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Ho MP. Traumatic brain injury: Role of tranexamic acid. Am J Emerg Med 2024; 83:131. [PMID: 38760185 DOI: 10.1016/j.ajem.2024.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 05/08/2024] [Indexed: 05/19/2024] Open
Affiliation(s)
- Min-Po Ho
- Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan.
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Wang P, Yang X, Yang F, Cardiff K, Houchins M, Carballo N, Shear DA, Scultetus AH, Bailey ZS. Intravenous Administration of Anti-CD47 Antibody Augments Hematoma Clearance, Mitigates Acute Neuropathology, and Improves Cognitive Function in a Rat Model of Penetrating Traumatic Brain Injury. J Neurotrauma 2024. [PMID: 38874230 DOI: 10.1089/neu.2024.0047] [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: 06/15/2024] Open
Abstract
Traumatic brain injury (TBI)-induced intracerebral hematoma is a major driver of secondary injury pathology such as neuroinflammation, cerebral edema, neurotoxicity, and blood-brain barrier dysfunction, which contribute to neuronal loss, motor deficits, and cognitive impairment. Cluster of differentiation 47 (CD47) is an antiphagocytic cell surface protein inhibiting hematoma clearance. This study was designed to evaluate the safety and efficacy of blockade of CD47 via intravenous (i.v.) administration of anti-CD47 antibodies following penetrating ballistic-like brain injury (PBBI) with significant traumatic intracerebral hemorrhage (tICH). The pharmacokinetic (PK) profile of the anti-CD47 antibody elicited that antibody concentration decayed over 7 days post-administration. Blood tests and necropsy analysis indicated no severe adverse events following treatment. Cerebral hemoglobin levels were significantly increased after injury, however, anti-CD47 antibody administration at 0.1 mg/kg resulted in a significant reduction in cerebral hemoglobin levels at 72 h post-administration, indicating augmentation of hematoma clearance. Immunohistochemistry assessment of glial fibrillary acidic protein (GFAP) and ionized calcium-binding adaptor molecule 1 (IBA1) demonstrated a significant reduction of GFAP levels in the lesion core and peri-lesional area. Based on these analyses, the optimal dose was identified as 0.1 mg/kg. Lesion volume showed a reduction following treatment. Rotarod testing revealed significant motor deficits in all injured groups but no significant therapeutic benefits. Spatial learning performance revealed significant deficits in all injured groups, which were significantly improved by the last testing day. Anti-CD47 antibody treated rats showed significantly improved attention deficits, but not retention scores. These results provide preliminary evidence that blockade of CD47 using i.v. administration of anti-CD47 antibodies may serve as a potential therapeutic for TBI with ICH.
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Affiliation(s)
- Ping Wang
- Brain Trauma Neuroprotection, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Xiaofang Yang
- Brain Trauma Neuroprotection, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Fangzhou Yang
- Brain Trauma Neuroprotection, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Katherine Cardiff
- Brain Trauma Neuroprotection, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Melonie Houchins
- Brain Trauma Neuroprotection, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Noemy Carballo
- Brain Trauma Neuroprotection, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Deborah A Shear
- Brain Trauma Neuroprotection, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Anke H Scultetus
- Brain Trauma Neuroprotection, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Zachary S Bailey
- Brain Trauma Neuroprotection, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
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Zhang M, Liu T. Efficacy and safety of tranexamic acid in acute traumatic brain injury: A meta-analysis of randomized controlled trials. Am J Emerg Med 2024; 80:35-43. [PMID: 38502985 DOI: 10.1016/j.ajem.2024.03.005] [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: 11/15/2023] [Revised: 01/10/2024] [Accepted: 03/05/2024] [Indexed: 03/21/2024] Open
Abstract
INTRODUCTION Tranexamic acid (TXA) holds a pivotal role in the therapeutic approach to traumatic conditions. Nevertheless, its precise influence on diminishing mortality and limiting the progression of intracranial hemorrhage (ICH) during the treatment of traumatic brain injury (TBI) remains indeterminate. METHODS PubMed, EMBASE, Cochrane Library, and Web of Science were searched for randomized controlled trials that compared TXA and a placebo in adults with TBI up to September 31, 2023. Two authors independently abstracted the data and assessed the quality of evidence. Additionally, subgroup analyses were performed to assess outcomes with low heterogenety. RESULTS Our search strategy yielded 11,299 patients from 11 studies. The result showed that TXA had no effect on mortality (RR 0.93 [0.86, 1.00], p = 0.06; I2: 0%, p = 0.79), poor clinical outcomes (RR 0.92 [0.78, 1.09], p = 0.34; I2: 0%, p = 0.40), adverse events (RR 0.94 [0.83, 1.07], p = 0.34; I2: 48%, p = 0.10), vascular occlusive events (RR 0.85 [0.68, 1.06], p = 0.16; I2: 32%, p = 0.22), pulmonary embolism (RR 0.76 [0.47, 1.22], p = 0.26; I2: 0%, p = 0.83), seizure (RR 1.11 [0.92, 1.35], p = 0.27; I2: 0%, p = 0.49) and hemorrhagic complications (RR 0.78 [0.55, 1.09], p = 0.14; I2: 0%, p = 0.42). TXA might reduce the rate of hemorrhagic expansion (RR 0.83 [0.70, 0.99], p = 0.03; I2: 18%, p = 0.29) and mean hemorrhage volume (SMD -0.39 [-0.60, -0.18], p <0.001; I2: 44%, p = 0.13).When the time interval from symptom onset to treatment was <3 h, TXA reduced mean hemorrhage volume (SMD -0.51 [-0.81, -0.20], p = 0.001; I2: 0%, p = 0.94). CONCLUSIONS TXA did not elevate the risk of adverse event, however, the lack of reduction in mortality and the poor clinical outcomes constrain the value of clinical application. Early administration of TXA (within 3 h) may significantly decrease the likelihood of ICH growth in patients with TBI.
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Affiliation(s)
- Minzhi Zhang
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Tao Liu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China; Key Laboratory of Post Neuro-Injury Neuro-Repair and Regeneration in Central NervousSystem, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China.
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Sarhan RM, Boshra MS, Abdelrahim MEA, Osama H. Tranexamic acid in patients with traumatic brain injury: a meta-analysis. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024; 71:360-367. [PMID: 38387502 DOI: 10.1016/j.redare.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 02/08/2023] [Accepted: 04/13/2023] [Indexed: 02/24/2024]
Abstract
BACKGROUND We performed a meta-analysis to assess the effectiveness and safety of tranexamic acid in patients with traumatic brain injury (TBI). METHODS We searched the literature for articles evaluating the effectiveness and safety of tranexamic acid (TXA) in TBI published between January 2012 and January 2021, and identified 8 studies with a total of 10860 patients: 5660 received TXA and 5200 served as controls. We used a dichotomous or continuous approach with a random or fixed-effect model to assess the efficacy and safety of TXA in TBI, and calculated the mean difference (MD) and odds ratio (OR) with the corresponding 95% confidence interval. RESULTS In patients with TBI, early administration of TXA was associated with a greater relative benefit (MD -2.45; 95% CI = -4.78 to -0.12; p=0.04) and less total haematoma expansion (MD - 2.52; 95% CI = -4.85 to -0.19; p=0.03) compared to controls. There were no statistically significant differences in mortality (OR 0.94; 95% CI=0.85-1.03; p=0.18), presence of progressive haemorrhage (OR 0.75; 95% CI=0.56-1.01; p=0.06), need for neurosurgery (OR 1.15; 95% CI=0.66-1.98; p=0.63), high Disability Rating Scale score (OR 0.90; 95% CI=0.56-1.45; p=0.68), and incidence of ischaemic or thromboembolic complications (OR 1.34; 95% CI=0.33-5.46; p=0.68) between TBI patients treated with TXA and controls. CONCLUSIONS Early administration of TXA in TBI patients may have a greater relative benefit and may inhibit haematoma expansion. There were no significant differences in mortality, presence of progressive haemorrhage, need for neurosurgery, high Disability Rating Scale score, and incidence of ischaemic or thromboembolic complications between TBI patients treated with TXA and controls. Further studies are needed to validate these results.
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Affiliation(s)
- R M Sarhan
- Departamento de Farmacia Clínica, Facultad de Farmacia, Universidad Beni-Suef, Beni-Suef, Egypt
| | - M S Boshra
- Departamento de Farmacia Clínica, Facultad de Farmacia, Universidad Beni-Suef, Beni-Suef, Egypt
| | - M E A Abdelrahim
- Departamento de Farmacia Clínica, Facultad de Farmacia, Universidad Beni-Suef, Beni-Suef, Egypt.
| | - H Osama
- Departamento de Farmacia Clínica, Facultad de Farmacia, Universidad Beni-Suef, Beni-Suef, Egypt
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Peng J, Luo T, Li X, Li B, Cheng Y, Huang Q, Su J. Imaging predictors of hemorrhagic progression of a contusion after traumatic brain injury: a systematic review and meta-analysis. Sci Rep 2024; 14:5961. [PMID: 38472247 PMCID: PMC10933276 DOI: 10.1038/s41598-024-56232-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 03/04/2024] [Indexed: 03/14/2024] Open
Abstract
The hemorrhagic progression of a contusion (HPC) after Traumatic brain injury (TBI) is one of the important causes of death in trauma patients. The purpose of this meta-analysis was to evaluate the predictive effect of imaging features of Computed tomography (CT) on HPC after TBI. A comprehensive systematic search was performed using PubMed, EMBASE, and WEB OF SCIENCE databases to identify all relevant literature. A total of 8 studies involving 2543 patients were included in this meta-analysis. Meta-analysis showed that subarachnoid hemorrhage (OR 3.28; 95% CI 2.57-4.20), subdural hemorrhage (OR 4.35; 95% CI 3.29-5.75), epidural hemorrhage (OR 1.47;95% CI 1.15-1.89), contrast extravasation (OR 11.81; 95% CI 4.86-28.71) had a predictive effect on the occurrence of HPC. Skull fracture (OR 1.64; 95% CI 0.84-3.19) showed no statistical significance, and midline displacement > 5 mm (OR 4.66; 95% CI 1.87-11.62) showed high heterogeneity. The results of this meta-analysis showed that some imaging features were effective predictors of HPC after TBI. Well-designed prospective studies are needed to more accurately assess the effective predictors of HPC after TBI.
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Affiliation(s)
- Jie Peng
- Department of Neurosurgery, The People's Hospital of Nanchuan, Chongqing, 408400, China
| | - Tao Luo
- Department of Neurosurgery, The People's Hospital of Nanchuan, Chongqing, 408400, China
| | - Xiaoyu Li
- Department of Neurosurgery, The People's Hospital of Nanchuan, Chongqing, 408400, China
| | - Bin Li
- Department of Neurosurgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Yuan Cheng
- Department of Neurosurgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Qin Huang
- Department of Neurosurgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China.
| | - Jun Su
- Department of Neurosurgery, The People's Hospital of Nanchuan, Chongqing, 408400, China.
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Song JX, Wu JX, Zhong H, Chen W, Zheng JC. Therapeutic efficacy of tranexamic acid on traumatic brain injury: a systematic review and meta-analysis. Scand J Trauma Resusc Emerg Med 2024; 32:18. [PMID: 38454455 PMCID: PMC10921791 DOI: 10.1186/s13049-024-01188-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 02/25/2024] [Indexed: 03/09/2024] Open
Abstract
OBJECTIVE Tranexamic acid (TXA) demonstrates therapeutic efficacy in the management of traumatic brain injury (TBI). The objective of this systematic review and meta-analysis was to evaluate the safety and effectiveness of TXA in patients with TBI. METHODS The databases, namely PubMed, Embase, Web of Science, and Cochrane Library databases, were systematically searched to retrieve randomized controlled trials (RCTs) investigating the efficacy of TXA for TBI from January 2000 to November 2023. RESULTS The present meta-analysis incorporates ten RCTs. Compared to the placebo group, administration of TXA in patients with TBI resulted in a significant reduction in mortality (P = 0.05), hemorrhage growth (P = 0.03), and volume of hemorrhage growth (P = 0.003). However, no significant impact was observed on neurosurgery outcomes (P = 0.25), seizure occurrence (P = 0.78), or pulmonary embolism incidence (P = 0.52). CONCLUSION The administration of TXA is significantly associated with reduced mortality and hemorrhage growth in patients suffering from TBI, while the need of neurosurgery, seizures, and incidence of pulmonary embolism remains comparable to that observed with placebo.
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Affiliation(s)
- Jia-Xing Song
- Department of Emergency, The Second Hospital of Jiaxing: The Second Affiliated Hospital of Jiaxing University, Jiaxing, 314000, Zhejiang Province, China
| | - Jian-Xiang Wu
- Department of Emergency, The Second Hospital of Jiaxing: The Second Affiliated Hospital of Jiaxing University, Jiaxing, 314000, Zhejiang Province, China
| | - Hai Zhong
- Department of Emergency, The Second Hospital of Jiaxing: The Second Affiliated Hospital of Jiaxing University, Jiaxing, 314000, Zhejiang Province, China
| | - Wei Chen
- Department of Emergency, The Second Hospital of Jiaxing: The Second Affiliated Hospital of Jiaxing University, Jiaxing, 314000, Zhejiang Province, China
| | - Jian-Chun Zheng
- Department of Emergency, The Second Hospital of Jiaxing: The Second Affiliated Hospital of Jiaxing University, Jiaxing, 314000, Zhejiang Province, China.
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Fletcher-Sandersjöö A, Svedung Wettervik T, Tatter C, Tjerkaski J, Nelson DW, Maegele M, Svensson M, Lewén A, Enblad P, Bellander BM, Thelin EP. Absolute Contusion Expansion Is Superior to Relative Expansion in Predicting Traumatic Brain Injury Outcomes: A Multi-Center Observational Cohort Study. J Neurotrauma 2024; 41:705-713. [PMID: 38062766 PMCID: PMC10902499 DOI: 10.1089/neu.2023.0274] [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] [Indexed: 12/29/2023] Open
Abstract
Contusion expansion (CE) is a potentially treatable outcome predictor in traumatic brain injury (TBI), and a suitable end-point for hemostatic therapy trials. However, there is no consensus on the definition of clinically relevant CE, both in terms of measurement criteria (absolute vs. relative volume increase) and cutoff values. In light of this, the aim of this study was to assess the predictive abilities of different CE definitions on outcome. We performed a multi-center observational cohort study of adults with moderate-to-severe TBI treated in an intensive care unit. The exposure of interest was CE, defined as the absolute and relative volume change between the first and second computed tomography scan. The primary outcome was the Glasgow Outcome Scale (GOS) at 6-12 months post-injury, dichotomized into unfavorable (GOS ≤3) or favorable (GOS ≥4). The secondary outcome was all-cause mortality. In total, 798 patients were included, with a median duration of 7.0 h between the first and second CT scan. The median absolute and relative CE was 1.5 mL (interquartile range [IQR] 0.1-8.3 mL) and 100% (IQR 10-530%), respectively. Both CE forms were independently associated with unfavorable GOS. Absolute CE outperformed relative CE in predicting both unfavorable GOS (area under the curve [AUC]: 0.65 vs. 0.60, p = 0.002) and all-cause mortality (AUC: 0.66 vs. 0.60, p = 0.003). For dichotomized CE, absolute cutoffs of 1-10 mL yielded the best results. We conclude that absolute CE demonstrates stronger outcome correlation than relative CE. In studies focusing on lesion progression in TBI, it may be advantageous to use absolute CE as the primary outcome metric. For dichotomized outcomes, cutoffs between 1 and 10 mL are suggested, depending on the desired sensitivity-specificity balance.
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Affiliation(s)
- Alexander Fletcher-Sandersjöö
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | | | - Charles Tatter
- Department of Clinical Neuroscience, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
- Department of Radiology, Stockholm Southern Hospital, Stockholm, Sweden
| | - Jonathan Tjerkaski
- Department of Clinical Neuroscience, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - David W. Nelson
- Function Perioperative Care and Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, 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, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Anders Lewén
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Per Enblad
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Bo-Michael Bellander
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Eric Peter Thelin
- Department of Clinical Neuroscience, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
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Ratan R, Mohindra S, Tripathi M, Singla R, Chauhan R. Factors determining the requirement of surgical intervention and prognosis in cases of traumatic bifrontal contusions: A prospective observational study. Surg Neurol Int 2023; 14:438. [PMID: 38213442 PMCID: PMC10783674 DOI: 10.25259/sni_754_2023] [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: 09/12/2023] [Accepted: 11/25/2023] [Indexed: 01/13/2024] Open
Abstract
Background Traumatic brain injury, being a notorious cause of mortality and morbidity across the globe, presents with a variety of lesions. One of the distinct patterns of injury is characterized by contusions of both frontal lobes, labeled "traumatic bifrontal contusions" (TBCs). TBC is often associated with the presence of significant edema and mass effect leading to rapid clinical deterioration after a usually benign presentation at the time of first evaluation. Formulating a management plan in a patient with TBC is often more difficult than in a patient with a major intracranial hematoma. Methods A prospective observational study with aims and objectives to identify predictors of an unfavorable outcome, analysis of the evolution of TBC, evaluation of the specific indications for surgery, and determination of the prognosis. All head trauma patients harboring bifrontal contusions were included in the study. Patients with other associated operable injuries involving blunt trauma abdomen and orthopedic injuries, counter-coupe injuries, and obvious open fractures noted over calvaria were excluded from the study. Glasgow coma scale (GCS) was recorded during the first assessment, followed by non-contrast computerized tomography (NCCT) Head. Results A total of 53 patients satisfying inclusion and exclusion criteria were included in the study. The average GCS score recorded before surgical intervention was 9. The mean and median best motor response noted was M5. The interval from the time of injury to the first NCCT of the brain at the study hospital ranged from 3 h to 163 h, averaging 17.66 h. The median category w.r.t Marshall's CT classification observed was "Diffuse Injury IV." The volume of the contusions in each scan was estimated, and the average anterior cranial fossa volume observed was 125 mL. "Upfront surgery" ("Bifrontal decompressive craniectomy" or "unilateral Fronto-Temporo-Parietal [FTP] decompressive hemicraniectomy") was carried out on the day of admission based on the findings on the first NCCT brain. About 49% of patients at presentation needed surgical intervention as per existing protocols. The duration of observation for patients who were initially observed but eventually had to undergo surgery ranged from 1 to 5 days, with an average observation period of 2 days. The duration of observation in those who did not subsequently need surgery ranged from 7 to 10 days, with an average duration of 9 days. Conclusion What leads to the poorly predictable, delayed, and rapid deterioration that sets TBCs apart from other traumatic brain injuries is still unclear. Our study finds that having a low threshold for repeat CT imaging of the patient led to earlier identification of progression, and a low threshold for surgical intervention led to favorable outcomes.
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Affiliation(s)
- Raj Ratan
- Department of Neurosurgery, Army Hospital Research and Referral, Delhi
| | - Sandeep Mohindra
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh
| | - Manjul Tripathi
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh
| | - Raghav Singla
- Department of Neurosurgery, All India Institute of Medical Sciences, Delhi
| | - Rajeev Chauhan
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Kamabu LK, Oboth R, Bbosa G, Baptist SJ, Kaddumukasa MN, Deng D, Lekuya HM, Kataka LM, Kiryabwire J, Moses G, Sajatovic M, Kaddumukasa M, Fuller AT. Predictive models for occurrence of expansive intracranial hematomas and surgical evacuation outcomes in traumatic brain injury patients in Uganda: A prospective cohort study. RESEARCH SQUARE 2023:rs.3.rs-3626631. [PMID: 38045250 PMCID: PMC10690308 DOI: 10.21203/rs.3.rs-3626631/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Abstract
BACKGROUND Hematoma expansion is a common manifestation of acute intracranial hemorrhage (ICH) which is associated with poor outcomes and functional status. Objective We determined the prevalence of expansive intracranial hematomas (EIH) and assessed the predictive model for EIH occurrence and surgical evacuation outcomes in patients with traumatic brain injury (TBI) in Uganda. Methods We recruited adult patients with TBI with intracranial hematomas in a prospective cohort study. Data analysis using logistic regression to identify relevant risk factors, assess the interactions between variables, and developing a predictive model for EIH occurrence and surgical evacuation outcomes in TBI patients was performed. The predictive accuracies of these algorithms were compared using the area under the receiver operating characteristic curve (AUC). A p-values of < 0.05 at a 95% Confidence interval (CI) was considered significant. Results A total of 324 study participants with intracranial hemorrhage were followed up for 6 months after surgery. About 59.3% (192/324) had expansive intracranial hemorrhage. The study participants with expansive intracranial hemorrhage had poor quality of life at both 3 and 6-months with p < 0.010 respectively. Among the 5 machine learning algorithms, the random forest performed the best in predicting EIH in both the training cohort (AUC = 0.833) and the validation cohort (AUC = 0.734). The top five features in the random forest algorithm-based model were subdural hematoma, diffuse axonal injury, systolic and diastolic blood pressure, association between depressed fracture and subdural hematoma. Other models demonstrated good discrimination with AUC for intraoperative complication (0.675) and poor discrimination for mortality (0.366) after neurosurgical evacuation in TBI patients. Conclusion Expansive intracranial hemorrhage is common among patients with traumatic brain injury in Uganda. Early identification of patients with subdural hematoma, diffuse axonal injury, systolic and diastolic blood pressure, association between depressed fracture and subdural hematoma, were crucial in predicting EIH and intraoperative complications.
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Wu YT, Chien CY, Matsushima K, Schellenberg M, Inaba K, Moore EE, Sauaia A, Knudson MM, Martin MJ. Early venous thromboembolism prophylaxis in patients with trauma intracranial hemorrhage: Analysis of the prospective multicenter Consortium of Leaders in Traumatic Thromboembolism study. J Trauma Acute Care Surg 2023; 95:649-656. [PMID: 37314427 DOI: 10.1097/ta.0000000000004007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND The optimal time to initiate venous thromboembolism prophylaxis (VTEp) for patients with intracranial hemorrhage (ICH) is controversial and must balance the risks of VTE with potential progression of ICH. We sought to evaluate the efficacy and safety of early VTEp initiation after traumatic ICH. METHODS This is a secondary analysis of the prospective multicenter Consortium of Leaders in the Study of Thromboembolism study. Patients with head Abbreviated Injury Scale score of > 2 and with immediate VTEp held because of ICH were included. Patients were divided into VTEp ≤ or >48 hours and compared. Outcome variables included overall VTE, deep vein thrombosis (DVT), pulmonary embolism, progression of intracranial hemorrhage (pICH), or other bleeding events. Univariate and multivariate logistic regressions were performed. RESULTS There were 881 patients in total; 378 (43%) started VTEp ≤48 hours (early). Patients starting VTEp >48 hours (late) had higher VTE (12.4% vs. 7.2%, p = 0.01) and DVT (11.0% vs. 6.1%, p = 0.01) rates than the early group. The incidence of pulmonary embolism (2.1% vs. 2.2%, p = 0.94), pICH (1.9% vs. 1.8%, p = 0.95), or any other bleeding event (1.9% vs. 3.0%, p = 0.28) was equivalent between early and late VTEp groups. On multivariate logistic regression analysis, VTEp >48 hours (odds ratio [OR], 1.86), ventilator days >3 (OR, 2.00), and risk assessment profile score of ≥5 (OR, 6.70) were independent risk factors for VTE (all p < 0.05), while VTEp with enoxaparin was associated with decreased VTE (OR, 0.54, p < 0.05). Importantly, VTEp ≤48 hours was not associated with pICH (OR, 0.75) or risk of other bleeding events (OR, 1.28) (both p = NS). CONCLUSION Early initiation of VTEp (≤48 hours) for patients with ICH was associated with decreased VTE/DVT rates without increased risk of pICH or other significant bleeding events. Enoxaparin is superior to unfractionated heparin as VTE prophylaxis in patients with severe TBI. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Yu-Tung Wu
- From the Division of Trauma, Emergency Surgery, and Surgical Critical Care (Y.-T.W., C.-Y.C., K.M., M.S., K.I., M.J.M.), LAC+USC Medical Center, University of Southern California, Los Angeles, California; Department of Trauma and Emergency Surgery (Y.-T.W.), Chang Gung Memorial Hospital, Linkou; Department of General Surgery (C.-Y.C.), Chang Gung Memorial Hospital, Keelung, Taiwan; Department of Surgery (E.E.M.), Ernest E Moore Shock Trauma Center at Denver Health Center; School of Public Health (A.S.), University of Colorado, Denver, Colorado; and Department of Surgery (M.M.K.), University of California San Francisco, San Francisco, California
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Kamabu LK, Bbosa GS, Lekuya HM, Cho EJ, Kyaruzi VM, Nyalundja AD, Deng D, Sekabunga JN, Kataka LM, Obiga DOD, Kiryabwire J, Kaddumukasa MN, Kaddumukasa M, Fuller AT, Galukande M. Burden, risk factors, neurosurgical evacuation outcomes, and predictors of mortality among traumatic brain injury patients with expansive intracranial hematomas in Uganda: a mixed methods study design. BMC Surg 2023; 23:326. [PMID: 37880635 PMCID: PMC10601114 DOI: 10.1186/s12893-023-02227-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 10/09/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND Expansive intracranial hematomas (EIH) following traumatic brain injury (TBI) continue to be a public health problem in Uganda. Data is limited regarding the neurosurgical outcomes of TBI patients. This study investigated the neurosurgical outcomes and associated risk factors of EIH among TBI patients at Mulago National Referral Hospital (MNRH). METHODS A total of 324 subjects were enrolled using a prospective cohort study. Socio-demographic, risk factors and complications were collected using a study questionnaire. Study participants were followed up for 180 days. Univariate, multivariable, Cox regression analyses, Kaplan Meir survival curves, and log rank tests were sequentially conducted. P-values of < 0.05 at 95% Confidence interval (CI) were considered to be statistically significant. RESULTS Of the 324 patients with intracranial hematomas, 80.6% were male. The mean age of the study participants was 37.5 ± 17.4 years. Prevalence of EIH was 59.3% (0.59 (95% CI: 0.54 to 0.65)). Participants who were aged 39 years and above; PR = 1.54 (95% CI: 1.20 to 1.97; P = 0.001), and those who smoke PR = 1.21 (95% CI: 1.00 to 1.47; P = 0.048), and presence of swirl sign PR = 2.26 (95% CI: 1.29 to 3.95; P = 0.004) were found to be at higher risk for EIH. Kaplan Meier survival curve indicated that mortality at the 16-month follow-up was 53.4% (95% CI: 28.1 to 85.0). Multivariate Cox regression indicated that the predictors of mortality were old age, MAP above 95 mmHg, low GCS, complications such as infection, spasticity, wound dehiscence, CSF leaks, having GOS < 3, QoLIBRI < 50, SDH, contusion, and EIH. CONCLUSION EIH is common in Uganda following RTA with an occurrence of 59.3% and a 16-month higher mortality rate. An increased age above 39 years, smoking, having severe systemic disease, and the presence of swirl sign are independent risk factors. Old age, MAP above 95 mmHg, low GCS, complications such as infection, spasticity, wound dehiscence, CSF leaks, having a GOS < 3, QoLIBRI < 50, ASDH, and contusion are predictors of mortality. These findings imply that all patients with intracranial hematomas (IH) need to be monitored closely and a repeat CT scan to be done within a specific period following their initial CT scan. We recommend the development of a protocol for specific surgical and medical interventions that can be implemented for patients at moderate and severe risk for EIH.
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Affiliation(s)
- Larrey Kasereka Kamabu
- Department of Surgery, Neurosurgery, College of Medicine, Makerere University, Kampala, Uganda.
- Faculty of Medicine, Université Catholique du Graben, Butembo, Democratic Republic of the Congo.
- Department of Surgery, Makerere University College of Health Medicine, Mulago Upper Hill, Kampala, Uganda.
| | - Godfrey S Bbosa
- Department of Pharmacology & Therapeutics, Makerere University College of Health Sciences, Kampala, Uganda
| | - Hervé Monka Lekuya
- Department of Surgery, Neurosurgery, College of Medicine, Makerere University, Kampala, Uganda
- Directorate of Surgical Services, Neurosurgical Unit, Mulago National Referral Hospital, Kampala, Uganda
- Department of Human Structure & Repair/ Neurosurgery, Faculty of Medicine, Ghent University, Ghent, Belgium
| | | | - Victor Meza Kyaruzi
- Department of Surgery, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Arsene Daniel Nyalundja
- Faculty of Medicine, Université Catholique de Bukavu, Bukavu, South Kivu, Democratic Republic of the Congo
| | - Daniel Deng
- Duke Global Neurosurgery, Neurology and Health System, Duke University, Durham, NC, USA
| | - Juliet Nalwanga Sekabunga
- Department of Surgery, Neurosurgery, College of Medicine, Makerere University, Kampala, Uganda
- Directorate of Surgical Services, Neurosurgical Unit, Mulago National Referral Hospital, Kampala, Uganda
| | - Louange Maha Kataka
- Faculty of Medicine, Université Catholique du Graben, Butembo, Democratic Republic of the Congo
| | - Doomwin Oscar Deogratius Obiga
- Department of Surgery, Neurosurgery, College of Medicine, Makerere University, Kampala, Uganda
- Directorate of Surgical Services, Neurosurgical Unit, Mulago National Referral Hospital, Kampala, Uganda
| | - Joel Kiryabwire
- Department of Surgery, Neurosurgery, College of Medicine, Makerere University, Kampala, Uganda
- Directorate of Surgical Services, Neurosurgical Unit, Mulago National Referral Hospital, Kampala, Uganda
| | - Martin N Kaddumukasa
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
| | - Mark Kaddumukasa
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
| | - Anthony T Fuller
- Duke University, Durham, NC, USA
- Duke Global Neurosurgery, Neurology and Health System, Duke University, Durham, NC, USA
| | - Moses Galukande
- Department of Surgery, Neurosurgery, College of Medicine, Makerere University, Kampala, Uganda
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12
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Gil-Jardiné C, Payen JF, Bernard R, Bobbia X, Bouzat P, Catoire P, Chauvin A, Claessens YE, Douay B, Dubucs X, Galanaud D, Gauss T, Gauvrit JY, Geeraerts T, Glize B, Goddet S, Godier A, Le Borgne P, Rousseau G, Sapin V, Velly L, Viglino D, Vigue B, Cuvillon P, Frasca D, Claret PG. Management of patients suffering from mild traumatic brain injury 2023. Anaesth Crit Care Pain Med 2023; 42:101260. [PMID: 37285919 DOI: 10.1016/j.accpm.2023.101260] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To develop a multidisciplinary French reference that addresses initial pre- and in-hospital management of a mild traumatic brain injury patient. DESIGN A panel of 22 experts was formed on request from the French Society of Emergency Medicine (SFMU) and the French Society of Anaesthesiology and Critical Care Medicine (SFAR). A policy of declaration and monitoring of links of interest was applied and respected throughout the process of producing the guidelines. Similarly, no funding was received from any company marketing a health product (drug or medical device). The expert panel had to respect and follow the Grade® (Grading of Recommendations Assessment, Development and Evaluation) methodology to evaluate the quality of the evidence on which the recommendations were based. Given the impossibility of obtaining a high level of evidence for most of the recommendations, it was decided to adopt a "Recommendations for Professional Practice" (RPP) format, rather than a Formalized Expert Recommendation (FER) format, and to formulate the recommendations using the terminology of the SFMU and SFAR Guidelines. METHODS Three fields were defined: 1) pre-hospital assessment, 2) emergency room management, and 3) emergency room discharge modalities. The group assessed 11 questions related to mild traumatic brain injury. Each question was formulated using a PICO (Patients Intervention Comparison Outcome) format. RESULTS The experts' synthesis work and the application of the GRADE® method resulted in the formulation of 14 recommendations. After two rounds of rating, strong agreement was obtained for all recommendations. For one question, no recommendation could be made. CONCLUSION There was strong agreement among the experts on important, transdisciplinary recommendations, the purpose of which is to improve management practices for patients with mild head injury.
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Affiliation(s)
- Cédric Gil-Jardiné
- Centre Hospitalier Universitaire de Bordeaux, Hôpital Pellegrin, Service des Urgences-Adultes, Population Health, INSERM U1219, équipe aHeAD, Université de Bordeaux, Bordeaux, France.
| | - Jean-François Payen
- Department of Anesthesiology and Critical Care, Grenoble Alpes University Hospital, University Grenoble Alpes, F-38000 Grenoble, France
| | - Rémy Bernard
- Department of Anaesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Xavier Bobbia
- Montpellier University, UR UM 103 (IMAGINE), Department of Emergency Medicine, CHU Montpellier, Montpellier, France
| | - Pierre Bouzat
- Department of Anesthesiology and Critical Care, Grenoble Alpes University Hospital, University Grenoble Alpes, F-38000 Grenoble, France
| | - Pierre Catoire
- Emergency Consultant, Academic Clinical Fellow (Pitié-Salpétrière University, General Emergency Department, Paris) - Tactical Ultrasound Course for Ukraine (TUSC-UA) Course Director - Mehad, France
| | - Anthony Chauvin
- Service d'Accueil des Urgences/SMUR, CHU Lariboisière, Université de Paris - Inserm U942 MASCOT, Université de Paris, Paris, France
| | - Yann-Erick Claessens
- Département de Médecine d'urgence, Centre Hospitalier Princesse Grace, Avenue Pasteur, MC-98002, Monaco
| | - Bénédicte Douay
- SMUR/Service des Urgences, Hôpital Beaujon, AP-HP Nord, Clichy, France
| | - Xavier Dubucs
- Emergency Departement, Centre Hospitalo-Universitaire de Toulouse, Place du Docteur Baylac, 31300 Toulouse, France
| | - Damien Galanaud
- Service de Neuroradiologie, GH Pitié Salpêtrière, Sorbonne Université, Paris, France
| | - Tobias Gauss
- Department of Anesthesiology and Critical Care, Grenoble Alpes University Hospital, University Grenoble Alpes, F-38000 Grenoble, France
| | - Jean-Yves Gauvrit
- Service de Neuroradiologie, Hôpital Pontchaillou, CHU Rennes, Rennes, France
| | - Thomas Geeraerts
- Pole Anesthesie Réanimation et INSERM Tonic, CHU de Toulouse et Universite Toulouse 3, Toulouse, France
| | - Bertrand Glize
- PMR Department, CHU de Bordeaux, ACTIVE Team, BPH INSERM U1219, University of Bordeaux, France
| | - Sybille Goddet
- Samu-21, CHU de Dijon, SAU-Smur, CH du Creusot, Dijon, France
| | - Anne Godier
- Université Paris Cité, APHP, Hôpital Européen Georges Pompidou, Service d'anesthésie Réanimation and Inserm UMRS_1140, Paris, France
| | - Pierrick Le Borgne
- Emergency Department, University Hospitals of Strasbourg, 1 place de l'hôpital, 67000 Strasbourg, France - INSERM UMR 1260, Regenerative NanoMedicine (RNM), Fédération de Médecine Translationnelle (FMTS), Faculté de Médecine, Université de Strasbourg, 4 rue Kirschleger, 67085 Strasbourg Cedex, France
| | | | - Vincent Sapin
- Service de Biochimie et de Génétique Moléculaire, Centre de Biologie, CHU de Clermont-Ferrand, France
| | - Lionel Velly
- Department of Anaesthesiology and Critical Care Medicine, University Hospital Timone, Aix Marseille University, Marseille, France
| | - Damien Viglino
- University Grenoble-Alpes, Emergency Department, CHU Grenoble-Alpes, Grenoble, France - HP2 Laboratory INSERM U1300, Grenoble, France
| | - Bernard Vigue
- Département d'Anesthésie Réanimation, Hôpital Universitaire de Bicêtre, Le Kremlin Bicêtre, France
| | - Philippe Cuvillon
- EA 2992 IMAGINE, Prévention et Prise en Charge de la Défaillance Circulatoire des Patients en état de Choc, Anaesthesiology Department, CHU Nîmes, University Montpellier, 30000 Nîmes, France
| | - Denis Frasca
- Université de Poitiers, UFR de Médecine-Pharmacie, Poitiers, France, Service d'Anesthésie, Réanimation et Médecine Péri-Opératoire, CHU de Poitiers, France, INSERM U1246, Methods in Patients-Centered Outcomes and Health Research - SPHERE, Nantes, France
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13
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Li T, Zhuang D, Cai S, Ding F, Tian F, Huang M, Li L, Chen W, Li K, Sheng J. Low serum calcium is a novel predictor of unfavorable prognosis after traumatic brain injury. Heliyon 2023; 9:e18475. [PMID: 37576228 PMCID: PMC10412893 DOI: 10.1016/j.heliyon.2023.e18475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 06/21/2023] [Accepted: 07/19/2023] [Indexed: 08/15/2023] Open
Abstract
Background Accurate and convenient serological markers for prognosis after traumatic brain injury (TBI) are still lacking. We aimed to explore the predictive value of serum calcium for prognosing outcomes within 6 months after TBI. Methods In this multicenter retrospective study, 1255 and 719 patients were included in development and validation cohorts, respectively, and their 6-month prognoses were recorded. Serum calcium was measured through routine blood tests within 24 h of hospital admission. Two multivariate predictive models with or without serum calcium for prognosis were developed. Receiver operating characteristics and calibration curves were applied to estimate their performance. Results The patients with lower serum calcium levels had a higher frequency of unfavorable 6-month prognosis than those without. Lower serum calcium level at admission was associated with an unfavorable 6-month prognosis in a wide spectrum of patients with TBI. Lower serum calcium level and our prognostic model including calcium performed well in predicting the 6-month unfavorable outcome. The calcium nomogram maintained excellent performance in discrimination and calibration in the external validation cohort. Conclusions Lower serum calcium level upon admission is an independent risk factor for an unfavorable 6-month prognosis after TBI. Integrating serum calcium into a multivariate predictive model improves the performance for predicting 6-month unfavorable outcomes.
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Affiliation(s)
- Tian Li
- Shantou University Medical College, Department of Microbiology and Immunology & Guangdong Provincial Key Laboratory of Infectious Diseases and Molecular Immunopathology, Shantou, Guangdong, China
| | - Dongzhou Zhuang
- First Affiliated Hospital of Shantou University Medical College, Department of Neurosurgery, Shantou, Guangdong, China
- Fuzong Clinical Medical College of Fujian Medical University, Department of Neurosurgery, Fuzhou, Fujian, China
| | - Shirong Cai
- First Affiliated Hospital of Shantou University Medical College, Department of Neurosurgery, Shantou, Guangdong, China
| | - Faxiu Ding
- First Affiliated Hospital of Shantou University Medical College, Department of Neurosurgery, Shantou, Guangdong, China
| | - Fei Tian
- Second Affiliated Hospital of Shantou University Medical College, Department of Neurosurgery, Shantou, Guangdong, China
| | - Mindong Huang
- Affiliated Jieyang Hospital of Sun Yat-sen University, Department of Neurosurgery, Jieyang, Guangdong, China
| | - Lianjie Li
- Fuzong Clinical Medical College of Fujian Medical University, Department of Neurosurgery, Fuzhou, Fujian, China
| | - Weiqiang Chen
- First Affiliated Hospital of Shantou University Medical College, Department of Neurosurgery, Shantou, Guangdong, China
| | - Kangsheng Li
- Shantou University Medical College, Department of Microbiology and Immunology & Guangdong Provincial Key Laboratory of Infectious Diseases and Molecular Immunopathology, Shantou, Guangdong, China
| | - Jiangtao Sheng
- Shantou University Medical College, Department of Microbiology and Immunology & Guangdong Provincial Key Laboratory of Infectious Diseases and Molecular Immunopathology, Shantou, Guangdong, China
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14
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Wang R, Yang DX, Ding J, Guo Y, Ding WH, Tian HL, Yuan F. Classification, risk factors, and outcomes of patients with progressive hemorrhagic injury after traumatic brain injury. BMC Neurol 2023; 23:68. [PMID: 36782124 PMCID: PMC9926699 DOI: 10.1186/s12883-023-03112-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 02/08/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND According to the pathoanatomic classification system, progressive hemorrhagic injury (PHI) can be categorized into progressive intraparenchymal contusion or hematoma (pIPCH), epidural hematoma (pEDH), subdural hematoma (pSDH), and traumatic subarachnoid hemorrhage (ptSAH). The clinical features of each type differ greatly. The objective of this study was to determine the predictors, clinical management, and outcomes of PHI according to this classification. METHODS Multivariate logistic regression analysis was used to identify independent risk factors for PHI and each subgroup. Patients with IPCH or EDH were selected for subgroup propensity score matching (PSM) to exclude confounding factors before evaluating the association of hematoma progression with the outcomes by classification. RESULTS In the present cohort of 419 patients, 123 (29.4%) demonstrated PHI by serial CT scan. Of them, progressive ICPH (58.5%) was the most common type, followed by pEDH (28.5%), pSDH (9.8%), and ptSAH (3.2%). Old age (≥ 60 years), lower motor Glasgow Coma Scale score, larger primary lesion volume, and higher level of D-dimer were independent risk factors related to PHI. These factors were also independent predictors for pIPCH, but not for pEDH. The time to first CT scan and presence of skull linear fracture were robust risk factors for pEDH. After PSM, the 6-month mortality and unfavorable survival rates were significantly higher in the pIPCH group than the non-pIPCH group (24.2% vs. 1.8% and 12.1% vs. 7.3%, respectively, p < 0.001), but not significantly different between the pEDH group and the non-pEDH group. CONCLUSIONS Understanding the specific patterns of PHI according to its classification can help early recognition and suggest targeted prevention or treatment strategies to improve patients' neurological outcomes.
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Affiliation(s)
- Ren Wang
- grid.16821.3c0000 0004 0368 8293Department of Neurosurgery, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Dian-Xu Yang
- grid.16821.3c0000 0004 0368 8293Department of Neurosurgery, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jun Ding
- grid.16821.3c0000 0004 0368 8293Department of Neurosurgery, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yan Guo
- grid.16821.3c0000 0004 0368 8293Department of Neurosurgery, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Wan-Hai Ding
- grid.16821.3c0000 0004 0368 8293Department of Neurosurgery, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Heng-Li Tian
- Department of Neurosurgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
| | - Fang Yuan
- Department of Neurosurgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
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15
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Salasky VR, Chang WTW. Neurotrauma Update. Emerg Med Clin North Am 2023; 41:19-33. [DOI: 10.1016/j.emc.2022.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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16
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Tranexamic acid for traumatic brain injury. Am J Emerg Med 2023; 63:151. [PMID: 36153260 DOI: 10.1016/j.ajem.2022.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 09/14/2022] [Indexed: 12/13/2022] Open
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17
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Fletcher-Sandersjöö A, Tatter C, Tjerkaski J, Bartek J, Maegele M, Nelson DW, Svensson M, Thelin EP, Bellander BM. Time Course and Clinical Significance of Hematoma Expansion in Moderate-to-Severe Traumatic Brain Injury: An Observational Cohort Study. Neurocrit Care 2023; 38:60-70. [PMID: 36167951 PMCID: PMC9935722 DOI: 10.1007/s12028-022-01609-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 09/09/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Preventing intracranial hematoma expansion has been advertised as a possible treatment opportunity in traumatic brain injury (TBI). However, the time course of hematoma expansion, and whether the expansion affects outcome, remains poorly understood. In light of this, the aim of this study was to use 3D volume rendering to determine how traumatic intracranial hematomas expand over time and evaluate its impact on outcome. METHODS Single-center, population-based, observational cohort study of adults with moderate-to-severe TBI. Hematoma expansion was defined as the change in hematoma volume from the baseline computed tomography scan until the lesion had stopped progressing. Volumes were calculated by using semiautomated volumetric segmentation. Functional outcome was measured by using the 12 month Glasgow outcome scale (GOS). RESULTS In total, 643 patients were included. The mean baseline hematoma volume was 4.2 ml, and the subsequent mean hematoma expansion was 3.8 ml. Overall, 33% of hematomas had stopped progressing within 3 h, and 94% of hematomas had stopped progressing within 24 h of injury. Contusions expanded significantly more, and for a longer period of time, than extra-axial hematomas. There was a significant dose-response relationship between hematoma expansion and 12 month GOS, even after adjusting for known outcome predictors, with every 1-ml increase in hematoma volume associated with a 6% increased risk of 1-point GOS deduction. CONCLUSIONS Hematoma expansion is a driver of unfavorable outcome in TBI, with small changes in hematoma volume also impacting functional outcome. This study also proposes a wider window of opportunity to prevent lesion progression than what has previously been suggested.
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Affiliation(s)
- Alexander Fletcher-Sandersjöö
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden. .,Department of Clinical Neuroscience, Karolinska Institutet, Bioclinicum J5:20, 171 64 , Solna, Stockholm, Sweden.
| | - Charles Tatter
- grid.24381.3c0000 0000 9241 5705Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden ,grid.4714.60000 0004 1937 0626Department of Clinical Neuroscience, Karolinska Institutet, Bioclinicum J5:20, 171 64 Solna, Stockholm, Sweden
| | - Jonathan Tjerkaski
- grid.4714.60000 0004 1937 0626Department of Clinical Neuroscience, Karolinska Institutet, Bioclinicum J5:20, 171 64 Solna, Stockholm, Sweden
| | - Jiri Bartek
- grid.24381.3c0000 0000 9241 5705Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden ,grid.4714.60000 0004 1937 0626Department of Clinical Neuroscience, Karolinska Institutet, Bioclinicum J5:20, 171 64 Solna, Stockholm, Sweden ,grid.475435.4Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
| | - Marc Maegele
- grid.412581.b0000 0000 9024 6397Department for Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center, Witten/Herdecke University, Cologne, Germany ,grid.412581.b0000 0000 9024 6397Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
| | - David W. Nelson
- grid.4714.60000 0004 1937 0626Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden ,grid.24381.3c0000 0000 9241 5705Function Perioperative Care and Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Mikael Svensson
- grid.24381.3c0000 0000 9241 5705Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden ,grid.4714.60000 0004 1937 0626Department of Clinical Neuroscience, Karolinska Institutet, Bioclinicum J5:20, 171 64 Solna, Stockholm, Sweden
| | - Eric Peter Thelin
- grid.4714.60000 0004 1937 0626Department of Clinical Neuroscience, Karolinska Institutet, Bioclinicum J5:20, 171 64 Solna, Stockholm, Sweden ,grid.24381.3c0000 0000 9241 5705Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Bo-Michael Bellander
- grid.24381.3c0000 0000 9241 5705Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden ,grid.4714.60000 0004 1937 0626Department of Clinical Neuroscience, Karolinska Institutet, Bioclinicum J5:20, 171 64 Solna, Stockholm, Sweden
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18
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Fadzil F, Mei AKC, Mohd Khairy A, Kumar R, Mohd Azli AN. Value of Repeat CT Brain in Mild Traumatic Brain Injury Patients with High Risk of Intracerebral Hemorrhage Progression. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:14311. [PMID: 36361190 PMCID: PMC9658041 DOI: 10.3390/ijerph192114311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 10/11/2022] [Accepted: 10/21/2022] [Indexed: 06/16/2023]
Abstract
UNLABELLED Patients with mild traumatic brain injury (MTBI) with intracerebral hemorrhage (ICH), particularly those at higher risk of having ICH progression, are typically prescribed a second head Computer Tomography (CT) scan to monitor the disease development. This study aimed to evaluate the role of a repeat head CT in MTBI patients at a higher risk of ICH progression by comparing the intervention rate between patients with and without ICH progression. METHODS 192 patients with MTBI and ICH were treated between November 2019 to December 2020 at a single level II trauma center. The Glasgow Coma Scale (GCS) was used to classify MTBI, and initial head CT was performed according to the Canadian CT head rule. Patients with a higher risk of ICH progression, including the elderly (≥65 years old), patients on antiplatelets or anticoagulants, or patients with an initial head CT that revealed EDH, contusional bleeding, or SDH > 5 mm, and multiple ICH underwent a repeat head CT within 12 to 24 h later. Data regarding types of intervention, length of stay in the hospital, and outcome were collected. The risk of further neurological deterioration and readmission rates were compared between these two groups. All patients were followed up in the clinic after one month or contacted via phone if they did not return. RESULTS 189 patients underwent scheduled repeated head CT, 18% had radiological intracranial bleed progression, and 82% had no changes. There were no statistically significant differences in terms of intervention rate, risk of neurological deterioration in the future, or readmission between them. CONCLUSION Repeat head CT in mild TBI patients with no neurological deterioration is not recommended, even in patients with a higher risk of ICH progression.
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Affiliation(s)
- Farizal Fadzil
- Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur 56000, Malaysia
| | - Amy Khor Cheng Mei
- Department of Surgery, Hospital Tengku Ampuan Rahimah, Klang 41200, Selangor, Malaysia
| | - Azudin Mohd Khairy
- Department of Surgery, Hospital Tengku Ampuan Rahimah, Klang 41200, Selangor, Malaysia
| | - Ramesh Kumar
- Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur 56000, Malaysia
| | - Anis Nabillah Mohd Azli
- Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur 56000, Malaysia
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19
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Bryant P, Yengo-Kahn A, Smith C, Smith M, Guillamondegui O. Decision Support Tool to Judiciously Assign High-Frequency Neurologic Examinations in Traumatic Brain Injury. J Surg Res 2022; 280:557-566. [PMID: 36096021 DOI: 10.1016/j.jss.2022.07.045] [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: 02/25/2022] [Revised: 07/11/2022] [Accepted: 07/14/2022] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Traumatic brain injury (TBI) management includes serial neurologic examinations to assess for changes dictating neurosurgical interventions. We hypothesized hourly examinations are overassigned. We conducted a decision tree analysis to determine an algorithm to judiciously assign hourly examinations. METHODS A retrospective cohort study of 1022 patients with TBI admitted to a Level 1 trauma center from January 1, 2019, to December 31, 2019, was conducted. Patients with penetrating TBI or immediate or planned interventions and those with nonsurvivable injuries were excluded. Patients were stratified by whether they underwent an unplanned intervention (e.g., craniotomy or invasive intracranial monitoring). Univariate analysis identified factors for inclusion in chi-square automatic interaction detection technique, classifying those at risk for unplanned procedures. RESULTS A total of 830 patients were included, 287 (35%) were assigned hourly (Q1) examinations, and 17 (2%) had unplanned procedures, with 16 of 17 (94%) on Q1 examinations. Patients requiring unplanned procedures were more likely to have mixed intracranial hemorrhage pattern (82% versus 39%; P = 0.001), midline shift (35% versus 14%; P = 0.023), an initial poor neurologic examination (Glasgow Comas Scale ≤8, 77% versus 14%; P < 0.001), and be intubated (88% versus 17%; P < 0.001). Using chi-square automatic interaction detection, the decision tree demonstrated low-risk (2% misclassification) and excellent discrimination (area under the curve = 0.915, 95% confidence interval 0.844-0.986; P < 0.001) of patients at risk of an unplanned procedure. By following the algorithm, 167 fewer patients could have been assigned Q1 examinations, resulting in an estimated 6012 fewer examinations. CONCLUSIONS Using a 4-factor algorithm can optimize the assignment of neuro examinations and substantially reduce neuro examination burden without sacrificing patient safety.
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Affiliation(s)
- Peter Bryant
- Division of Trauma And Surgical Critical Care, Vanderbilt University Medical Center Nashville, Tennessee.
| | - Aaron Yengo-Kahn
- Department of Neurosurgery, Vanderbilt University Medical Center Nashville, Tennessee
| | - Candice Smith
- Division of Trauma And Surgical Critical Care, Vanderbilt University Medical Center Nashville, Tennessee
| | - Melissa Smith
- Division of Trauma And Surgical Critical Care, Vanderbilt University Medical Center Nashville, Tennessee
| | - Oscar Guillamondegui
- Division of Trauma And Surgical Critical Care, Vanderbilt University Medical Center Nashville, Tennessee
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Jakowenko ND, Kopp BJ, Erstad BL. Appraising the use of tranexamic acid in traumatic and non‐traumatic intracranial hemorrhage: A narrative review. J Am Coll Emerg Physicians Open 2022; 3:e12777. [PMID: 35859856 PMCID: PMC9286528 DOI: 10.1002/emp2.12777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/06/2022] [Accepted: 06/16/2022] [Indexed: 11/17/2022] Open
Abstract
Recently there has been increasing interest and debate on the use of tranexamic acid (TXA), an antifibrinolytic drug, in both traumatic and non‐traumatic intracranial hemorrhage. In this review we aim to discuss recent investigations looking at TXA in traumatic brain injury (TBI) and different categories of spontaneous intracranial hemorrhage. We also discuss differences between setting (hospital vs pre‐hospital), dosing and timing strategies, and other logistical challenges surrounding optimal use of TXA for isolated intracranial hemorrhage. Last, we hope to provide guidance for clinicians when considering the use of TXA in a patient with traumatic or non‐traumatic intracranial hemorrhage based on appraisal of the available literature as well as some potential ideas for future research in this area.
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Affiliation(s)
| | - Brian J. Kopp
- Department of Pharmacy Banner University Medical Center–Tucson Tucson Arizona USA
| | - Brian L. Erstad
- Department of Pharmacy Practice and Science University of Arizona College of Pharmacy Tucson Arizona USA
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21
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Application of a TEG-Platelet Mapping Algorithm to Guide Reversal of Antiplatelet Agents in Adults with Mild-to-Moderate Traumatic Brain Injury: An Observational Pilot Study. Neurocrit Care 2022; 37:638-648. [PMID: 35705826 DOI: 10.1007/s12028-022-01535-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 05/13/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Traumatic intracranial hemorrhages expand in one third of cases, and antiplatelet medications may exacerbate hematoma expansion. However, the reversal of an antiplatelet effect with platelet transfusion has been associated with harm. We sought to determine whether a thromboelastography platelet mapping (TEG-PM)-guided algorithm could limit platelet transfusion in patients with hemorrhagic traumatic brain injury (TBI) prescribed antiplatelet medications without a resultant clinically significant increase in hemorrhage volume, late hemostatic treatments, or delayed operative intervention. METHODS A total of 175 consecutive patients with TBI were admitted to our university-affiliated, level I trauma center between March 2016 and December 2019: 54 preintervention patients (control) and 121 patients with TEG-PM (study). After exclusion for anticoagulant administration, availability of neuroimaging and emergent neurosurgery, 62 study patients and 37 control patients remained. Intervention consisted of administration of desmopressin (DDAVP) for nonsurgical patients with significant inhibition at the arachidonic acid or adenosine diphosphate receptor sites. For surgical patients with significant inhibition, dual therapy with DDAVP and platelet transfusion was employed. Study patients were compared with a group of historical controls, which were identified from a prospectively maintained registry and typically treated with empiric platelet transfusion. RESULTS Median age was 75 years (interquartile range 85-67) and 77 years (interquartile range 81-65) in the TEG-PM and control patient groups, respectively. Admission hemorrhage volumes were similar (10.7 cm3 [20.1] in patients with TEG-PM vs. 14.1 cm3 [19.7] in controls; p = 0.41). There were no significant differences in admission Glasgow Coma Scale, mechanism of trauma, or baseline comorbidities. A total of 57% of controls versus 10% of patients with TEG-PM (p < 0.001) were transfused platelets; 52% of intervention patients and 0% controls were treated with DDAVP. Expansion hemorrhage volumes were not significantly different (14.0 cm3 [20.2] patients with TEG-PM versus 13.6 cm3 [23.7] controls; p = 0.93). There was no significant difference in rates of clinical deterioration, delayed neurosurgical intervention, or late platelet transfusion between groups. CONCLUSIONS Among patients with hemorrhagic TBI prescribed preinjury antiplatelet therapy, our study suggests that the use of a TEG-PM algorithm may reduce platelet transfusions without a concurrent increase in clinically significant hematoma expansion. Further study is required to prove a causative relationship.
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Yang Q, Sun J, Guo Y, Zeng P, Jin K, Huang C, Xu J, Hou L, Li C, Feng J. Radiomics Features on Computed Tomography Combined With Clinical-Radiological Factors Predicting Progressive Hemorrhage of Cerebral Contusion. Front Neurol 2022; 13:839784. [PMID: 35775053 PMCID: PMC9237337 DOI: 10.3389/fneur.2022.839784] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 04/29/2022] [Indexed: 01/02/2023] Open
Abstract
Background Traumatic brain injury (TBI) is the main cause of death and severe disability in young adults worldwide. Progressive hemorrhage (PH) worsens the disease and can cause a poor neurological prognosis. Radiomics analysis has been used for hematoma expansion of hypertensive intracerebral hemorrhage. This study attempts to develop an optimal radiomics model based on non-contrast CT to predict PH by machine learning (ML) methods and compare its prediction performance with clinical-radiological models. Methods We retrospectively analyzed 165 TBI patients, including 89 patients with PH and 76 patients without PH, whose data were randomized into a training set and a testing set at a ratio of 7:3. A total of 10 different machine learning methods were used to predict PH. Univariate and multivariable logistic regression analyses were implemented to screen clinical-radiological factors and to establish a clinical-radiological model. Then, a combined model combining clinical-radiological factors with the radiomics score was constructed. The area under the receiver operating characteristic curve (AUC), accuracy and F1 score, sensitivity, and specificity were used to evaluate the models. Results Among the 10 various ML algorithms, the support vector machine (SVM) had the best prediction performance based on 12 radiomics features, including the AUC (training set: 0.918; testing set: 0.879) and accuracy (training set: 0.872; test set: 0.834). Among the clinical and radiological factors, the onset-to-baseline CT time, the scalp hematoma, and fibrinogen were associated with PH. The radiomics model's prediction performance was better than the clinical-radiological model, while the predictive nomogram combining the radiomics features with clinical-radiological characteristics performed best. Conclusions The radiomics model outperformed the traditional clinical-radiological model in predicting PH. The nomogram model of the combined radiomics features and clinical-radiological factors is a helpful tool for PH.
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Affiliation(s)
- Qingning Yang
- Department of Radiology, Chongqing University Central Hospital, Chongqing, China
| | - Jun Sun
- Department of Radiology, Chongqing University Central Hospital, Chongqing, China
| | - Yi Guo
- Department of Radiology, Chongqing University Central Hospital, Chongqing, China
- *Correspondence: Yi Guo
| | - Ping Zeng
- Department of Radiology, Chongqing University Central Hospital, Chongqing, China
- Ping Zeng
| | - Ke Jin
- Department of Research Collaboration, R&D Center, Beijing Deepwise & League of PHD Technology Co., Beijing, China
| | - Chencui Huang
- Department of Research Collaboration, R&D Center, Beijing Deepwise & League of PHD Technology Co., Beijing, China
| | - Jingxu Xu
- Department of Research Collaboration, R&D Center, Beijing Deepwise & League of PHD Technology Co., Beijing, China
| | - Liran Hou
- Department of Radiology, Panjiang Central Hospital, Guizhou, China
| | - Chuanming Li
- Department of Radiology, Chongqing University Central Hospital, Chongqing, China
| | - Junbang Feng
- Department of Radiology, Chongqing University Central Hospital, Chongqing, China
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Lara-Reyna J, Alali L, Wedderburn R, Margetis K. Compliance with venous thromboembolism chemoprophylaxis guidelines in non-operative traumatic brain injury. Clin Neurol Neurosurg 2022; 215:107212. [DOI: 10.1016/j.clineuro.2022.107212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/08/2022] [Accepted: 03/12/2022] [Indexed: 11/03/2022]
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Kalra S, Banderwal R, Arora K, Kumar S, Singh G, Chawla PA, Behl T, Sehgal A, Singh S, Bhatia S, Al-Harrasi A, Aleya L, Dhiman A. An update on pathophysiology and treatment of sports-mediated brain injury. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2022; 29:16786-16798. [PMID: 34994929 DOI: 10.1007/s11356-021-18391-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 12/24/2021] [Indexed: 06/14/2023]
Abstract
Traumatic brain injury (TBI) is a neurological disorder which represents a major health issue worldwide. It causes mortality and disability among all group ages, caused by external force, sports-related events or violence and road traffic accidents. In the USA, approximately one-third people die annually due to injury and 1.7 million people suffer from traumatic brain injury. Every year in India around 1.6 million individuals suffer from sustain brain injury with 200,000 deaths and approximately one million person needed recovery treatment at any stage of time. Sports-related head impact and trauma has become an extremely controversial public health and medico-legal problem that accounts for 20% of all brain injury (including concussion). It is difficult to reverse the primary injury but the secondary injury can be minimized by using proper pharmacological intervention during the initial hours of injury. This article highlights the pathophysiology and types of TBI along with treatment therapies. Till date, there is no single medication that can decrease the progression of the disease so that symptomatic treatment is given to the patient by determining proper pathology. Recently various herbal medicine therapies and traditional supplements have been developed for TBI. Nutritional supplementation and nutraceuticals have exposed potential in the treatment of TBI when used before and after TBI. The compiled data will enable the readers to know the pathophysiology as well as the allopathic and natural remedies to treat the TBI.
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Affiliation(s)
- Sunishtha Kalra
- Department of Pharmaceutical Sciences, Maharshi Dayanand University, Rohtak, Haryana, India
| | - Rittu Banderwal
- Department of Pharmaceutical Sciences, Maharshi Dayanand University, Rohtak, Haryana, India
| | - Kaushal Arora
- Department of Pharmaceutical Sciences, Maharshi Dayanand University, Rohtak, Haryana, India
| | - Sandeep Kumar
- Department of Pharmaceutical Sciences, Maharshi Dayanand University, Rohtak, Haryana, India
| | - Govind Singh
- Department of Pharmaceutical Sciences, Maharshi Dayanand University, Rohtak, Haryana, India
| | - Pooja A Chawla
- Department of Pharmaceutical Chemistry and Analysis, ISF College of Pharmacy Moga, Punjab, India
| | - Tapan Behl
- Chitkara College of Pharmacy, Chitkara University, Punjab, India.
| | - Aayush Sehgal
- Chitkara College of Pharmacy, Chitkara University, Punjab, India
| | - Sukhbir Singh
- Chitkara College of Pharmacy, Chitkara University, Punjab, India
| | - Saurabh Bhatia
- School of Health Science, University of Petroleum and Energy Studies, Dehradun, Uttarakhand, India
- Natural & Medical Sciences Research Centre, University of Nizwa, Birkat Al Mauz, Nizwa, Oman
| | - Ahmed Al-Harrasi
- Natural & Medical Sciences Research Centre, University of Nizwa, Birkat Al Mauz, Nizwa, Oman
| | - Lotfi Aleya
- Chrono-Environment Laboratory, UMR CNRS 6249, Bourgogne Franche-Comté University, Besançon, France
| | - Anju Dhiman
- Department of Pharmaceutical Sciences, Maharshi Dayanand University, Rohtak, Haryana, India.
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Sheng J, Chen W, Zhuang D, Li T, Yang J, Cai S, Chen X, Liu X, Tian F, Huang M, Li L, Li K. A Clinical Predictive Nomogram for Traumatic Brain Parenchyma Hematoma Progression. Neurol Ther 2022; 11:185-203. [PMID: 34855160 PMCID: PMC8857351 DOI: 10.1007/s40120-021-00306-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 11/22/2021] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Acute traumatic intraparenchymal hematoma (tICH) expansion is a major cause of clinical deterioration after brain contusion. Here, an accurate prediction tool for acute tICH expansion is proposed. METHODS A multicenter hospital-based study for multivariable prediction model was conducted among patients (889 patients in a development dataset and 264 individuals in an external validation dataset) with initial and follow-up computed tomography (CT) imaging for tICH volume evaluation. Semi-automated software was employed to assess tICH expansion. Two multivariate predictive models for acute tICH expansion were developed and externally validated. RESULTS A total of 198 (22.27%) individuals had remarkable acute tICH expansion. The novel Traumatic Parenchymatous Hematoma Expansion Aid (TPHEA) model retained several variables, including age, coagulopathy, baseline tICH volume, time to baseline CT time, subdural hemorrhage, a novel imaging marker of multihematoma fuzzy sign, and an inflammatory index of monocyte-to-lymphocyte ratio. Compared with multihematoma fuzzy sign, monocyte-to-lymphocyte ratio, and the basic model, the TPHEA model exhibited optimal discrimination, calibration, and clinical net benefits for patients with acute tICH expansion. A TPHEA nomogram was subsequently introduced from this model to facilitate clinical application. In an external dataset, this device showed good predicting performance for acute tICH expansion. CONCLUSIONS The main predictive factors in the TPHEA nomogram are the monocyte-to-lymphocyte ratio, baseline tICH volume, and multihematoma fuzzy sign. This user-friendly tool can estimate acute tICH expansion and optimize personalized treatments for individuals with brain contusion.
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Affiliation(s)
- Jiangtao Sheng
- Department of Microbiology and Immunology, Guangdong Provincial Key Laboratory of Infectious Disease and Molecular Immunopathology, Shantou University Medical College, 22 Xinling Road, Shantou, 515041, Guangdong, Chin
| | - Weiqiang Chen
- Department of Neurosurgery, First Affiliated Hospital of Shantou University Medical College, 57 Changping Road, Shantou, 515041, Guangdong, China
| | - Dongzhou Zhuang
- Department of Neurosurgery, First Affiliated Hospital of Shantou University Medical College, 57 Changping Road, Shantou, 515041, Guangdong, China
| | - Tian Li
- Department of Microbiology and Immunology, Guangdong Provincial Key Laboratory of Infectious Disease and Molecular Immunopathology, Shantou University Medical College, 22 Xinling Road, Shantou, 515041, Guangdong, China
| | - Jinhua Yang
- Department of Neurosurgery, First Affiliated Hospital of Shantou University Medical College, 57 Changping Road, Shantou, 515041, Guangdong, China
| | - Shirong Cai
- Department of Neurosurgery, First Affiliated Hospital of Shantou University Medical College, 57 Changping Road, Shantou, 515041, Guangdong, China
| | - Xiaoxuan Chen
- Department of Microbiology and Immunology, Guangdong Provincial Key Laboratory of Infectious Disease and Molecular Immunopathology, Shantou University Medical College, 22 Xinling Road, Shantou, 515041, Guangdong, China
| | - Xueer Liu
- Department of Microbiology and Immunology, Guangdong Provincial Key Laboratory of Infectious Disease and Molecular Immunopathology, Shantou University Medical College, 22 Xinling Road, Shantou, 515041, Guangdong, China
| | - Fei Tian
- Department of Neurosurgery, Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Mindong Huang
- Department of Neurosurgery, Affiliated Jieyang Hospital of Sun Yat-Sen University, Jieyang, Guangdong, China
| | - Lianjie Li
- Department of Neurosurgery, Affiliated East Hospital of Xiamen University Medical College, Fuzhou, Fujian, China
| | - Kangsheng Li
- Department of Microbiology and Immunology, Guangdong Provincial Key Laboratory of Infectious Disease and Molecular Immunopathology, Shantou University Medical College, 22 Xinling Road, Shantou, 515041, Guangdong, China
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Singh A, Trivedi R, Ahmed N. Therapeutic Strategies in Traumatic Intracranial Hemorrhage and Outcomes. J Neurol Surg A Cent Eur Neurosurg 2022; 84:377-385. [PMID: 35158390 DOI: 10.1055/s-0041-1741530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Traumatic intracranial hemorrhage (TICH) and its progression have historically resulted in poor prognosis and functional disability. Such outcomes can impact the daily lives and financial condition of patients' families as well as add burden to the health care system. This review examines the diverse therapeutic intervention that were observed in randomized clinical trials (RCT) on various outcomes. Many demographic and clinical risk factors have been identified for poor prognosis after a TICH. Among the many therapeutic strategies studied, few found to have some beneficial effect in minimizing the progression of hemorrhage and reducing the overall mortality. METHODS A literature review was conducted of all relevant sources using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to include articles that were RCTs for patients aged 18 years and above to include a total of 19 articles. RESULTS Across studies, many therapies have been assessed; however, only few findings including infusion of tranexamic acid (TXA), use of β-blocker, and early operative evacuation of TICH yielded favorable results. Use of steroid and blood transfusion to target higher hemoglobin levels showed evidence of adversely impacting the outcome. CONCLUSION Of the many therapeutic strategies available for TICH, very few therapies have proven to be beneficial.
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Affiliation(s)
- Amanjung Singh
- Division of Trauma, Jersey Shore University Medical Center, Neptune, New Jersey, United States
| | - Radhika Trivedi
- Division of Trauma, Jersey Shore University Medical Center, Neptune, New Jersey, United States
| | - Nasim Ahmed
- Division of Trauma and Surgical Critical Care, Jersey Shore University Medical Center, Neptune, New Jersey, United States.,Hackensack Meridian School of Medicine, Nutley, New Jersey, United States
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Barton CA, Oetken HJ, Hall NL, Webb AJ, Hoops HE, Schreiber M. Incidence of traumatic intracranial hemorrhage expansion after stable repeat head imaging: A retrospective cohort study. Am J Surg 2022; 224:775-779. [DOI: 10.1016/j.amjsurg.2022.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 12/31/2021] [Accepted: 01/30/2022] [Indexed: 11/01/2022]
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Abedzadeh-Kalahroudi M, Fakharian E, Atoof F, Nooranipour V, Azadbakht J. The impact of tranexamic acid on brain contusion and intraparenchymal hemorrhage in patients with head injury. ARCHIVES OF TRAUMA RESEARCH 2022. [DOI: 10.4103/atr.atr_43_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Yu S, Choi HJ, Kim BC, Ha M, Kim K, Lee JH. Prognosis Prediction in Severe Traumatic Brain Injury According to Initial Time of Brain Computed Tomography Scan Using the Rotterdam Scoring System. Korean J Neurotrauma 2022; 18:161-168. [PMID: 36381467 PMCID: PMC9634299 DOI: 10.13004/kjnt.2022.18.e53] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 08/27/2022] [Accepted: 09/07/2022] [Indexed: 11/07/2022] Open
Abstract
Objective The Rotterdam scoring system (RSS) is useful for prognosis prediction in patients with severe traumatic brain injury (sTBI). It comprises basal cistern, midline shifting (MLS), epidural hematoma (EDH), and subarachnoid hemorrhage (SAH)/intraventricular hemorrhage (IVH) status. Brain computed tomography (CT) is important to assessing patients with sTBI; however, results often change over time. We aimed to determine whether RSS outcome prediction differs by initial brain CT scan time after the trauma in patients with sTBI. Methods We used data from the second Korea Neurotrauma Data Bank, and analyzed 455 patients; RSS, Glasgow Outcome Scale Extended (GOSE) on 6-months, and the CT scan time were obtained. Unfavorable outcomes were defined as a GOSE score of 1–4. Participants were divided into 2 groups according to when brain CT scan was performed (> or ≤ 2 hours after trauma). The relationship between the prognosis of patients with sTBI and RSS score was examined by calculating the odds ratios. Univariate and multivariate analyses were performed. Results In both univariate and multivariate analysis, the total RSS and basal cistern status were statistically correlated with prognosis in both groups. EDH and SAH/IVH showed statistically significant difference according to CT scan time. MLS was associated with prognosis in both groups in univariate analysis although not in multivariate analysis. Conclusion The total RSS score predicted prognosis 6 months after trauma in patients with sTBI, regardless of CT scan time. However, the prognostic predictive power of each item constituting the RSS varied according to CT scan time.
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Affiliation(s)
- Seunghan Yu
- Department of Neurosurgery, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Hyuk Jin Choi
- Department of Neurosurgery, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Byung Chul Kim
- Department of Neurosurgery, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Mahnjeong Ha
- Department of Neurosurgery, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Kyungbin Kim
- Department of Pathology, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Jung Hwan Lee
- Department of Neurosurgery, Medical Research Institute, Pusan National University Hospital, Busan, Korea
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Zhu Y, Jin X, Xu L, Han P, Lin S, Lu Z. Establishment and validation of prognosis model for patients with cerebral contusion. BMC Neurol 2021; 21:463. [PMID: 34844563 PMCID: PMC8628400 DOI: 10.1186/s12883-021-02482-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 11/03/2021] [Indexed: 11/10/2022] Open
Abstract
Background And Objective Cerebral Contusion (CC) is one of the most serious injury types in patients with traumatic brain injury (TBI). In this study, the baseline data, imaging features and laboratory examinations of patients with CC were summarized and analyzed to develop and validate a prediction model of nomogram to evaluate the clinical outcomes of patients. Methods A total of 426 patients with cerebral contusion (CC) admitted to the People’s Hospital of Qinghai Province and Affiliated Hospital of Qingdao University from January 2018 to January 2021 were included in this study, We randomly divided the cohort into a training cohort (n = 284) and a validation cohort (n = 142) with a ratio of 2:1.At Least absolute shrinkage and selection operator (Lasso) regression were used for screening high-risk factors affecting patient prognosis and development of the predictive model. The identification ability and clinical application value of the prediction model were analyzed through the analysis of receiver operating characteristic curve (ROC), calibration curve, and decision curve analysis (DCA). Results Twelve independent prognostic factors, including age, Glasgow Coma Score (GCS), Basal cistern status, Midline shift (MLS), Third ventricle status, intracranial pressure (ICP) and CT grade of cerebral edema,etc., were selected by Lasso regression analysis and included in the nomogram. The model showed good predictive performance, with a C index of (0.87, 95% CI, 0.026–0.952) in the training cohort and (0.93, 95% CI, 0.032–0.965) in the validation cohort. Clinical decision curve analysis (DCA) also showed that the model brought high clinical benefits to patients. Conclusion This study established a high accuracy of nomogram model to predict the prognosis of patients with CC, its low cost, easy to promote, is especially applicable in the acute environment, at the same time, CSF-glucose/lactate ratio(C-G/L), volume of contusion, and mean CT values of edema zone, which were included for the first time in this study, were independent predictors of poor prognosis in patients with CC. However, this model still has some limitations and deficiencies, which require large sample and multi-center prospective studies to verify and improve our results. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-021-02482-4.
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Affiliation(s)
- Yufeng Zhu
- Department of Graduate School, Qinghai University, Xining, 810016, Qinghai, China
| | - Xiaoqing Jin
- Department of Neurosurgery, Qinghai Provincial People's Hospital, Xining, 810007, Qinghai, China
| | - Lulu Xu
- Department of Geriatric Medicine, the Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Pei Han
- Department of Neurosurgery, Qinghai Provincial People's Hospital, Xining, 810007, Qinghai, China
| | - Shengwu Lin
- Department of Graduate School, Qinghai University, Xining, 810016, Qinghai, China
| | - Zhongsheng Lu
- Department of Neurosurgery, Qinghai Provincial People's Hospital, Xining, 810007, Qinghai, China.
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van Wessem KJP, Jochems D, Leenen LPH. The effect of prehospital tranexamic acid on outcome in polytrauma patients with associated severe brain injury. Eur J Trauma Emerg Surg 2021; 48:1589-1599. [PMID: 34775510 PMCID: PMC8590807 DOI: 10.1007/s00068-021-01827-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 11/01/2021] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Tranexamic acid (TXA) has shown to be beneficial in selected patients with hemorrhagic shock. Recently, TXA has gained interest in isolated traumatic brain injury (TBI) patients with variable results. There are limited data on TXA in polytrauma with associated TBI. This study investigated the role of TXA in severely injured patients with associated severe TBI. METHODS A 7.5-year prospective cohort study was performed to investigate the relation between prehospital TXA and mortality in consecutive trauma patients with associated severe TBI (Abbreviated Injury Scale (AIS)head ≥ 3) admitted to a Level-1 Trauma Center ICU. Indication for prehospital TXA administration was (suspicion of) hemorrhagic shock, and/or systolic blood pressure (SBP) ≤ 90 mmHg. Demographics, data on physiology, resuscitation, and outcomes were prospectively collected. RESULTS Two hundred thirty-four patients (67% males) with median age of 49 years and ISS 33 (98% blunt injuries) were included. Thirteen patients (6%) developed thromboembolic complications; mortality rate was 24%. Fifty-one percent of patients received prehospital TXA. TXA patients were younger, had more deranged physiology on arrival, and received more crystalloids and blood products ≤ 24 h. There was, however, no difference in overall outcome between TXA patients and no-TXA patients. CONCLUSIONS Despite having a more deranged physiology TXA patients had similar outcome compared to no-TXA patients who were much older. Thromboembolic complication rate was low. Prehospital tranexamic acid has no evident effect on outcome in polytrauma patients with associated critical brain injury.
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Affiliation(s)
- Karlijn J. P. van Wessem
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Denise Jochems
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Luke P. H. Leenen
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
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Abstract
PURPOSE OF REVIEW Traumatic brain injury (TBI) encompasses a group of heterogeneous manifestations of a disease process with high neurologic morbidity and, for severe TBI, high probability of mortality and poor neurologic outcomes. This article reviews TBI in neurocritical care, hence focusing on moderate and severe TBI, and includes an up-to-date review of the many variables to be considered in clinical care. RECENT FINDINGS With advances in medicine and biotechnology, understanding of the impact of TBI has substantially elucidated the distinction between primary and secondary brain injury. Consequently, care of TBI is evolving, with intervention-based modalities targeting multiple physiologic variables. Multimodality monitoring to assess intracranial pressure, cerebral oxygenation, cerebral metabolism, cerebral blood flow, and autoregulation is at the forefront of such advances. SUMMARY Understanding the anatomic and physiologic principles of acute brain injury is necessary in managing moderate to severe TBI. Management is based on the prevention of secondary brain injury from resultant trauma. Care of patients with TBI should occur in a dedicated critical care unit with subspecialty expertise. With the advent of multimodality monitoring and targeted biomarkers in TBI, patient outcomes have a higher probability of improving in the future.
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Jha RM, Zusman BE, Puccio AM, Okonkwo DO, Pease M, Desai SM, Leach M, Conley YP, Kochanek PM. Genetic Variants Associated With Intraparenchymal Hemorrhage Progression After Traumatic Brain Injury. JAMA Netw Open 2021; 4:e2116839. [PMID: 34309670 PMCID: PMC8314141 DOI: 10.1001/jamanetworkopen.2021.16839] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE Intracerebral hemorrhage progression is associated with unfavorable outcome after traumatic brain injury (TBI). No effective treatments are currently available. This secondary injury process reflects an extreme form of vasogenic edema and blood-brain barrier breakdown. The sulfonylurea receptor 1-transient receptor potential melastatin 4 (SUR1-TRPM4) cation channel is a key underlying mechanism. A phase 2 trial of SUR1-TRPM4 inhibition in contusional TBI is ongoing, and a phase 3 trial is being designed. Targeted identification of patients at increased risk for hemorrhage progression may inform prognostication, trial design (including patient selection), and ultimately treatment response. OBJECTIVE To determine whether ABCC8 (SUR1) and TRPM4 genetic variability are associated with intraparenchymal hemorrhage (IPH) progression after severe TBI, based on the putative involvement of the SUR1-TRPM4 channel in this pathophysiology. DESIGN, SETTING, AND PARTICIPANTS In this genetic association study, DNA was extracted from 416 patients with severe TBI prospectively enrolled from a level I trauma academic medical center from May 9, 2002, to August 8, 2014. Forty ABCC8 and TRPM4 single-nucleotide variants (SNVs) were genotyped (multiplex, unbiased). Data were analyzed from January 7, 2020, to May 3, 2021. MAIN OUTCOMES AND MEASURES Primary analyses addressed IPH progression at 6, 24, and 120 hours in patients without acute craniectomy (n = 321). Multivariable regressions and receiver operating characteristic curves assessed SNV and haplotype associations with progression. Spatial modeling and functional predictions were determined using standard software. RESULTS Of the 321 patients included in the analysis (mean [SD] age, 37.0 [16.3] years; 247 [76.9%] male), IPH progression occurred in 102. Four ABCC8 SNVs were associated with markedly increased odds of progression (rs2237982 [odds ratio (OR), 2.60-3.80; 95% CI, 1.14-5.90 to 1.80-8.02; P = .02 to P < .001], rs2283261 [OR, 3.37-4.77; 95% CI, 1.07-10.77 to 1.89-12.07; P = .04 to P = .001], rs3819521 [OR, 2.96-3.92; 95% CI, 1.13-7.75 to 1.42-10.87; P = .03 to P = .009], and rs8192695 [OR, 3.06-4.95; 95% CI, 1.02-9.12 to 1.67-14.68]; P = .03-.004). These are brain-specific expression quantitative trait loci (eQTL) associated with increased ABCC8 messenger RNA levels. Regulatory annotations revealed promoter and enhancer marks and strong and/or active brain-tissue transcription, directionally consistent with increased progression. Three SNVs (rs2283261, rs2237982, and rs3819521) in this cohort have been associated with intracranial hypertension. Four TRPM4 SNVs were associated with decreased IPH progression (rs3760666 [OR, 0.40-0.49; 95% CI, 0.19-0.86 to 0.27-0.89; P = .02 to P = .009], rs1477363 [OR, 0.40-0.43; 95% CI, 0.18-0.88 to 0.23-0.81; P = .02 to P = .006], rs10410857 [OR, 0.36-0.41; 95% CI, 0.20-0.67 to 0.20-0.85; P = .02 to P = .001], and rs909010 [OR, 0.27-0.40; 95% CI, 0.12-0.62 to 0.16-0.58; P = .002 to P < .001]). Significant SNVs in both genes cluster downstream, flanking exons encoding the receptor site and SUR1-TRPM4 binding interface. Adding genetic variation to clinical models improved receiver operating characteristic curve performance from 0.6959 to 0.8030 (P = .003). CONCLUSIONS AND RELEVANCE In this genetic association study, 8 ABCC8 and TRPM4 SNVs were associated with IPH progression. Spatial clustering, brain-specific eQTL, and regulatory annotations suggest biological plausibility. These findings may have important implications for neurocritical care risk stratification, patient selection, and precision medicine, including an upcoming phase 3 trial design for SUR1-TRPM4 inhibition in severe TBI.
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Affiliation(s)
- Ruchira M. Jha
- Department of Neurology, Barrow Neurological Institute, Phoenix, Arizona
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
- Department of Neurobiology, Barrow Neurological Institute, Phoenix, Arizona
| | - Benjamin E. Zusman
- medical student at School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- now affiliated with Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Ava M. Puccio
- Department of Neurological Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David O. Okonkwo
- Department of Neurological Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Matthew Pease
- Department of Neurological Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Shashvat M. Desai
- Department of Neurology, Barrow Neurological Institute, Phoenix, Arizona
| | - Matthew Leach
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Yvette P. Conley
- School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania
- Clinical and Translational Science Institute, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Patrick M. Kochanek
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Clinical and Translational Science Institute, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Safar Center for Resuscitation Research, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Milling TJ, Warach S, Johnston SC, Gajewski B, Costantini T, Price M, Wick J, Roward S, Mudaranthakam D, Dula AN, King B, Muddiman A, Lip GY. Restart TICrH: An Adaptive Randomized Trial of Time Intervals to Restart Direct Oral Anticoagulants after Traumatic Intracranial Hemorrhage. J Neurotrauma 2021; 38:1791-1798. [PMID: 33470152 PMCID: PMC8219199 DOI: 10.1089/neu.2020.7535] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Anticoagulants prevent thrombosis and death in patients with atrial fibrillation and venous thromboembolism (VTE) but also increase bleeding risk. The benefit/risk ratio favors anticoagulation in most of these patients. However, some will have a bleeding complication, such as the common trip-and-fall brain injury in elderly patients that results in traumatic intracranial hemorrhage. Clinicians must then make the difficult decision about when to restart the anticoagulant. Restarting too early risks making the bleeding worse. Restarting too late risks thrombotic events such as ischemic stroke and VTE, the indications for anticoagulation in the first place. There are more data on restarting patients with spontaneous intracranial hemorrhage, which is very different than traumatic intracranial hemorrhage. Spontaneous intracranial hemorrhage increases the risk of rebleeding because intrinsic vascular changes are widespread and irreversible. In contrast, traumatic cases are caused by a blow to the head, usually an isolated event portending less future risk. Clinicians generally agree that anticoagulation should be restarted but disagree about when. This uncertainty leads to long restart delays causing a large, potentially preventable burden of strokes and VTE, which has been unaddressed because of the absence of high quality evidence. Restart Traumatic Intracranial Hemorrhage (the "r" distinguished intracranial from intracerebral) (TICrH) is a prospective randomized open label blinded end-point response-adaptive clinical trial that will evaluate the impact of delays to restarting direct oral anticoagulation (1, 2, or 4 weeks) on the composite of thrombotic events and bleeding in patients presenting after traumatic intracranial hemorrhage.
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Affiliation(s)
| | - Steven Warach
- Seton Dell Medical School Stroke Institute, Austin, Texas, USA
| | | | - Byron Gajewski
- Department of Biostatistics and Data Science, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Todd Costantini
- Department of Surgery, University of California – San Diego, La Jolla, California, USA
| | - Michelle Price
- Coalition for National Trauma Research, San Antonio, Texas, USA
| | - Jo Wick
- Department of Biostatistics and Data Science, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Simin Roward
- Department of Surgery, Dell Seton Medical Center at The University of Texas, Austin, Texas, USA
| | - Dinesh Mudaranthakam
- Department of Biostatistics and Data Science, University of Kansas Medical Center, Kansas City, Kansas, USA
| | | | - Ben King
- Department of Health Systems and Population Health, University of Houston, College of Medicine, Houston, Texas, USA
| | | | - Gregory Y.H. Lip
- Liverpool Centre for Cardiovascular Science, Institute of Life Course & Medical Sciences, University of Liverpool, Liverpool, United Kingdom
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35
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de Souza MR, Fagundes CF, Solla DJF, da Silva GCL, Barreto RB, Teixeira MJ, Oliveira de Amorim RL, Kolias AG, Godoy D, Paiva WS. Mismatch between midline shift and hematoma thickness as a prognostic factor of mortality in patients sustaining acute subdural hematoma. Trauma Surg Acute Care Open 2021; 6:e000707. [PMID: 34104799 PMCID: PMC8144027 DOI: 10.1136/tsaco-2021-000707] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/05/2021] [Accepted: 04/11/2021] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Acute subdural hematoma (ASDH) is a traumatic lesion commonly found secondary to traumatic brain injury. Radiological findings on CT, such as hematoma thickness (HT) and structures midline shift (MLS), have an important prognostic role in this disease. The relationship between HT and MLS has been rarely studied in the literature. Thus, this study aimed to assess the prognostic accuracy of the difference between MLS and HT for acute outcomes in patients with ASDH in a low-income to middle-income country. METHODS This was a post-hoc analysis of a prospective cohort study conducted in a university-associated tertiary-level hospital in Brazil. The TRIPOD (Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis) statement guidelines were followed. The difference values between MLS and HT (Zumkeller index, ZI) were divided into three categories (<0.00, 0.01-3, and >3). Logistic regression analyses were performed to reveal the OR of categorized ZI in predicting primary outcome measures. A Cox regression was also performed and the results were presented through HR. The discriminative ability of three multivariate models including clinical and radiological variables (ZI, Rotterdam score, and Helsinki score) was demonstrated. RESULTS A total of 114 patients were included. Logistic regression demonstrated an OR value equal to 8.12 for the ZI >3 category (OR 8.12, 95% CI 1.16 to 40.01; p=0.01), which proved to be an independent predictor of mortality in the adjusted model for surgical intervention, age, and Glasgow Coma Scale (GCS) score. Cox regression analysis demonstrated that this category was associated with 14-day survival (HR 2.92, 95% CI 1.38 to 6.16; p=0.005). A multivariate analysis performed for three models including age and GCS with categorized ZI or Helsinki or Rotterdam score demonstrated area under the receiver operating characteristic curve values of 0.745, 0.767, and 0.808, respectively. CONCLUSIONS The present study highlights the potential usefulness of the difference between MLS and HT as a prognostic variable in patients with ASDH. LEVEL OF EVIDENCE Level III, epidemiological study.
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Affiliation(s)
| | | | - Davi Jorge Fontoura Solla
- Department of Neurology, University of São Paulo, São Paulo, Brazil
- Department of Neurology, University of Cambridge, Cambridge, UK
| | | | | | | | | | - Angelos G Kolias
- Department of Clinical Neuroscience - Division of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK
| | - Daniel Godoy
- Intensive Care Unit, San Juan Bautista Hospital, San Fernando del Valle de Catamarca, Argentina
| | - Wellingson Silva Paiva
- Department of Neurology, University of São Paulo, São Paulo, Brazil
- Department of Neurology, University of Cambridge, Cambridge, UK
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36
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Thango NS, Rohlwink UK, Dlamini L, Tshavhungwe MP, Banderker E, Salie S, Enslin JMN, Figaji AA. Brain interstitial glycerol correlates with evolving brain injury in paediatric traumatic brain injury. Childs Nerv Syst 2021; 37:1713-1721. [PMID: 33585956 DOI: 10.1007/s00381-021-05058-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 01/22/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE A better understanding of the complex pathophysiology of traumatic brain injury (TBI) is needed to improve our current therapies. Cerebral microdialysis (CMD) is an advanced method to monitor the brain, but little is known about its parameters in children. Brain glycerol, one of the CMD variables, is an essential component of the phospholipid bilayer cell membrane and is considered a useful marker of tissue hypoxia in adults. This study examined the time course of glycerol and its associations in paediatric TBI. METHODS In this retrospective cohort study, we collected data on children (< 13years) with severe TBI who underwent CMD monitoring. The relationship of glycerol was examined with respect to physiological, radiological variables, and clinical outcome. RESULTS Twenty-eight children underwent CMD monitoring and had evaluable data. Lesion progression on head computed tomography (CT) demonstrated a strong relationship with glycerol (median glycerol, maximum and initial-to-maximum) when lesion size increased by > 30% (p=0.01, p=0.04 and p=0.004). Absolute glycerol values had a weak but statistically significant association with intracranial pressure and brain oxygenation. We did not find an association with clinical outcome. CONCLUSION This is the first study to provide data on brain interstitial glycerol in children. CMD glycerol, particularly an increase from baseline, is associated with other markers of injury and with a significant increase in lesion size on repeat head CT. As such, it may represent a useful monitorable marker for evolving injury in paediatric TBI.
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Affiliation(s)
- Nqobile S Thango
- Division of Neurosurgery, Department of Surgery, University of Cape Town, Cape Town, South Africa
| | - Ursula K Rohlwink
- Division of Neurosurgery, Department of Surgery, University of Cape Town, Cape Town, South Africa.,Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Lindizwe Dlamini
- Division of Neurosurgery, Department of Surgery, University of Cape Town, Cape Town, South Africa
| | - M Phophi Tshavhungwe
- Division of Neurosurgery, Department of Surgery, University of Cape Town, Cape Town, South Africa
| | - E Banderker
- Department of Radiology, University of Cape Town, Cape Town, South Africa
| | - Shamiel Salie
- Paediatric Intensive Care Unit, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - J M N Enslin
- Division of Neurosurgery, Department of Surgery, University of Cape Town, Cape Town, South Africa
| | - Anthony A Figaji
- Division of Neurosurgery, Department of Surgery, University of Cape Town, Cape Town, South Africa. .,Neuroscience Institute, University of Cape Town, Cape Town, South Africa.
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Roberts I, Brenner A, Shakur-Still H. Tranexamic Acid Treatment for Trauma Victims. Semin Thromb Hemost 2021; 47:520-526. [PMID: 33878785 DOI: 10.1055/s-0041-1725097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Worldwide, traumatic injury is responsible for over 5 million deaths per year, the majority due to exsanguination and head injury. The antifibrinolytic drug tranexamic acid is the only drug proven to reduce deaths after traumatic injury. Several large randomized controlled trials have provided high-quality evidence of its effectiveness and safety in trauma patients. Early tranexamic acid reduces deaths on the day of the injury in polytrauma patients and patients with isolated traumatic brain injury by around 20%. Treatment is time critical; for patients to benefit, tranexamic acid must be given as soon as possible after injury. Intramuscular administration is well tolerated and rapidly absorbed, with the potential to reduce time to treatment. Because the proportional reduction in bleeding death with tranexamic acid does not vary by baseline risk, a wide range of trauma patients stands to benefit. There are far more low-risk trauma patients than high-risk patients, with a substantial proportion of bleeding deaths in the low-risk group. As such, treatment should not be limited to patients with severe traumatic hemorrhage. We must give paramedics and physicians the confidence to treat a far wider range of trauma patients while emphasizing the importance of early treatment.
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Affiliation(s)
- Ian Roberts
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Amy Brenner
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Haleema Shakur-Still
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Figueroa JM, Berry K, Boddu J, Kader M, Silva M, Luther E, Ayala V, Starke RM, Jagid J, Benveniste R. Treatment strategies for patients with concurrent blunt cerebrovascular and traumatic brain injury. J Clin Neurosci 2021; 88:243-250. [PMID: 33992192 DOI: 10.1016/j.jocn.2021.03.044] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 03/20/2021] [Accepted: 03/31/2021] [Indexed: 01/17/2023]
Abstract
Patients who present with traumatic brain injury (TBI) combined with blunt cerebrovascular injuries (BCVI) are difficult to manage, in part because treatment for each entity may exacerbate the other. It is necessary to develop a treatment paradigm that ensures maximum benefit while mitigating the opposing risks. A cohort of 150 patients from 2015 to present, with either internal carotid artery (ICA) and/or vertebral artery (VA) dissections or pseudoaneurysms, was cross-referenced with those who had sustained TBI. Of the 38 patients identified with both TBI and BCVI, 25 suffered ICA injuries, 10 had VA injuries and 3 had combined ICA/VA injuries. Unilateral BCVI occurred in 30 patients, while 8 had bilateral BCVI. Two patients required surgical intervention for TBI, and 5 patients required endovascular intervention for BCVI. Positive emboli detection studies (EDS) on transcranial dopplers (TCD) were demonstrated in 19 patients, with 9 patients having radiographic evidence of stroke. Anti-platelet therapy was initiated in 32 patients, and anti-coagulation in 10 patients, without new or worsening intracranial hemorrhages (ICH). Overall, 76% of patients were able to be discharged home or to rehabilitation, with good recovery demonstrated in 73% of the patients who had appropriate follow-up. In the setting of concurrent TBI and BCVI, use of anti-platelet/coagulation to prevent stroke can be safe if monitored closely. Here we describe a treatment paradigm which weighs the risk and benefits of therapies based on severity of ICH and stroke prevention, which tended to result in good disposition and recovery.
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Affiliation(s)
- Javier M Figueroa
- University of Miami Miller School of Medicine, Department of Neurosurgery, USA.
| | - Katherine Berry
- University of Miami Miller School of Medicine, Department of Neurosurgery, USA
| | - James Boddu
- University of Miami Miller School of Medicine, Department of Neurosurgery, USA
| | - Michael Kader
- University of Miami Miller School of Medicine, Department of Neurosurgery, USA
| | - Michael Silva
- University of Miami Miller School of Medicine, Department of Neurosurgery, USA
| | - Evan Luther
- University of Miami Miller School of Medicine, Department of Neurosurgery, USA
| | - Veronica Ayala
- University of Miami Miller School of Medicine, Department of Neurosurgery, USA
| | - Robert M Starke
- University of Miami Miller School of Medicine, Department of Neurosurgery, USA
| | - Jonathan Jagid
- University of Miami Miller School of Medicine, Department of Neurosurgery, USA
| | - Ronald Benveniste
- University of Miami Miller School of Medicine, Department of Neurosurgery, USA
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Webb AJ, Brown CS, Naylor RM, Rabinstein AA, Mara KC, Nei AM. Thromboelastography is a Marker for Clinically Significant Progressive Hemorrhagic Injury in Severe Traumatic Brain Injury. Neurocrit Care 2021; 35:738-746. [PMID: 33846901 DOI: 10.1007/s12028-021-01217-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 02/20/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Coagulopathy in traumatic brain injury (TBI) is associated with increased risk of poor outcomes, but accurate prediction of clinically significant progressive hemorrhagic injury (PHI) in patients with severe TBI remains a challenge. Thromboelastography (TEG) is a real-time test of whole blood coagulation that provides dynamic information about global hemostasis. This study aimed to identify differences in TEG values between patients with severe TBI who did or did not experience clinically significant PHI. METHODS This was a single-center retrospective cohort study of adult patients with severe TBI. Patients were eligible for inclusion if initial Glasgow coma scale (GCS) was ≤ 8 and baseline head computed tomography (CT) imaging and TEG were available. Exclusion criteria included receipt of hemostatic agents prior to TEG. PHI was defined as bleeding expansion on CT within 24 h associated with 2-point drop in GCS, neurosurgical intervention, or mortality within 24 h. The primary endpoint was TEG value differences between patients with and without PHI. Secondary endpoints included differences in conventional coagulation tests (CCTs) between groups. RESULTS Of the 526 patients evaluated, 141 met inclusion criteria. The most common reason for exclusion was lack of baseline TEG and receipt of reversal product prior to TEG. Sixty-four patients experienced PHI in the first 24 h after presentation. K time (2.03 min vs. 1.33 min, P = 0.035) and alpha angle (65° vs. 69°, P = 0.015) were found to be significantly different in patients experiencing PHI. R time (5.25 min vs. 4.71 min), maximum amplitude (61 mm vs. 63 mm), and clot lysis at 30 min after maximum clot strength (3.5% vs. 1.7%) were not significantly different between groups. Of the CCTs, only activated partial thromboplastin time (30.3 s vs. 27.6 s, P = 0.014) was found to be different in patients with PHI. CONCLUSIONS Prolonged K time and narrower alpha angle were found to be associated with developing clinically significant PHI in patients with severe TBI. Despite differences detected in alpha angle, median values in both groups were within normal reference ranges. These abnormalities may reflect pathologic hypoactivity of fibrinogen, and further study is warranted to evaluate TEG-guided cryoprecipitate administration in this patient population.
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Affiliation(s)
- Andrew J Webb
- Department of Pharmacy, Oregon Health and Science University, Portland, OR, USA.
| | | | - Ryan M Naylor
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | | | - Kristin C Mara
- Department of Biomedical Statistics, Mayo Clinic, Rochester, MN, USA
| | - Andrea M Nei
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
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40
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Roberts I, Shakur-Still H, Aeron-Thomas A, Beaumont D, Belli A, Brenner A, Cargill M, Chaudhri R, Douglas N, Frimley L, Gilliam C, Geer A, Jamal Z, Jooma R, Mansukhani R, Miners A, Pott J, Prowse D, Shokunbi T, Williams J. Tranexamic acid to reduce head injury death in people with traumatic brain injury: the CRASH-3 international RCT. Health Technol Assess 2021; 25:1-76. [PMID: 33928903 PMCID: PMC8107835 DOI: 10.3310/hta25260] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Tranexamic acid safely reduces mortality in traumatic extracranial bleeding. Intracranial bleeding is common after traumatic brain injury and can cause brain herniation and death. We assessed the effects of tranexamic acid in traumatic brain injury patients. OBJECTIVE To assess the effects of tranexamic acid on death, disability and vascular occlusive events in traumatic brain injury patients. We also assessed cost-effectiveness. DESIGN Randomised trial and economic evaluation. Patients were assigned by selecting a numbered treatment pack from a box containing eight packs that were identical apart from the pack number. Patients, caregivers and those assessing outcomes were masked to allocation. All analyses were by intention to treat. We assessed the cost-effectiveness of tranexamic acid versus no treatment from a UK NHS perspective using the trial results and a Markov model. SETTING 175 hospitals in 29 countries. PARTICIPANTS Adults with traumatic brain injury within 3 hours of injury with a Glasgow Coma Scale score of ≤ 12 or any intracranial bleeding on computerised tomography scan, and no major extracranial bleeding, were eligible. INTERVENTION Tranexamic acid (loading dose 1 g over 10 minutes then infusion of 1 g over 8 hours) or matching placebo. MAIN OUTCOME MEASURES Head injury death in hospital within 28 days of injury in patients treated within 3 hours of injury. Secondary outcomes were early head injury deaths, all-cause and cause-specific mortality, disability, vascular occlusive events, seizures, complications and adverse events. RESULTS Among patients treated within 3 hours of injury (n = 9127), the risk of head injury death was 18.5% in the tranexamic acid group versus 19.8% in the placebo group (855/4613 vs. 892/4514; risk ratio 0.94, 95% confidence interval 0.86 to 1.02). In a prespecified analysis excluding patients with a Glasgow Coma Scale score of 3 or bilateral unreactive pupils at baseline, the results were 12.5% in the tranexamic acid group versus 14.0% in the placebo group (485/3880 vs. 525/3757; risk ratio 0.89, 95% confidence interval 0.80 to 1.00). There was a reduction in the risk of head injury death with tranexamic acid in those with mild to moderate head injury (166/2846 vs. 207/2769; risk ratio 0.78, 95% confidence interval 0.64 to 0.95), but in those with severe head injury (689/1739 vs. 685/1710; risk ratio 0.99, 95% confidence interval 0.91 to 1.07) there was no apparent reduction (p-value for heterogeneity = 0.030). Early treatment was more effective in mild and moderate head injury (p = 0.005), but there was no obvious impact of time to treatment in cases of severe head injury (p = 0.73). The risk of disability, vascular occlusive events and seizures was similar in both groups. Tranexamic acid is highly cost-effective for mild and moderate traumatic brain injury (base case of £4288 per quality-adjusted life-year gained). CONCLUSION Early tranexamic acid treatment reduces head injury deaths. Treatment is cost-effective for patients with mild or moderate traumatic brain injury, or those with both pupils reactive. FUTURE WORK Further trials should examine early tranexamic acid treatment in mild head injury. Research on alternative routes of administration is needed. LIMITATIONS Time to treatment may have been underestimated. TRIAL REGISTRATION Current Controlled Trials ISRCTN15088122, ClinicalTrials.gov NCT01402882, EudraCT 2011-003669-14, Pan African Clinical Trial Registry PACTR20121000441277. FUNDING The project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 26. See the NIHR Journals Library website for further project information. In addition, funding was provided by JP Moulton Charitable Trust, Joint Global Health Trials (Medical Research Council, Department for International Development and the Wellcome Trust). This project was funded by the NIHR Global Health Trials programme.
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Affiliation(s)
- Ian Roberts
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | - Danielle Beaumont
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Antonio Belli
- National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, UK
| | - Amy Brenner
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Madeleine Cargill
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Rizwana Chaudhri
- Department of Obstetrics and Gynaecology, Rawalpindi Medical University, Rawalpinidi, Pakistan
| | - Nicolas Douglas
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Lauren Frimley
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Catherine Gilliam
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Amber Geer
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Zahra Jamal
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Rashid Jooma
- Department of Surgery, The Aga Khan University Medical College, Karachi, Pakistan
| | - Raoul Mansukhani
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Alec Miners
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Jason Pott
- Emergency Department, Barts Health NHS Trust, The Royal London Hospital, London, UK
| | - Danielle Prowse
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Temitayo Shokunbi
- Department of Anatomy and Surgery, University of Ibadan, Ibadan, Nigeria
| | - Jack Williams
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
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Eastman DK, Spilman SK, Tang K, Sidwell RA, Pelaez CA. Platelet Reactivity Testing for Aspirin Patients Who Sustain Traumatic Intracranial Hemorrhage. J Surg Res 2021; 263:186-192. [PMID: 33677146 DOI: 10.1016/j.jss.2021.01.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 11/12/2020] [Accepted: 01/15/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients who take aspirin and sustain traumatic intracranial hemorrhage (tICH) are often transfused platelets in an effort to prevent bleeding progression. The efficacy of platelet transfusion is questionable, however, and some medical societies recommend that platelet reactivity testing (PRT) should guide transfusion decisions. The study hypothesis was that utilization of PRT to guide platelet transfusion for tICH patients suspected of taking aspirin would safely identify patients who did not require platelet transfusion. METHODS This was a retrospective study of patients with blunt tICH who received PRT for known or suspected aspirin use between June 2014 and December 2017 at a level I trauma center. Chart abstraction was conducted to determine home aspirin status, and PRT values were used to classify patients as therapeutic or nontherapeutic on aspirin. Differences were assessed with Kruskal-Wallis and chi-square tests. RESULTS 157 patients met study inclusion criteria, and 118 (75%) patients had documented prior aspirin use. PRT results were available approximately 1.7 h (IQR: 0.9, 3.2) after arrival. Upon initial PRT, 70% of patients were considered inhibited and 88% of those patients had aspirin documented as a home medication. Conversely, 18% of patients with home aspirin use had normal platelet reactivity. Clinically significant worsening of the tICH did not significantly differ when comparing those who received platelet transfusion with those who did not (8% versus 7%, P = 0.87). CONCLUSIONS Platelet reactivity testing can detect platelet inhibition related to aspirin and should guide transfusion decisions for head injured patients in the initial hours after trauma.
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Affiliation(s)
- Darla K Eastman
- Drake University, College of Pharmacy and Health Sciences, Des Moines, Iowa.
| | | | - Kelly Tang
- Osteopathic Medicine Program, Des Moines University, Des Moines, Iowa
| | - Richard A Sidwell
- Trauma Services, UnityPoint Health, Des Moines, Iowa; Trauma Surgery, The Iowa Clinic, Des Moines, Iowa
| | - Carlos A Pelaez
- Trauma Services, UnityPoint Health, Des Moines, Iowa; Trauma Surgery, The Iowa Clinic, Des Moines, Iowa
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42
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Macki M, Pawloski J, Fadel H, Hamilton T, Haider S, Elmenini J, Fakih M, Johnson JL, Rock J. The Effect of Antithrombotics on Hematoma Expansion in Small- to Moderate-Sized Traumatic Intraparenchymal Hemorrhages. World Neurosurg 2021; 149:e101-e107. [PMID: 33640526 DOI: 10.1016/j.wneu.2021.02.072] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 02/15/2021] [Accepted: 02/16/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Although pre-injury antithrombotic agents, including antiplatelets and anticoagulants, are historically associated with expansion of traumatic intraparenchymal hemorrhage (tIPH), the literature has poorly elucidated the actual risk of hematoma expansion on repeat computed tomography (CT). The objective was to determine the effect of antithrombotic agents on hematoma expansion in tIPH by comparing patients with and without pre-injury antithrombotic medication. METHODS The volume of all tIPHs over a 5-year period at an academic Level 1 trauma center was measured retrospectively. The initial tIPH was divided into 3 equally sized quantiles. The third tercile, representing the largest subset of tIPH, was then removed from the study population because these patients reflect a different pathophysiologic mechanism that may require a more acute and aggressive level of care with reversal agents and/or operative management. Per institutional policy, all patients with small- to moderate-sized hemorrhages received a 24-hour stability CT scan. Patients who received reversal agents were excluded. RESULTS Of the 105 patients with a tIPH on the initial head CT scan, small- to moderate-sized hemorrhages were <5 cm3. The size of tIPH on initial imaging did not statistically significantly differ between the antithrombotic cohort (0.7 ± 0.1 cm3) and the non-antithrombotic cohort (0.5 ± 0.1 cm3) (P = 0.091). Similarly, the volume of tIPH failed to differ on 24-hour repeat imaging (1.0 ± 0.2 cm3 vs. 0.6 ± 0.1 cm3, respectively, P = 0.172). Following a multiple linear regression, only history of stroke, not antithrombotic medications, predicted increased tIPH on 24-hour repeat imaging. CONCLUSIONS In small- to moderate-sized tIPH, withholding antithrombotic agents without reversal may be sufficient.
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Affiliation(s)
- Mohamed Macki
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Jacob Pawloski
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Hassan Fadel
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Travis Hamilton
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Sameah Haider
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Jaafar Elmenini
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Mohamed Fakih
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Jeffrey L Johnson
- Department of Acute Care Surgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Jack Rock
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA.
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43
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Adatia K, Newcombe VFJ, Menon DK. Contusion Progression Following Traumatic Brain Injury: A Review of Clinical and Radiological Predictors, and Influence on Outcome. Neurocrit Care 2021; 34:312-324. [PMID: 32462411 PMCID: PMC7253145 DOI: 10.1007/s12028-020-00994-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Secondary injuries remain an important cause of the morbidity and mortality associated with traumatic brain injury (TBI). Progression of cerebral contusions occurs in up to 75% of patients with TBI, and this contributes to subsequent clinical deterioration and requirement for surgical intervention. Despite this, the role of early clinical and radiological factors in predicting contusion progression remains relatively poorly defined due to studies investigating progression of all types of hemorrhagic injuries as a combined cohort. In this review, we summarize data from recent studies on factors which predict contusion progression, and the effect of contusion progression on clinical outcomes.
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Affiliation(s)
- Krishma Adatia
- Division of Anaesthesia, University of Cambridge, Cambridge, UK.
| | | | - David K Menon
- Division of Anaesthesia, University of Cambridge, Cambridge, UK
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44
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Sheng J, Yang J, Cai S, Zhuang D, Li T, Chen X, Wang G, Dai J, Ding F, Tian L, Zheng F, Tian F, Huang M, Li K, Chen W. Development and external validation of a novel multihematoma fuzzy sign on computed tomography for predicting traumatic intraparenchymal hematoma expansion. Sci Rep 2021; 11:2042. [PMID: 33479430 PMCID: PMC7819987 DOI: 10.1038/s41598-021-81685-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 01/11/2021] [Indexed: 02/05/2023] Open
Abstract
Acute traumatic intraparenchymal hematoma (tICH) expansion is a devastating neurological complication that is associated with poor outcome after cerebral contusion. This study aimed to develop and validate a novel noncontrast computed tomography (CT) (NCCT) multihematoma fuzzy sign to predict acute tICH expansion. In this multicenter, prospective cohort study, multihematoma fuzzy signs on baseline CT were found in 212 (43.89%) of total 482 patients. Patients with the multihematoma fuzzy sign had a higher frequency of tICH expansion than those without (90.79% (138) vs. 46.71% (71)). The presence of multihematoma fuzzy sign was associated with increased risk for acute tICH expansion in entire cohort (odds ratio [OR]: 16.15; 95% confidence interval (CI) 8.85-29.47; P < 0.001) and in the cohort after propensity-score matching (OR: 9.37; 95% CI 4.52-19.43; P < 0.001). Receiver operating characteristic analysis indicated a better discriminative ability of the presence of multihematoma fuzzy sign for acute tICH expansion (AUC = 0.79; 95% CI 0.76-0.83), as was also observed in an external validation cohort (AUC = 0.76; 95% CI 0.67-0.84). The novel NCCT marker of multihematoma fuzzy sign could be easily identified on baseline CT and is an easy-to-use predictive tool for tICH expansion in the early stage of cerebral contusion.
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Affiliation(s)
- Jiangtao Sheng
- Department of Microbiology and Immunology and Key Immunopathology Laboratory of Guangdong Province, Shantou University Medical College, 22 Xinling Road, Shantou, Guangdong, China
| | - Jinhua Yang
- Department of Neurosurgery, First Affiliated Hospital of Shantou University Medical College, 57 Changping Road, Shantou, Guangdong, China
| | - Shirong Cai
- Department of Neurosurgery, First Affiliated Hospital of Shantou University Medical College, 57 Changping Road, Shantou, Guangdong, China
| | - Dongzhou Zhuang
- Department of Neurosurgery, First Affiliated Hospital of Shantou University Medical College, 57 Changping Road, Shantou, Guangdong, China
| | - Tian Li
- Department of Microbiology and Immunology and Key Immunopathology Laboratory of Guangdong Province, Shantou University Medical College, 22 Xinling Road, Shantou, Guangdong, China
| | - Xiaoxuan Chen
- Department of Microbiology and Immunology and Key Immunopathology Laboratory of Guangdong Province, Shantou University Medical College, 22 Xinling Road, Shantou, Guangdong, China
| | - Gefei Wang
- Department of Microbiology and Immunology and Key Immunopathology Laboratory of Guangdong Province, Shantou University Medical College, 22 Xinling Road, Shantou, Guangdong, China
| | - Jianping Dai
- Department of Microbiology and Immunology and Key Immunopathology Laboratory of Guangdong Province, Shantou University Medical College, 22 Xinling Road, Shantou, Guangdong, China
| | - Faxiu Ding
- Department of Neurosurgery, First Affiliated Hospital of Shantou University Medical College, 57 Changping Road, Shantou, Guangdong, China
| | - Lu Tian
- Department of Microbiology and Immunology and Key Immunopathology Laboratory of Guangdong Province, Shantou University Medical College, 22 Xinling Road, Shantou, Guangdong, China
| | - Fengqing Zheng
- Department of Microbiology and Immunology and Key Immunopathology Laboratory of Guangdong Province, Shantou University Medical College, 22 Xinling Road, Shantou, Guangdong, China
| | - Fei Tian
- Department of Neurosurgery, Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Mindong Huang
- Department of Neurosurgery, Affiliated Jieyang Hospital of Sun Yat-Sen University, Jieyang, Guangdong, China
| | - Kangsheng Li
- Department of Microbiology and Immunology and Key Immunopathology Laboratory of Guangdong Province, Shantou University Medical College, 22 Xinling Road, Shantou, Guangdong, China.
| | - Weiqiang Chen
- Department of Neurosurgery, First Affiliated Hospital of Shantou University Medical College, 57 Changping Road, Shantou, Guangdong, China.
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45
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Lim XT, Ang E, Lee ZX, Hajibandeh S, Hajibandeh S. Prognostic significance of preinjury anticoagulation in patients with traumatic brain injury: A systematic review and meta-analysis. J Trauma Acute Care Surg 2021; 90:191-201. [PMID: 33048909 DOI: 10.1097/ta.0000000000002976] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a leading cause of injury-related deaths and neurological disability globally. Considering the widespread anticoagulant use among the aging population, we aimed to perform a systematic review and meta-analysis to evaluate the prognostic significance of preinjury anticoagulation in TBI patients. METHODS This systematic review was conducted according to a predefined protocol (International Prospective Register of Systematic Reviews CRD42020192323). In compliance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-Analysis of Observational Studies in Epidemiology standards, a structured electronic database search was undertaken to identify all observational studies comparing preinjury anticoagulation with no preinjury anticoagulation in TBI patients. The primary outcome measure was overall mortality. The secondary outcome measures comprised in-hospital mortality, length of hospital stay, length of intensive care unit stay, need for neurosurgical procedure, and number of patients discharged home. All outcome data were analyzed using random effects modeling. RESULTS Twelve comparative studies enrolling a total of 4,417 patients were included. Preinjury anticoagulation was associated with higher risk of overall mortality (odds ratio [OR], 2.39; 95% confidence interval [CI], 1.63-3.50, p < 0.00001), in-hospital mortality (OR, 2.47; 95% CI, 1.56-3.93, p = 0.0001), and longer length of intensive care unit stay (mean difference, 1.06; 95% CI, 0.54-1.57; p < 0.0001) compared with no preinjury anticoagulation. No statistical difference was observed in length of hospital stay (mean difference, -2.15; 95% CI, -5.36 to 1.05, p = 0.19), need for neurosurgical procedure (OR, 1.30; 95% CI, 0.70-2.44; p = 0.41), and discharged home (OR, 0.76; 95% CI, 0.55-1.04; p = 0.09) between the two groups. CONCLUSION Preinjury anticoagulation is a powerful prognosticator of mortality in TBI patients. This highlights the need for dedicated triage and trauma team activation protocols considering earlier intervention and more aggressive imaging in all anticoagulated patients. Future studies should focus on strategies that can potentially reduce the risk of mortality in this population. The prognostic significance of direct oral anticoagulants versus warfarin remains unanswered. LEVEL OF EVIDENCE Systematic review and meta-analysis of observational studies, level III.
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Affiliation(s)
- Xin Tian Lim
- From the Wrexham Maelor Hospital (X.T.L., E.A., Z.X.L.), Betsi Cadwaladr University Health Board, Wrexham; Department of General Surgery (Shahin.H.), Sandwell and West Birmingham Hospitals NHS Trust, Birmingham; and Department of General Surgery (Shahab.H.), Glan Clwyd Hospital, Betsi Cadwaladr University Health Board, Rhyl, United Kingdom
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46
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Jha RM, Mondello S, Bramlett HM, Dixon CE, Shear DA, Dietrich WD, Wang KKW, Yang Z, Hayes RL, Poloyac SM, Empey PE, Lafrenaye AD, Yan HQ, Carlson SW, Povlishock JT, Gilsdorf JS, Kochanek PM. Glibenclamide Treatment in Traumatic Brain Injury: Operation Brain Trauma Therapy. J Neurotrauma 2020; 38:628-645. [PMID: 33203303 DOI: 10.1089/neu.2020.7421] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Glibenclamide (GLY) is the sixth drug tested by the Operation Brain Trauma Therapy (OBTT) consortium based on substantial pre-clinical evidence of benefit in traumatic brain injury (TBI). Adult Sprague-Dawley rats underwent fluid percussion injury (FPI; n = 45), controlled cortical impact (CCI; n = 30), or penetrating ballistic-like brain injury (PBBI; n = 36). Efficacy of GLY treatment (10-μg/kg intraperitoneal loading dose at 10 min post-injury, followed by a continuous 7-day subcutaneous infusion [0.2 μg/h]) on motor, cognitive, neuropathological, and biomarker outcomes was assessed across models. GLY improved motor outcome versus vehicle in FPI (cylinder task, p < 0.05) and CCI (beam balance, p < 0.05; beam walk, p < 0.05). In FPI, GLY did not benefit any other outcome, whereas in CCI, it reduced 21-day lesion volume versus vehicle (p < 0.05). On Morris water maze testing in CCI, GLY worsened performance on hidden platform latency testing versus sham (p < 0.05), but not versus TBI vehicle. In PBBI, GLY did not improve any outcome. Blood levels of glial fibrillary acidic protein and ubiquitin carboxyl terminal hydrolase-1 at 24 h did not show significant treatment-induced changes. In summary, GLY showed the greatest benefit in CCI, with positive effects on motor and neuropathological outcomes. GLY is the second-highest-scoring agent overall tested by OBTT and the only drug to reduce lesion volume after CCI. Our findings suggest that leveraging the use of a TBI model-based phenotype to guide treatment (i.e., GLY in contusion) might represent a strategic choice to accelerate drug development in clinical trials and, ultimately, achieve precision medicine in TBI.
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Affiliation(s)
- Ruchira M Jha
- Safar Center for Resuscitation Research, Department of Critical Care Medicine, Anesthesiology, and Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Departments of Neurology, Neurobiology, and Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | | | - Helen M Bramlett
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, Miller School of Medicine, University of Miami, and Bruce W. Carter Department of Veterans Affairs Medical Center, Miami, Florida, USA
| | - C Edward Dixon
- Department of Neurological Surgery, Brain Trauma Research Center, Anesthesiology, and Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Deborah A Shear
- Brain Trauma Neuroprotection Branch, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - W Dalton Dietrich
- Department of Neurological Surgery, Brain Trauma Research Center, Anesthesiology, and Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Kevin K W Wang
- Program for Neurotrauma, Neuroproteomics & Biomarkers Research, Department of Emergency Medicine, McKnight Brin Institute of the University of Florida, Gainesville, Florida, USA
| | - Zhihui Yang
- Program for Neurotrauma, Neuroproteomics & Biomarkers Research, Department of Emergency Medicine, McKnight Brin Institute of the University of Florida, Gainesville, Florida, USA
| | - Ronald L Hayes
- Center for Innovative Research, Center for Proteomics and Biomarkers Research, Banyan Biomarkers, Inc., Alachua, Florida, USA
| | - Samuel M Poloyac
- Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Philip E Empey
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Audrey D Lafrenaye
- Department of Anatomy and Neurobiology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Hong Q Yan
- Department of Neurological Surgery, Brain Trauma Research Center, Anesthesiology, and Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Shaun W Carlson
- Department of Neurological Surgery, Brain Trauma Research Center, Anesthesiology, and Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - John T Povlishock
- Department of Anatomy and Neurobiology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Janice S Gilsdorf
- Brain Trauma Neuroprotection Branch, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Patrick M Kochanek
- Safar Center for Resuscitation Research, Department of Critical Care Medicine, Anesthesiology, and Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Departments of Pediatrics, Anesthesiology, and Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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47
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Mojallal F, Nikooieh M, Hajimaghsoudi M, Baqherabadi M, Jafari M, Esmaeili A, Karimi NM, Zarepur E. The effect of intravenous tranexamic acid on preventing the progress of cerebral hemorrhage in patients with brain traumatic injuries compared to placebo: A randomized clinical trial. Med J Islam Repub Iran 2020; 34:107. [PMID: 33315982 PMCID: PMC7722959 DOI: 10.34171/mjiri.34.107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Indexed: 11/07/2022] Open
Abstract
Background: Head trauma is one of the common reasons for patient attendance in the emergency ward. This study investigated the effect of tranexamic acid as a cheap, easily available antifibrinolytic drug on reducing the progress of cerebral hemorrhage compared to placebo.
Methods: This double-blind controlled clinical trial was performed on 120 traumatized patients presenting to the emergency room of Shahid Rahnemoon hospital during 2014-2015, Yazd, Iran. Those patients who met the inclusion criteria were randomly allocated into 2 groups. Group A received tranexamic acid, while group B received placebo parenterally. Finally, 56 patients in Group A and 44 in Group B were analyzed. The patients underwent brain CT scan and were followed up for ICU stay in days. Also, the number of patients who died during the first 7 days of hospitalization was recorded. The data were analyzed with SPSS20 using independent samples t test and chi-square test.
Results: The mean age of the patients was 41±20.27 years. Also, 20 patients (20%) were female and 80 were male (80%). There was no significant difference between the drug group and placebo group in the rate of hemorrhage volume progress (p=0.824). Regarding patients’ ICU stay, the ICU stay of the tranexamic acid group decreased significantly compared to the placebo group (p=0.001). No significant difference was found between the intervention group and placebo group in the mortality rate of patients during the first 7 days of hospitalization (p=0.236).
Conclusion: Tranexamic acid has no effect on reducing cerebral hemorrhage volume in patients. Although this drug was not effective in reducing mortality rate in patients, it decreased their ICU stay.
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Affiliation(s)
- Fatemeh Mojallal
- Trauma Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Mehrnaz Nikooieh
- School of Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Majid Hajimaghsoudi
- Trauma Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Mehdi Baqherabadi
- School of Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Mohammadali Jafari
- School of Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Alireza Esmaeili
- School of Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | | | - Ehsan Zarepur
- Cardiology resident, PhD candidate, Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
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48
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King B, Milling T, Gajewski B, Costantini TW, Wick J, Price MA, Mudaranthakam D, Stein DM, Connolly S, Valadka A, Warach S. Restarting and timing of oral anticoagulation after traumatic intracranial hemorrhage: a review and summary of ongoing and planned prospective randomized clinical trials. Trauma Surg Acute Care Open 2020; 5:e000605. [PMID: 33313417 PMCID: PMC7716676 DOI: 10.1136/tsaco-2020-000605] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 11/18/2020] [Accepted: 11/19/2020] [Indexed: 11/27/2022] Open
Abstract
Anticoagulant-associated traumatic intracranial hemorrhage (tICrH) is a devastating injury with high morbidity and mortality. For survivors, treating clinicians face the dilemma of restarting oral anticoagulation with scarce evidence to guide them. Thromboembolic risk is high from the bleeding event, patients’ high baseline risks, that is, the pre-existing indication for anticoagulation, and the risk of immobility after the bleeding episode. This must be balanced with potentially devastating hematoma expansion or new hemorrhagic lesions. Retrospective evidence and expert opinion support restarting oral anticoagulants in most patients with tICrH, but timing is uncertain. Researchers have failed to make clear distinctions between tICrH and spontaneous intracranial hemorrhage (sICrH), which have differing natural histories. While both appear to benefit from restarting, sICrH has a higher rebleeding risk and similar or lower thrombotic risk. Clinical equipoise on restarting is also divergent. In sICrH, equipoise is centered on whether to restart. In tICrH, it is centered on when. Several prospective randomized clinical trials are ongoing or about to start to examine the risk–benefit of restarting. Most of them are restricted to patients with sICrH, with antiplatelet control groups. Most are also restricted to direct oral anticoagulants (DOACs), as they are associated with a lower overall risk of ICrH. There is some overlap with tICrH via subdural hematoma, and one trial is specific to restart timing with DOACs in only traumatic cases. This is a narrative review of the current evidence for restarting anticoagulation and restart timing after tICrH along with a summary of the ongoing and planned clinical trials.
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Affiliation(s)
- Ben King
- College of Medicine, Department of Health Systems and Population Health Sciences, University of Houston, Houston, Texas, USA
| | - Truman Milling
- Seton Dell Medical School Stroke Institute, Ascension Seton, Austin, Texas, USA
| | - Byron Gajewski
- Department of Biostatistics and Data Science, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Todd W Costantini
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, UC San Diego Health, San Diego, California, USA
| | - Jo Wick
- Department of Biostatistics and Data Science, University of Kansas Medical Center, Kansas City, Kansas, USA
| | | | - Dinesh Mudaranthakam
- Department of Biostatistics and Data Science, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Deborah M Stein
- Department of Surgery, University of California-San Francisco, School of Medicine, San Francisco, California, USA
| | - Stuart Connolly
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Alex Valadka
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Steven Warach
- Department of Neurology, The University of Texas at Austin Dell Medical School, Austin, Texas, USA
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Koyama H, Yagi K, Hara K, Matsubara S, Tao Y, Uno M. Combination Therapy Using Prothrombin Complex Concentrate and Vitamin K in Anticoagulated Patients with Traumatic Intracranial Hemorrhage Prevents Progressive Hemorrhagic Injury: A Historically Controlled Study. Neurol Med Chir (Tokyo) 2020; 61:47-54. [PMID: 33208582 PMCID: PMC7812312 DOI: 10.2176/nmc.oa.2020-0252] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Warfarin remains crucially involved in the treatment of patients at thrombotic or thromboembolic risk. However, warfarin increases the mortality rate among patients with traumatic intracranial hemorrhage (TICH) through progressive hemorrhagic injury (PHI). Therefore, a rapid anticoagulation reversal could be required in patients with TICH to prevent PHI. Differences in the warfarin reversal effect between combination therapy of prothrombin complex concentrate (PCC) with vitamin K (VK) and VK monotherapy remain unclear. However, studies have reported that PCC has greater effectiveness and safety for warfarin reversal compared with fresh frozen plasma (FFP). This retrospective study aimed to evaluate the warfarin reversal effects of combination therapy of PCC with VK and VK monotherapy on TICH. We compared the clinical outcomes between the periods before and after the PCC introduction in our hospital. There were 13 and 7 patients who received VK monotherapy and PCC with VK, respectively. PHI predictors were evaluated using univariate regression analyses. Warfarin reversal using PCC had a significant negative association with PHI (odds ratio: 0.03, 95% confidence interval: 0.00-0.41, P = 0.004). None of the patients presented with thrombotic complications. Warfarin reversal through a combination of PCC with VK could be more effective for inhibiting post-trauma PHI compared with VK monotherapy. This could be attributed to a rapid and stable warfarin reversal. PCC should be administered to patients with TICH taking warfarin for PHI prevention.
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Affiliation(s)
- Hiroshi Koyama
- Department of Neurosurgery, Kawasaki Medical School.,Department of Neurosurgery, Tokushima University Hospital
| | - Kenji Yagi
- Department of Neurosurgery, Kawasaki Medical School
| | - Keijiro Hara
- Department of Neurosurgery, Kawasaki Medical School
| | | | | | - Masaaki Uno
- Department of Neurosurgery, Kawasaki Medical School
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Gao B, Xue T, Rong X, Yang Y, Wang Z, Chen Z, Wang Z. Tranexamic Acid Inhibits Hematoma Expansion in Intracerebral Hemorrhage and Traumatic Brain Injury. Does Blood Pressure Play a Potential Role? A Meta-Analysis from Randmized Controlled Trials. J Stroke Cerebrovasc Dis 2020; 30:105436. [PMID: 33171426 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105436] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/08/2020] [Accepted: 10/29/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Tranexamic acid (TXA) is an antifibrinolytic agent, which has shown an effect on reducing blood loss in many diseases. Many studies focus on the effect of TXA on cerebral hemorrhage, however, whether TXA can inhibit hematoma expansion is still controversial. Our meta-analysis performed a quantitative analysis to evaluate the efficacy of TXA for the hematoma expansion in spontaneous and traumatic intracranial hematoma. METHOD Pubmed (MEDLINE), Embase, and Cochrane Library were searched from January 2001 to May 2020 for randomized controlled trials (RCTs). RESULT We pooled 3102 patients from 7 RCTs to evaluate the efficacy of TXA for hematoma expansion. Hematoma expansion (HE) rate and hematoma volume (HV) change from baseline were used to analyze. We found that TXA led to a significant reduction in HE rate (P = 0.002) and HV change (P = 0.03) compared with the placebo. Patients with moderate or serious hypertension benefit more from TXA. (HE rate: P = 0.02, HV change: P = 0.04) TXA tends to have a better efficacy on HV change in intracerebral hemorrhage (ICH). (P = 0.06) CONCLUSIONS: TXA showed good efficacy for hematoma expansion in spontaneous and traumatic intracranial hemorrhage. Patients with moderate/severe hypertension and ICH may be more suitable for TXA administration in inhibiting hematoma expansion .
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Affiliation(s)
- Bixi Gao
- Department of Neurosurgery& Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, 215006, China
| | - Tao Xue
- Department of Neurosurgery& Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, 215006, China
| | - Xiaoci Rong
- Department of Neurosurgery& Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, 215006, China
| | - Yanbo Yang
- Department of Neurosurgery& Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, 215006, China
| | - Zilan Wang
- Department of Neurosurgery& Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, 215006, China
| | - Zhouqing Chen
- Department of Neurosurgery& Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, 215006, China
| | - Zhong Wang
- Department of Neurosurgery& Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, 215006, China.
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