- Department of Neurosciences, Universiti Sains Malaysia Health Campus, Kubang Kerian, Kelantan, Malaysia
| | - Zamzuri Idris
- Department of Neurosurgery, Hospital Kuala Lumpur, Jalan Pahang, Kuala Lumpur, Malaysia
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Endogenous plasminogen activators mediate progressive intracerebral hemorrhage after traumatic brain injury in mice. Blood 2015; 125:2558-67. [PMID: 25673638 DOI: 10.1182/blood-2014-08-588442] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 01/15/2015] [Indexed: 12/11/2022] Open
Abstract
Persistent intracerebral hemorrhage (ICH) is a major cause of death and disability after traumatic brain injury (TBI) for which no medical treatment is available. Delayed bleeding is often ascribed to consumptive coagulopathy initiated by exposed brain tissue factor. We examined an alternative hypothesis, namely, that marked release of tissue-type plasminogen activator (tPA) followed by delayed synthesis and release of urokinase plasminogen activator (uPA) from injured brain leads to posttraumatic bleeding by causing premature clot lysis. Using a murine model of severe TBI, we found that ICH is reduced in tPA(-/-) and uPA(-/-) mice but increased in PAI-1(-/-) mice compared with wild-type (WT) mice. tPA(-/-), but not uPA(-/-), mice developed a systemic coagulopathy post-TBI. Tranexamic acid inhibited ICH expansion in uPA(-/-)mice but not in tPA(-/-) mice. Catalytically inactive tPA-S(481)A inhibited plasminogen activation by tPA and uPA, attenuated ICH, lowered plasma d-dimers, lessened thrombocytopenia, and improved neurologic outcome in WT, tPA(-/-), and uPA(-/-) mice. ICH expansion was also inhibited by tPA-S(481)A in WT mice anticoagulated with warfarin. These data demonstrate that protracted endogenous fibrinolysis induced by TBI is primarily responsible for persistent ICH and post-TBI coagulopathy in this model and offer a novel approach to interrupt bleeding.
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Beynon C, Unterberg AW, Sakowitz OW. Point of care coagulation testing in neurosurgery. J Clin Neurosci 2014; 22:252-7. [PMID: 25439750 DOI: 10.1016/j.jocn.2014.07.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 07/13/2014] [Accepted: 07/28/2014] [Indexed: 11/19/2022]
Abstract
Impaired haemostasis represents a major risk factor for bleeding complications in neurosurgical patients. Coagulopathy commonly occurs after (brain) trauma and major haemorrhage or originates from antithrombotic medication. Point of care (POC) devices for bedside assessment of haemostatic parameters are increasingly used in various medical specialties. Results can be instantly implemented into treatment modalities as results are delivered within a very short period. POC coagulation testing has also shown beneficial effects in the treatment of neurosurgical patients. Identification of hyperfibrinolysis is achieved through viscoelastic testing of haemostasis and bedside coagulometry hastens the management of anticoagulated patients in need of urgent neurosurgical procedures. Results of POC testing of platelet function have been correlated with patient outcomes after traumatic brain injury and furthermore, quantification of antiplatelet medication effects on platelet activity is made possible through the use of these devices. Further studies are needed to characterise the potential of POC testing of platelet function. Antiplatelet medication plays an important role in regard to haemorrhagic and thromboembolic risks. Therefore, POC testing of platelet activity may improve treatment modalities in patients undergoing neurosurgical procedures as well as neurointerventional procedures (such as intracranial stent placement). In this article we summarise the available data of POC testing in neurosurgical patients and discuss the potential of these devices in this field. POC technologies have improved patient care in various medical fields and in our view it is likely that this will also apply to the field of neurosurgery.
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Affiliation(s)
- Christopher Beynon
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany.
| | - Andreas W Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Oliver W Sakowitz
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
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The significance of platelet count in traumatic brain injury patients on antiplatelet therapy. J Trauma Acute Care Surg 2014; 77:417-21. [PMID: 25159244 DOI: 10.1097/ta.0000000000000372] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Platelet dysfunction has been attributed to progression of initial intracranial hemorrhage (ICH) on repeat head computed tomographic (RHCT) scans in patients on prehospital antiplatelet therapy. However, there is little emphasis on the effect of platelet count and progression of ICH in patients with traumatic brain injury. The aim of this study was to determine the platelet count cutoff for progression on RHCT and neurosurgical intervention in patients on antiplatelet therapy. METHODS We performed a prospective cohort analysis of all traumatic brain injury patients with an ICH on prehospital antiplatelet therapy. Antiplatelet therapy was defined as aspirin, clopidogrel, or a combination of both. Admission platelet count was recorded and used for analysis. Receiver operating characteristic curves were plotted to identify the optimal platelet count for progression on RHCT scan and neurosurgical intervention in patients on antiplatelet therapy. RESULTS A total of 264 patients were enrolled. Platelet count of 135,000/µL or less (area under the curve, 0.80) and platelet count of 95,000/µL or less (area under the curve, 0.92) were the optimal threshold points for progression on RHCT scan and neurosurgical intervention, respectively. Patients with platelet count of 135,000/µL or less were 12.4 times (95% confidence interval, 7.1-18.4) more likely to have progression on RHCT scan and patients with platelet count 95,000/µL or less were 31.5 times (95% confidence interval, 19.7-96.2) more likely to require neurosurgical intervention. CONCLUSION A platelet count of less than 135,000/µL in patients on antiplatelet therapy is predictive of both radiographic and clinical worsening. This is a clinically relevant target intended to help tailor and improve management in patients on antiplatelet therapy. LEVEL OF EVIDENCE Therapeutic study, level III.
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Abstract
Coagulopathy is often observed after traumatic brain injury (TBI), but the pathogenic mechanisms of this phenomenon remain elusive. Brain injury is the leading cause of trauma deaths, and the development of coagulopathy after TBI is associated with increased morbidity and mortality in these patients. The coagulopathy after TBI comprises a hypocoagulable and a hypercoagulable state with hemorrhagic and thrombotic phenotypes that are both associated with worse outcome. Some theories of its pathogenesis include massive release of tissue factor, altered protein C homeostasis, microparticle upregulation, and platelet hyperactivity. This article aims to examine the coagulopathy associated with blunt head injury, to review its effect on progression of hemorrhagic injury, and to discuss the possible relevant pathophysiological mechanisms.
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Affiliation(s)
- Monisha A Kumar
- Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care, Perelman School of Medicine, Hospital of the University of Pennsylvania, 3 West Gates Building, 3400 Spruce Street, Philadelphia, PA, 19104, USA,
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Acquired coagulopathy of traumatic brain injury defined by routine laboratory tests: which laboratory values matter? J Trauma Acute Care Surg 2014; 76:121-5. [PMID: 24368366 DOI: 10.1097/ta.0b013e3182a9cc95] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Coagulopathy is a major determinant of disability and death in patients with traumatic intracranial hemorrhage. However, the correlation between coagulopathy defined by routine coagulation tests and clinical outcomes in traumatic brain injury (TBI) is not well defined. The aim of our study was to determine the effect of coagulopathy diagnosed by routine laboratory tests on outcomes in TBI patients. METHODS We performed a retrospective cohort analysis of all isolated TBI patients exclusive of prehospital antiplatelet and anticoagulants with coagulation tests, namely, international normalized ratio (INR), platelet count, and partial thromboplastin time at admission. We defined coagulopathy by an INR of 1.5 or greater, partial thromboplastin time of 35 or greater, or platelet count of 100 × 10(3)/µL or less. Outcome measures were progression on repeat head computed tomography (RHCT), need for neurosurgical intervention, and mortality. RESULTS A total of 591 patients were enrolled, with a mean (SD) age of 47.4 (26.5) years and 67% being male. Of the patients, 13.3% were coagulopathic at admission. Platelet count of 100 × 10(3)/µL or less was an independent predictor of progression on RHCT (odd ratio [OR], 4; 95% confidence interval [CI], 1.7-10), need for neurosurgical intervention (OR, 3.6; 95% CI, 1.2-6.1), and mortality (OR, 2.6; 95% CI, 1.1-4.8). INR was an independent predictor of progression on RHCT (OR, 2; 95% CI, 1.1-4.3). CONCLUSION Routine bedside coagulation parameters at admission play an important role in predicting outcomes in blunt TBI. Platelet count is the strongest predictor for progression of initial insult on RHCT, need for neurosurgical intervention, and mortality. LEVEL OF EVIDENCE Prognostic study, level III.
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Activity of factor VII in patients with isolated blunt traumatic brain injury. J Trauma Acute Care Surg 2014; 76:114-20. [DOI: 10.1097/ta.0b013e3182a8fe48] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Raj R, Siironen J, Kivisaari R, Hernesniemi J, Tanskanen P, Handolin L, Skrifvars MB. External Validation of the International Mission for Prognosis and Analysis of Clinical Trials Model and the Role of Markers of Coagulation. Neurosurgery 2013; 73:305-11; discussion 311. [DOI: 10.1227/01.neu.0000430326.40763.ec] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Abstract
BACKGROUND:
Markers of coagulation have shown to have important value in predicting traumatic brain injury outcome.
OBJECTIVE:
To externally validate and investigate the role of markers of coagulation for outcome prediction by using the International Mission for Prognosis and Analysis of Clinical Trials (IMPACT) model while adjusting for overall injury severity.
METHODS:
A retrospective chart analysis of traumatic brain injury patients admitted to Helsinki University Central Hospital between 2009 and 2010 was performed. Outcome was estimated by using the criteria of the IMPACT model. Admission international normalized ratio (INR) and platelet count were used as markers of coagulation. Overall injury severity was categorized with the injury severity score (ISS). Variables were added to the calculated IMPACT risk, generating new models. Model performance was assessed by analyzing and comparing the area under the curve (AUC) of the models.
RESULTS:
For 342 included patients, 6-month mortality was 32% and unfavorable neurological outcome was 36%. Patients with a poor outcome had lower platelets and higher INR and ISS than those with good outcome (P < .001). The IMPACT model had an AUC of 0.85 for predicting mortality and 0.81 for neurological outcome. Addition of INR but not ISS or platelets to the IMPACT predicted risk improved the predictive validity for mortality ([INCREMENT]AUC 0.02, P = .034) but not neurological outcome ([INCREMENT]AUC 0.00, P = .401). In multivariate analysis, INR remained significant for mortality but not for neurological outcome when adjusting for IMPACT risk and ISS (P = .012).
CONCLUSION:
The IMPACT model showed excellent performance, and INR was an independent predictor for mortality, independent of overall injury severity.
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Affiliation(s)
- Rahul Raj
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland
- Department of Anaesthesiology and Intensive Care Medicine, Helsinki University Central Hospital, Helsinki, Finland
| | - Jari Siironen
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland
| | - Riku Kivisaari
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland
| | - Juha Hernesniemi
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland
| | - Päivi Tanskanen
- Department of Anaesthesiology and Intensive Care Medicine, Helsinki University Central Hospital, Helsinki, Finland
| | - Lauri Handolin
- Department of Orthopedics and Traumatology, Helsinki University Central Hospital, Helsinki, Finland
| | - Markus B. Skrifvars
- Department of Anaesthesiology and Intensive Care Medicine, Helsinki University Central Hospital, Helsinki, Finland
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Takayama Y, Yokota H, Sato H, Naoe Y, Araki T. Pathophysiology, Mortality, Treatment of Acute Phase of Haemostatic Disorders of Traumatic Brain Injury. ACTA ACUST UNITED AC 2013. [DOI: 10.7887/jcns.22.837] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Risk Factors for Reoperation after Traumatic Intracranial Hemorrhage. Korean J Neurotrauma 2013. [DOI: 10.13004/kjnt.2013.9.2.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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