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Sugie A, Yokoyama K, Ikeda N, Tanaka H, Ito Y, Yamada M, Nomura Y, Fujita M, Nakatani T, Kawanishi M. Plasma D-Dimer Levels Can Provide Useful Diagnostic Information on Acute Vertebral Compression Fractures in Patients with Low Back Pain in the Emergency Room. World Neurosurg 2024; 185:e860-e866. [PMID: 38447741 DOI: 10.1016/j.wneu.2024.02.142] [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: 02/23/2024] [Revised: 02/25/2024] [Accepted: 02/26/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Patients with acute vertebral compression fractures (aVCFs) are frequently transferred to an emergency department by ambulance. The most useful imaging modality is magnetic resonance imaging (MRI); however, which patients should be prioritized for MRI evaluation may be unclear. The aim of this study was to evaluate plasma D-dimer levels as a biomarker for aVCFs. METHODS This retrospective cohort study included patients with low back pain in the emergency department between November 2017 and October 2020. Patients with infections, patients with coagulation disorders, and patients without D-dimer level measurements were excluded. The presence of an aVCF was detected with MRI. Blood samples were collected for routine blood tests. The predictive factors for aVCFs were evaluated with univariate and multivariable logistic regression analyses. RESULTS Overall, 191 consecutive MRI evaluations were ordered. After exclusions, 101 patients were reviewed. Based on MRI, 65 (64.4%) patients were diagnosed with aVCF. The presence of aVCF was significantly correlated with age (odds ratio [OR] = 1.052, 95% confidence interval [CI] 1.018-1.191), an old vertebral compression fracture (OR = 3.290, 95% CI 1.342-8.075), hemoglobin (OR = 0.699, 95% CI 0.535-0.912), and D-dimer levels (OR = 1.829, 95% CI 1.260-2.656). Results from a multivariable logistic regression analysis showed that D-dimer levels (OR = 1.642, 95% CI 1.188-2.228) remained a significant risk factor for the presence of aVCFs after adjustment for potential confounders. CONCLUSIONS Plasma D-dimer levels can provide useful diagnostic information about whether an aVCF is present.
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Affiliation(s)
- Akira Sugie
- Department of Neurosurgery, Ijinkai Takeda General Hospital, Kyoto, Japan; Department of Emergency Medicine, Ijinkai Takeda General Hospital, Kyoto, Japan.
| | - Kunio Yokoyama
- Department of Neurosurgery, Ijinkai Takeda General Hospital, Kyoto, Japan
| | - Naokado Ikeda
- Department of Neurosurgery, Ijinkai Takeda General Hospital, Kyoto, Japan
| | - Hidekazu Tanaka
- Department of Neurosurgery, Ijinkai Takeda General Hospital, Kyoto, Japan
| | - Yutaka Ito
- Department of Neurosurgery, Ijinkai Takeda General Hospital, Kyoto, Japan
| | - Makoto Yamada
- Department of Neurosurgery, Ijinkai Takeda General Hospital, Kyoto, Japan
| | - Yukiya Nomura
- Department of Emergency Medicine, Ijinkai Takeda General Hospital, Kyoto, Japan
| | - Masutsugu Fujita
- Department of Emergency Medicine, Ijinkai Takeda General Hospital, Kyoto, Japan
| | - Toshio Nakatani
- Department of Emergency Medicine, Ijinkai Takeda General Hospital, Kyoto, Japan
| | - Masahiro Kawanishi
- Department of Neurosurgery, Ijinkai Takeda General Hospital, Kyoto, Japan
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Durbin S, Brito A, Johnson A, Cotton B, Rowell S, Schreiber M. Association of fibrinolysis phenotype with patient outcomes following traumatic brain injury. J Trauma Acute Care Surg 2024; 96:482-486. [PMID: 37700441 PMCID: PMC10922039 DOI: 10.1097/ta.0000000000004122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
BACKGROUND Impaired coagulation is associated with elevated risk of mortality in trauma patients. Prior studies have demonstrated increased mortality in patients with hyperfibrinolysis (HF) and fibrinolysis shutdown (SD). In addition, prior studies have demonstrated no effect of tranexamic acid (TXA) on fibrinolysis phenotypes. We examined the association of admission fibrinolysis phenotype with traumatic brain injury (TBI) patient outcomes. METHODS Data were extracted from a placebo-controlled multicenter clinical trial. Patients ≥15 years with TBI (Glasgow Coma Scale score, 3-12) and systolic blood pressure ≥90 mm Hg were randomized in the out-of-hospital setting to receive placebo bolus/placebo infusion (Placebo), 1 gram (g) TXA bolus/1 g TXA infusion (bolus maintenance [BM]); or 2 g TXA bolus/placebo infusion (bolus only [BO]). Fibrinolysis phenotypes on admission were determined by clot lysis at 30 minutes (LY30): SD, ≤0.8%; physiologic, 0.9% to 2.9%; HF, ≥3%. Logistic regression was used to control for age, sex, penetrating injury, Injury Severity Score, maximum head AIS, and TXA treatment group. RESULTS Seven hundred forty-seven patients met inclusion criteria. Fibrinolysis shutdown was the most common phenotype in all treatment groups and was associated with increased age, Injury Severity Score, and presence of intracranial hemorrhage (ICH). Inpatient mortality was 15.2% for SD and HF, and 10.6% for physiologic ( p = 0.49). No differences in mortality, disability rating scale at 6 months, acute kidney injury, acute respiratory distress syndrome, or multi-organ failure were noted between fibrinolysis phenotypes. CONCLUSION SD is the most common phenotype expressed in moderate to severe TBI. In TBI, there is no association between fibrinolysis phenotype and mortality or other major complications. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
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Affiliation(s)
| | - Alexandra Brito
- Oregon Health & Science University, Portland, OR
- The Queen’s Medical Center, Honolulu, HI
| | | | | | - Susan Rowell
- The University of Chicago Medicine & Biological Sciences, Chicago, IL
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Favors L, Harrell K, Miles V, Hicks RC, Rippy M, Parmer H, Edwards A, Brown C, Stewart K, Day L, Wilson A, Maxwell R. Analysis of fibrinolytic shutdown in trauma patients with traumatic brain injury. Am J Surg 2024; 227:72-76. [PMID: 37802703 DOI: 10.1016/j.amjsurg.2023.09.034] [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: 06/30/2023] [Revised: 09/01/2023] [Accepted: 09/25/2023] [Indexed: 10/08/2023]
Abstract
BACKGROUND Coagulation profiles following major trauma vary depending on injury pattern and degree of shock. The physiologic mechanisms involved in coagulation function at any given time are varied and remain poorly understood. Thromboelastography (TEG) has been used evaluate coagulation profiles in the trauma population with some reports demonstrating a spectrum of fibrinolysis to fibrinolytic shutdown on initial presentation. The objective of this study was to evaluate the fibrinolytic profile of patients with TBI using thromboelastography (TEG). We hypothesized that patients with TBI would demonstrate low fibrinolytic activity. METHODS All trauma activations at an ACS-verified level 1 trauma center received a TEG analysis upon arrival from December 2019 to June 2021. A retrospective review of the results and outcomes was conducted, and TBI patients were compared to patients without TBI. Linear regression was used to evaluate the effect of patient and injury factors on fibrinolysis. Hyperfibrinolysis was defined as LY30 > 7.7%, physiologic fibrinolysis as LY30 0.6-7.7%, and fibrinolytic shutdown as LY30 < 0.6%. RESULTS A total of 1369 patients received an admission TEG analysis. Patients with TBI had a significantly higher median ISS (16 vs. 8, p < 0.001), lower median admission Glasgow Coma Scale (14 vs. 15, p < 0.001), longer intensive care unit length of stay (3 vs. 2 days, p < 0.0001), increased ventilator days (216 vs. 183, p < 0.001), higher mortality (14.6% vs. 5.1%, p < 0.001), but lower shock index (0.6 vs. 0.7, p < 0.0001) compared to those without TBI. Median LY30 was found to be decreased in the TBI group (0.1 vs. 0.2, p = 0.0006). Patients with TBI were found to have a higher rate of fibrinolytic shutdown compared those without TBI (68.7% vs. 63.5%, p = 0.054). ISS, sex, and shock index were found to be predictive of LY30 on linear regression, but TBI was not (Β: 0.09, SE: 0.277, p = 0.745). The rate of DVT/PE did not appear to be elevated in patients with TBI (0.8%) and without TBI (1.2%). CONCLUSIONS Trauma patients with and without TBI were found to have high rates of fibrinolytic shutdown. Although there was a high incidence of fibrinolytic shutdown, it did not appear to have an impact on the rate of thrombotic complications. The clinical significance of these results is unclear and differs significantly from recent reports which demonstrated that TBI is associated with a 25% rate of fibrinolytic shutdown. Further investigation is needed to better define the fibrinolytic pathway in patients with trauma and TBI to develop optimal treatment algorithms.
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Affiliation(s)
- L Favors
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA.
| | - K Harrell
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA.
| | - V Miles
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA.
| | - R C Hicks
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA
| | - M Rippy
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA
| | - H Parmer
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA
| | - A Edwards
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA
| | - C Brown
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA
| | - K Stewart
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA
| | - L Day
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA
| | - A Wilson
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA
| | - R Maxwell
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA.
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Coleman JR, D'Alessandro A, LaCroix I, Dzieciatkowska M, Lutz P, Mitra S, Gamboni F, Ruf W, Silliman CC, Cohen MJ. A metabolomic and proteomic analysis of pathologic hypercoagulability in traumatic brain injury patients after dura violation. J Trauma Acute Care Surg 2023; 95:925-934. [PMID: 37405823 DOI: 10.1097/ta.0000000000004019] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2023]
Abstract
BACKGROUND The coagulopathy of traumatic brain injury (TBI) remains poorly understood. Contradictory descriptions highlight the distinction between systemic and local coagulation, with descriptions of systemic hypercoagulability despite intracranial hypocoagulopathy. This perplexing coagulation profile has been hypothesized to be due to tissue factor release. The objective of this study was to assess the coagulation profile of TBI patients undergoing neurosurgical procedures. We hypothesize that dura violation is associated with higher tissue factor and conversion to a hypercoagulable profile and unique metabolomic and proteomic phenotype. METHODS This is a prospective, observational cohort study of all adult TBI patients at an urban, Level I trauma center who underwent a neurosurgical procedure from 2019 to 2021. Whole blood samples were collected before and then 1 hour following dura violation. Citrated rapid and tissue plasminogen activator (tPA) thrombelastography (TEG) were performed, in addition to measurement of tissue factory activity, metabolomics, and proteomics. RESULTS Overall, 57 patients were included. The majority (61%) were male, the median age was 52 years, 70% presented after blunt trauma, and the median Glasgow Coma Score was 7. Compared with pre-dura violation, post-dura violation blood demonstrated systemic hypercoagulability, with a significant increase in clot strength (maximum amplitude of 74.4 mm vs. 63.5 mm; p < 0.0001) and a significant decrease in fibrinolysis (LY30 on tPAchallenged TEG of 1.4% vs. 2.6%; p = 0.04). There were no statistically significant differences in tissue factor. Metabolomics revealed notable increases in metabolites involved in late glycolysis, cysteine, and one-carbon metabolites, and metabolites involved in endothelial dysfunction/arginine metabolism/responses to hypoxia. Proteomics revealed notable increase in proteins related to platelet activation and fibrinolysis inhibition. CONCLUSION A systemic hypercoagulability is observed in TBI patients, characterized by increased clot strength and decreased fibrinolysis and a unique metabolomic and proteomics phenotype independent of tissue factor levels.
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Affiliation(s)
- Julia R Coleman
- From the Department of Surgery (J.R.C.), The Ohio State University, Columbus, Ohio; Department of Biochemistry and Molecular Genetics (A.D.'A., I.L.C. M.D., F.G., P.L., S.M., M.J.C.), University of Colorado, Aurora, Colorado; Department of Immunology and Microbiology (W.R.), Scripps Research, La Jolla, California; Vitalant Research Institute (C.C.S.), Denver; and Department of Pediatrics (C.C.S.), University of Colorado, Aurora, Colorado
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Zhang Q, Kuang HM, Qiao DJ, Zhong XL, Kang JJ, Ma RN, Li M. Association Between High-Level D-Dimer at Admission and Early Intubation in Patients With Moderate Traumatic Brain Injury. Neurotrauma Rep 2023; 4:715-723. [PMID: 37908323 PMCID: PMC10615076 DOI: 10.1089/neur.2023.0068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023] Open
Abstract
It is unclear who can benefit from tracheal intubation in the moderate (mTBI) traumatic brain injury (TBI) population. Given that mTBI patients are conscious, intubation can cause intense stress, possibly triggering neurological deterioration. Therefore, identifying potential risk factors for intubation in mTBI patients can serve as a valuable clinical warning. We sought to investigate whether elevated D-dimer is a possible risk factor for intubation in mTBI patients. Using the STROBE statement, adult patients with isolated TBI (Glasgow Coma Scale [GCS] score 9-13) treated at a high-volume neurotrauma center between January 2015 and December 2020 were reviewed. The demographics, clinical presentation, neuroimaging, and laboratory information were collected based on the patients' electronic medical record. D-dimer values were assessed from serum when patients were admitted to the hospital. The primary study end-point was that the mTBI patient was intubated within 72 h upon admission. A total of 557 patients with mTBI were finally included in this study. Of these, 85 (15.3%) patients were intubated. Multi-variate logistic regression analysis showed that high-level D-dimer (≥17.9mg/L) was significantly associated with early tracheal intubation in mTBI patients (odds ratio, 3.10 [1.16-8.25]; p = 0.024) after adjusting for age, sex, GCS scores, Marshall scores, and Injury Severity Scores. Sensitivity analysis showed that high-level D-dimer had a robust correlation with intubation in the different subgroups or after propensity score matching. High-level D-dimer on admission is an independent risk factor for early tracheal intubation in isolated mTBI patients.
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Affiliation(s)
- Qi Zhang
- College of Basic Medicine, The Fourth Military Medical University, Xi'an, China
- Department of Critical Care Medicine, The Second Affiliated Hospitals, The Fourth Military Medical University, Xi'an, China
| | - Hong Min Kuang
- College of Basic Medicine, The Fourth Military Medical University, Xi'an, China
- Department of Critical Care Medicine, The Second Affiliated Hospitals, The Fourth Military Medical University, Xi'an, China
| | - Du Juan Qiao
- Department of Critical Care Medicine, The Second Affiliated Hospitals, The Fourth Military Medical University, Xi'an, China
| | - Xiang Lin Zhong
- College of Basic Medicine, The Fourth Military Medical University, Xi'an, China
- Department of Critical Care Medicine, The Second Affiliated Hospitals, The Fourth Military Medical University, Xi'an, China
| | - Jia Jia Kang
- Department of Neurosurgery, The Fourth Military Medical University, Xi'an, China
| | - Rui Na Ma
- Department of Pulmonary and Critical Care Medicine, The Fourth Military Medical University, Xi'an, China
| | - Min Li
- Department of Critical Care Medicine, The Second Affiliated Hospitals, The Fourth Military Medical University, Xi'an, China
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Peng S, Lv K. The role of fibrinogen in traumatic brain injury: from molecular pathological mechanisms to clinical management. Eur J Trauma Emerg Surg 2023; 49:1665-1672. [PMID: 35972516 DOI: 10.1007/s00068-022-02084-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 08/08/2022] [Indexed: 11/28/2022]
Abstract
Fibrinogen is the substrate of plasma coagulation. It plays an important role in the formation of reticular network, which is crucial to the strength and stability of blood clots. In addition to directly participating in coagulation, fibrinogen also participates in the destruction of blood-brain barrier and neuroinflammation. This article reviews the pathophysiological changes of fibrinogen after traumatic brain injury. Considerable efforts have been made to understand the mechanisms by which fibrinogen damages the central nervous system. Combined with the latest research hotspots, potentially promising treatment strategies at the molecular level were discussed. We believe that understanding the role of fibrinogen-mediated damage in nerve and blood-brain barrier function will enable timely intervention in patients with nerve damage, and guide the development of novel targeted therapeutics.
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Affiliation(s)
- Shixin Peng
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Yuzhong District, Chongqing, 400016, China
| | - Ke Lv
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Yuzhong District, Chongqing, 400016, China.
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Takahashi M, Wada T, Nakae R, Fujiki Y, Kanaya T, Takayama Y, Suzuki G, Naoe Y, Yokobori S. Antithrombin activity levels for predicting long-term outcomes in the early phase of isolated traumatic brain injury. Front Immunol 2022; 13:981826. [PMID: 36248813 PMCID: PMC9558212 DOI: 10.3389/fimmu.2022.981826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 09/15/2022] [Indexed: 11/13/2022] Open
Abstract
Coagulopathy management is an important strategy for preventing secondary brain damage in patients with traumatic brain injury (TBI). Antithrombin (AT) is a natural anticoagulant that controls coagulation and inflammation pathways. However, the significance of AT activity levels for outcomes in patients with trauma remains unclear. This study aimed to investigate the relationship between AT activity levels and long-term outcomes in patients with TBI; this was a sub-analysis of a prior study that collected blood samples of trauma patients prospectively in a tertiary care center in Kawaguchi City, Japan. We included patients with isolated TBI (iTBI) aged ≥16 years admitted directly to our hospital within 1 h after injury between April 2018 and March 2021. General coagulofibrinolytic and specific molecular biomarkers, including AT, were measured at 1, 3, 6, 12, and 24 h after injury. We analyzed changes in the AT activity levels during the study period and the impact of the AT activity levels on long-term outcomes, the Glasgow Outcome Scale-Extended (GOSE), 6 months after injury. 49 patients were included in this study; 24 had good neurological outcomes (GOSE 6–8), and 25 had poor neurological outcomes (GOSE 1–5). Low AT activity levels were shown within 1 h after injury in patients in the poor GOSE group; this was associated with poor outcomes. Furthermore, AT activity levels 1 h after injury had a strong predictive value for long-term outcomes (area under the receiver operating characteristic curve of 0.871; 95% CI: 0.747–0.994). Multivariate logistic regression analysis with various biomarkers showed that AT was an independent factor of long-term outcome (adjusted odds ratio: 0.873; 95% CI: 0.765–0.996; p=0.043). Another multivariate analysis with severity scores showed that low AT activity levels were associated with poor outcomes (adjusted odds ratio: 0.909; 95% CI: 0.822–1.010; p=0.063). We demonstrated that the AT activity level soon after injury could be a predictor of long-term neurological prognosis in patients with iTBI.
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Affiliation(s)
- Masaki Takahashi
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Takeshi Wada
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
- *Correspondence: Takeshi Wada,
| | - Ryuta Nakae
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, Tokyo, Japan
| | - Yu Fujiki
- Emergency and Critical Care Center, Kawaguchi Municipal Medical Center, Saitama, Japan
| | - Takahiro Kanaya
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, Tokyo, Japan
| | - Yasuhiro Takayama
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, Tokyo, Japan
| | - Go Suzuki
- Emergency and Critical Care Center, Kawaguchi Municipal Medical Center, Saitama, Japan
| | - Yasutaka Naoe
- Emergency and Critical Care Center, Kawaguchi Municipal Medical Center, Saitama, Japan
| | - Shoji Yokobori
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, Tokyo, Japan
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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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Shammassian BH, Ronald A, Smith A, Sajatovic M, Mangat HS, Kelly ML. Viscoelastic Hemostatic Assays and Outcomes in Traumatic Brain Injury: A Systematic Literature Review. World Neurosurg 2022; 159:221-236.e4. [PMID: 34844010 DOI: 10.1016/j.wneu.2021.10.180] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 10/27/2021] [Accepted: 10/28/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Coagulopathy in traumatic brain injury (TBI) occurs frequently and is associated with poor outcomes. Conventional coagulation assays (CCA) traditionally used to diagnose coagulopathy are often not time sensitive and do not assess complete hemostatic function. Viscoelastic hemostatic assays (VHAs) including thromboelastography and rotational thromboelastography provide a useful rapid and comprehensive point-of-care alternative for identifying coagulopathy, which is of significant consequence in patients with TBI with intracranial hemorrhage. METHODS A systematic review was performed in accordance with PRISMA guidelines to identify studies comparing VHA with CCA in adult patients with TBI. The following differences in outcomes were assessed based on ability to diagnose coagulopathy: mortality, need for neurosurgical intervention, and progression of traumatic intracranial hemorrhage (tICH). RESULTS Abnormal reaction time (R time), maximum amplitude, and K value were associated with increased mortality in certain studies but not all studies. This association was reflected across studies using different statistical parameters with different outcome definitions. An abnormal R time was the only VHA parameter found to be associated with the need for neurosurgical intervention in 1 study. An abnormal R time was also the only VHA parameter associated with progression of tICH. Overall, many studies also reported abnormal CCAs, mainly activated partial thromboplastin time, to be associated with poor outcomes. CONCLUSIONS Given the heterogenous nature of the available evidence including methodology and study outcomes, the comparative difference between VHA and CCA in predicting rates of neurosurgical intervention, tICH progression, or mortality in patients with TBI remains inconclusive.
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Affiliation(s)
- Berje H Shammassian
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA; Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.
| | - Andrew Ronald
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Arvin Smith
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Martha Sajatovic
- Neurological and Behavioral Outcomes Center, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Halinder S Mangat
- Department of Neurology, Division of Neurocritical Care, University of Kansas Medical Center Kansas City, Kansas, USA
| | - Michael L Kelly
- Metrohealth Medical Center, Department of Neurological Surgery, Cleveland, Ohio, USA
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TRAUMATIC BRAIN INJURY PROVOKES LOW FIBRINOLYTIC ACTIVITY IN SEVERELY INJURED PATIENTS. J Trauma Acute Care Surg 2022; 93:8-12. [PMID: 35170585 DOI: 10.1097/ta.0000000000003559] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) in combination with shock has been associated with hypocoagulability. However, recent data suggest that TBI itself can promote a systemic procoagulant state via the release of brain-derived extracellular vesicles. The objective of our study was to identify if TBI was associated with differences in thrombelastography (TEG) indices when controlling for other variables associated with coagulopathy following trauma. We hypothesized that TBI is independently associated with a less coagulopathic state. METHODS Prospective study including all highest-level trauma activations at an urban level 1 trauma center, from 2014-2020. TBI was defined as AIS Head ≥3. Blood samples were drawn at ED admission. Linear regression was used to assess the role of independent predictors on TIC. Models adjusted for ISS, shock (defined as ED SBP < 70, or ED SBP < 90 and ED HR > 108, or first hospital base deficit ≥10), and prehospital GCS. RESULTS Of the 1,023 patients included, 291 (28%) suffered a TBI. TBI patients more often were female (26% vs. 19%, p = 0.01), had blunt trauma (83% vs. 43%, p < 0.0001), shock (33% vs. 25%, p = 0.009), and higher median ISS (29 vs. 10, p < 0.0001). Fibrinolysis shutdown (25% vs. 18%) was more common in the TBI group (p < 0.0001). When controlled for the confounding effects of ISS and shock, the presence of TBI independently decreases LY30 (Beta estimate: - 0.16 ± 0.06, p = 0.004). This effect of TBI on LY30 persisted when controlling for sex and mechanism of injury in addition to ISS and shock (Beta estimate: -0.13 ± 0.06, p = 0.022). CONCLUSIONS TBI is associated with lower LY30 independent of shock, tissue injury, sex, and mechanism of injury. These findings suggest a propensity toward a less coagulopathic state in patients with TBI, possibly due to fibrinolysis shutdown. Tranexamic acid has been reported to improve outcomes following TBI. Our data suggest the mechanism may be independent of changes in fibrinolysis. LEVEL OF EVIDENCE Level III, Prognostic and Epidemiological.
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El-Swaify ST, Refaat MA, Ali SH, Abdelrazek AEM, Beshay PW, Kamel M, Bahaa B, Amir A, Basha AK. Controversies and evidence gaps in the early management of severe traumatic brain injury: back to the ABCs. Trauma Surg Acute Care Open 2022; 7:e000859. [PMID: 35071780 PMCID: PMC8734008 DOI: 10.1136/tsaco-2021-000859] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 12/10/2021] [Indexed: 11/04/2022] Open
Abstract
Traumatic brain injury (TBI) accounts for around 30% of all trauma-related deaths. Over the past 40 years, TBI has remained a major cause of mortality after trauma. The primary injury caused by the injurious mechanical force leads to irreversible damage to brain tissue. The potentially preventable secondary injury can be accentuated by addressing systemic insults. Early recognition and prompt intervention are integral to achieve better outcomes. Consequently, surgeons still need to be aware of the basic yet integral emergency management strategies for severe TBI (sTBI). In this narrative review, we outlined some of the controversies in the early care of sTBI that have not been settled by the publication of the Brain Trauma Foundation’s 4th edition guidelines in 2017. The topics covered included the following: mode of prehospital transport, maintaining airway patency while securing the cervical spine, achieving adequate ventilation, and optimizing circulatory physiology. We discuss fluid resuscitation and blood product transfusion as components of improving circulatory mechanics and oxygen delivery to injured brain tissue. An outline of evidence-based antiplatelet and anticoagulant reversal strategies is discussed in the review. In addition, the current evidence as well as the evidence gaps for using tranexamic acid in sTBI are briefly reviewed. A brief note on the controversial emergency surgical interventions for sTBI is included. Clinicians should be aware of the latest evidence for sTBI. Periods between different editions of guidelines can have an abundance of new literature that can influence patient care. The recent advances included in this review should be considered both for formulating future guidelines for the management of sTBI and for designing future clinical studies in domains with clinical equipoise.
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Affiliation(s)
| | - Mazen A Refaat
- Department of surgery, Ain Shams University Hospital, Cairo, Egypt
| | - Sara H Ali
- Department of surgery, Ain Shams University Hospital, Cairo, Egypt
| | | | | | - Menna Kamel
- Department of surgery, Ain Shams University Hospital, Cairo, Egypt
| | - Bassem Bahaa
- Department of surgery, Ain Shams University Hospital, Cairo, Egypt
| | - Abdelrahman Amir
- Department of surgery, Ain Shams University Hospital, Cairo, Egypt
| | - Ahmed Kamel Basha
- Department of neurosurgery, Ain Shams University Faculty of Medicine, Cairo, Egypt
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Anderson TN, Schreiber MA, Rowell SE. Viscoelastic Testing in Traumatic Brain Injury: Key Research Insights. Transfus Med Rev 2021; 35:108-112. [PMID: 34607730 DOI: 10.1016/j.tmrv.2021.08.002] [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: 06/03/2021] [Revised: 08/26/2021] [Accepted: 08/29/2021] [Indexed: 10/20/2022]
Abstract
The role of viscoelastic testing in the evaluation and management of traumatic brain injury (TBI) remains a subject of ongoing exploration. This review highlights four key publications that provide significant insights into this subject. Holcomb et al. provided early evidence of the relationship between thromboelastography (TEG) and conventional coagulation tests (CCTs). Later, Samuels et al. used TEG to identify a unique coagulopathy phenotype in TBI characterized by a notable absence of fibrinolytic abnormalities. Dixon et al. built upon these findings by exploring the application of TEG in the context of antifibrinolytic administration, noting a similar lack of effect on LY30. Finally, Guillotte et al. demonstrated the utility of TEG-PM in assessing platelet dysfunction in TBI. While these studies provide key early support for the utility of viscoelastic testing in the TBI, further exploration is needed to define evidence-based guidelines for clinical application.
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Affiliation(s)
- Taylor N Anderson
- Department of Surgery, Stanford University, Stanford, California, USA.
| | - Martin A Schreiber
- Professor of Surgery, Division of Trauma, Critical Care & Acute Care Surgery, Oregon Health & Science University, USA
| | - Susan E Rowell
- Professor of Surgery, Division of Trauma Surgery and Critical Care Medicine, University of Chicago, USA
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Liu HB, Xu WM, Wang SS, Wei LF, Hong JF, Wang C, Xian L. Analysis of changes in the volume of edema around brain contusions and the influencing factors: A single-center, retrospective, observational study. Medicine (Baltimore) 2021; 100:e27246. [PMID: 34559127 PMCID: PMC8462588 DOI: 10.1097/md.0000000000027246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 08/26/2021] [Indexed: 01/05/2023] Open
Abstract
Traumatic brain injury (TBI), a common neurosurgical condition, has well-known treatment guidelines. However, the mechanisms underlying the varying severity of brain edema secondary to TBI are largely unknown, leading to controversial treatments.This study seeks to measure edema volumes around brain contusions in different regions, analyze factors related to differences in edema volume and provide a theoretical basis for brain edema treatment.Data from 113 brain contusion patients treated at the Department of Neurosurgery of Fuzhou General Hospital from January 2017 to November 2019 were analyzed retrospectively. Based on computed tomography (CT) data, the patients were divided into the venous group (brain contusion in regions with large cortical veins, n = 47) and the nonvenous group (brain contusions in other regions, n = 66). Here, 3D Slicer software was used to calculate the brain contusion volume on the first CT obtained after injury and the brain contusion volume and its surrounding edema on the 5th day after injury. The brain contusion volume to surrounding edema volume ratio was calculated, and the number of patients who showed brain contusion progression requiring surgery was determined. Hematocrit (Hct), fibrinogen (Fg), and d-dimer levels within 6 hours and on the 5th day after admission were also compared.Patients in the venous group had a significantly increased percentage of area with edema around the brain contusion compared with patients in the nonvenous group (P < .05), and the 2 groups showed no significant difference in the number of patients with brain contusion progression or surgical treatment (P > .05) or Hct, Fg, or d-dimer (D-D) levels. For all patients, Hct, Fg, and D-D levels within 6 hours after admission were significantly different from those on the 5th day (P < .05 for all).Cortical venous obstruction may be the most important factor influencing edema around brain contusions. The Fg level decreased slightly, and the D-D level increased to its peak rapidly after mild-moderate TBI. This change was followed by a gradual increase in the former and a gradual decrease in the latter.
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Affiliation(s)
- Hai-Bing Liu
- Department of Neurosurgery of the 900th Hospital, Fuzong Clinical Medical School of Fujian Medical University, Fuzhou, Fujian Province, China
| | - Wei-Ming Xu
- Department of Neurosurgery, Hospital of Fuzhou Changle District, Fuzhou, Fujian Province, China
| | - Shou-Sen Wang
- Department of Neurosurgery of the 900th Hospital, Fuzong Clinical Medical School of Fujian Medical University, Fuzhou, Fujian Province, China
| | - Liang-Feng Wei
- Department of Neurosurgery of the 900th Hospital, Fuzong Clinical Medical School of Fujian Medical University, Fuzhou, Fujian Province, China
| | - Jing-Fang Hong
- Department of Neurosurgery of the 900th Hospital, Fuzong Clinical Medical School of Fujian Medical University, Fuzhou, Fujian Province, China
| | - Cheng Wang
- Department of Neurosurgery of the 900th Hospital, Fuzong Clinical Medical School of Fujian Medical University, Fuzhou, Fujian Province, China
| | - Liang Xian
- Department of Neurosurgery of the 900th Hospital, Fuzong Clinical Medical School of Fujian Medical University, Fuzhou, Fujian Province, China
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Hinson HE, Li P, Myers L, Agarwal C, Pollock J, McWeeney S. Incorporating Immunoproteins in the Development of Classification Models of Progression of Intracranial Hemorrhage After Traumatic Brain Injury. J Head Trauma Rehabil 2021; 36:E322-E328. [PMID: 33656476 PMCID: PMC8380269 DOI: 10.1097/htr.0000000000000654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To define clinical, radiographic, and blood-based biomarker features to be incorporated into a classification model of progression of intracranial hemorrhage (PICH), and to provide a pilot assessment of those models. METHODS Patients with hemorrhage on admission head computed tomography were identified from a prospectively enrolled cohort of subjects with traumatic brain injury. Initial and follow-up images were interpreted both by 2 independent readers, and disagreements adjudicated. Admission plasma samples were analyzed and principal components (PCs) composed of the immune proteins (IPs) significantly associated with the outcome of interest were selected for further evaluation. A series of logistic regression models were constructed based on (1) clinical variables (CV) and (2) clinical variables + immune proteins (CV+IP). Error rates of these models for correct classification of PICH were estimated; significance was set at P < .05. RESULTS We identified 106 patients, 36% had PICH. Dichotomized admission Glasgow Coma Scale (P = .004), Marshall score (P = .004), and 3 PCs were significantly associated with PICH. For the CV only model, sensitivity was 1.0 and specificity was 0.29 (95% CI, 0.07-0.67). The CV+IP model performed significantly better, with a sensitivity of 0.93 (95% CI, 0.64-0.99) and a specificity of 1.0 (P = .008). Adjustments to refine the definition of PICH and better define radiographic predictors of PICH did not significantly improve the models' performance. CONCLUSIONS In this pilot investigation, we observed that composites of IPs may improve PICH classification models when combined with CVs. However, overall model performance must be further optimized; results will inform feature inclusion included in follow-up models.
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Affiliation(s)
- H E Hinson
- Departments of Neurology (Drs Hinson and Agarwal and Mr Myers) and Radiology (Drs Li and Pollock), and Division of Bioinformatics & Computational Biology, Department of Medical Informatics and Clinical Epidemiology (Dr McWeeney), Oregon Health & Sciences University, Portland
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Hinson HE, Jacobs J, McWeeney S, Wachana A, Shi T, Martin K, Rodland K. Antibody-Free Mass Spectrometry Identification of Vascular Integrity Markers in Major Trauma. Neurotrauma Rep 2021; 2:322-329. [PMID: 34318300 PMCID: PMC8310742 DOI: 10.1089/neur.2021.0007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Antibody mediated strategies for protein biomarker detection are common, but may limit discovery. We hypothesized that the use of antibody-free proteomics is feasible for detecting protein biomarkers in plasma of patients sustaining major trauma. A subset of subjects with major trauma from a prospective observational trial were analyzed. Patients were assigned to one of four groups based on their presenting Abbreviated Injury Severity Score (AIS). Sensitive, antibody-free selective reaction monitoring (SRM) mass spectrometry (MS), with spiked-in isotopically labeled synthetic peptides, was used for targeted protein quantification of a panel of 10 prospective targets. An overall tiered sensitivity analytical approach was used for peptide detection and quantification based upon plasma immunoaffinity depletion and PRISM fractionation. Forty-four patients were included in the analysis, of which 82% were men with a mean age of 50 (±19) years. Half had isolated head injury (n = 22), with the remaining patients experiencing multiple injuries or polytrauma (n = 14), isolated body injury (n = 2), or minor injury (n = 6). Peptides from 3 proteins (vascular adhesion molecule 1 [VCAM1], intercellular adhesion molecule 1 [ICAM1], and matrix metalloproteinase 9 [MMP9]) were detected and quantified in non-depleted processed plasma. Peptides from 2 proteins (angiopoietin 2 [Ang2] and plasminogen activator inhibitor-1 [PAI1]) were detected and quantification in depleted plasma, whereas the remaining 5 of the 10 prospective targets were undetected. VCAM1 (p = 0.02) and MMP9 (p = 0.03) were significantly upregulated in in the major trauma groups (1–3) versus mild injury group (4), whereas the others were not. There were no differences in protein expression between patients with traumatic brain injury (TBI; groups 1 and 2) versus those without TBI (groups 3 and 4). We detected non-specific upregulation of proteins reflecting blood–brain barrier breakdown in severely injured patients, indicating label-free MS techniques are feasible and may be informative.
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Affiliation(s)
- H E Hinson
- Departments of Neurology, Developmental and Cancer Biology, Oregon Health & Sciences University, Portland, Oregon, USA
| | - Jon Jacobs
- Environmental and Molecular Sciences Laboratory, Pacific Northwest National Laboratories, Richland, Washington, USA
| | - Shannon McWeeney
- Division of Bioinformatics and Computational Biology, Department of Medical Informatics and Clinical Epidemiology, Developmental and Cancer Biology, Oregon Health & Sciences University, Portland, Oregon, USA
| | - Ann Wachana
- Portland State University, Portland, Oregon, USA
| | - Tujin Shi
- Environmental and Molecular Sciences Laboratory, Pacific Northwest National Laboratories, Richland, Washington, USA
| | - Kendall Martin
- Environmental and Molecular Sciences Laboratory, Pacific Northwest National Laboratories, Richland, Washington, USA
| | - Karin Rodland
- Environmental and Molecular Sciences Laboratory, Pacific Northwest National Laboratories, Richland, Washington, USA.,Department of Cell, Developmental and Cancer Biology, Oregon Health & Sciences University, Portland, Oregon, USA
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You CY, Lu SW, Fu YQ, Xu F. Relationship between admission coagulopathy and prognosis in children with traumatic brain injury: a retrospective study. Scand J Trauma Resusc Emerg Med 2021; 29:67. [PMID: 34016132 PMCID: PMC8136757 DOI: 10.1186/s13049-021-00884-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 05/10/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Coagulopathy in adult patients with traumatic brain injury (TBI) is strongly associated with unfavorable outcomes. However, few reports focus on pediatric TBI-associated coagulopathy. METHODS We retrospectively identified children with Glasgow Coma Scale ≤ 13 in a tertiary pediatric hospital from April 2012 to December 2019 to evaluate the impact of admission coagulopathy on their prognosis. A classification and regression tree (CART) analysis using coagulation parameters was performed to stratify the death risk among patients. The importance of these parameters was examined by multivariate logistic regression analysis. RESULTS A total of 281 children with moderate to severe TBI were enrolled. A receiver operating characteristic curve showed that activated partial thromboplastin time (APTT) and fibrinogen were effective predictors of in-hospital mortality. According to the CART analysis, APTT of 39.2 s was identified as the best discriminator, while 120 mg/dL fibrinogen was the second split in the subgroup of APTT ≤ 39.2 s. Patients were stratified into three groups, in which mortality was as follows: 4.5 % (APTT ≤ 39.2 s, fibrinogen > 120 mg/dL), 20.5 % (APTT ≤ 39.2 s and fibrinogen ≤ 120 mg/dL) and 60.8 % (APTT > 39.2 s). Furthermore, length-of-stay in the ICU and duration of mechanical ventilation were significantly prolonged in patients with deteriorated APTT or fibrinogen values. Multiple logistic regression analysis showed that APTT > 39.2 s and fibrinogen ≤ 120 mg/dL was independently associated with mortality in children with moderate to severe TBI. CONCLUSIONS We concluded that admission APTT > 39.2 s and fibrinogen ≤ 120 mg/dL were independently associated with mortality in children with moderate to severe TBI. Early identification and intervention of abnormal APTT and fibrinogen in pediatric TBI patients may be beneficial to their prognosis.
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Affiliation(s)
- Cheng-yan You
- Department of Critical Care Medicine, Childrens Hospital, Chongqing Medical University, 136# Zhongshan Er Road, Yu Zhong District, 400014 Chongqing, Peoples Republic of China
- Ministry of Education Key Laboratory of Child Development and Disorders, 400014 Chongqing, Peoples Republic of China
- National Clinical Research Center for Child Health and Disorders, 400014 Chongqing, Peoples Republic of China
- China International Science and Technology Cooperation base of Child development and Critical Disorders, 400014 Chongqing, Peoples Republic of China
- Chongqing Key Laboratory of Pediatrics, 400014 Chongqing, Peoples Republic of China
| | - Si-wei Lu
- Department of Critical Care Medicine, Childrens Hospital, Chongqing Medical University, 136# Zhongshan Er Road, Yu Zhong District, 400014 Chongqing, Peoples Republic of China
- Ministry of Education Key Laboratory of Child Development and Disorders, 400014 Chongqing, Peoples Republic of China
- National Clinical Research Center for Child Health and Disorders, 400014 Chongqing, Peoples Republic of China
- China International Science and Technology Cooperation base of Child development and Critical Disorders, 400014 Chongqing, Peoples Republic of China
- Chongqing Key Laboratory of Pediatrics, 400014 Chongqing, Peoples Republic of China
| | - Yue-qiang Fu
- Department of Critical Care Medicine, Childrens Hospital, Chongqing Medical University, 136# Zhongshan Er Road, Yu Zhong District, 400014 Chongqing, Peoples Republic of China
- Ministry of Education Key Laboratory of Child Development and Disorders, 400014 Chongqing, Peoples Republic of China
- National Clinical Research Center for Child Health and Disorders, 400014 Chongqing, Peoples Republic of China
- China International Science and Technology Cooperation base of Child development and Critical Disorders, 400014 Chongqing, Peoples Republic of China
- Chongqing Key Laboratory of Pediatrics, 400014 Chongqing, Peoples Republic of China
| | - Feng Xu
- Department of Critical Care Medicine, Childrens Hospital, Chongqing Medical University, 136# Zhongshan Er Road, Yu Zhong District, 400014 Chongqing, Peoples Republic of China
- Ministry of Education Key Laboratory of Child Development and Disorders, 400014 Chongqing, Peoples Republic of China
- National Clinical Research Center for Child Health and Disorders, 400014 Chongqing, Peoples Republic of China
- China International Science and Technology Cooperation base of Child development and Critical Disorders, 400014 Chongqing, Peoples Republic of China
- Chongqing Key Laboratory of Pediatrics, 400014 Chongqing, Peoples Republic of China
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Anderson TN, Farrell DH, Rowell SE. Fibrinolysis in Traumatic Brain Injury: Diagnosis, Management, and Clinical Considerations. Semin Thromb Hemost 2021; 47:527-537. [PMID: 33878779 DOI: 10.1055/s-0041-1722970] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Posttraumatic coagulopathy involves disruption of both the coagulation and fibrinolytic pathways secondary to tissue damage, hypotension, and inflammatory upregulation. This phenomenon contributes to delayed complications after traumatic brain injury (TBI), including intracranial hemorrhage progression and systemic disseminated intravascular coagulopathy. Development of an early hyperfibrinolytic state may result in uncontrolled bleeding and is associated with increased mortality in patients with TBI. Although fibrinolytic assays are not routinely performed in the assessment of posttraumatic coagulopathy, circulating biomarkers such as D-dimer and fibrin degradation products have demonstrated potential utility in outcome prediction. Unfortunately, the relatively delayed nature of these tests limits their clinical utility. In contrast, viscoelastic tests are able to provide a rapid global assessment of coagulopathy, although their ability to reliably identify disruptions in the fibrinolytic cascade remains unclear. Limited evidence supports the use of hypertonic saline, cryoprecipitate, and plasma to correct fibrinolytic disruption; however, some studies suggest more harm than benefit. Recently, early use of tranexamic acid in patients with TBI and confirmed hyperfibrinolysis has been proposed as a strategy to further improve clinical outcomes. Moving forward, further delineation of TBI phenotypes and the clinical implications of fibrinolysis based on phenotypic variation is needed. In this review, we summarize the clinical aspects of fibrinolysis in TBI, including diagnosis, treatment, and clinical correlates, with identification of targeted areas for future research efforts.
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Affiliation(s)
- Taylor N Anderson
- School of Medicine, Division of Trauma, Critical Care and Acute Care Surgery, Oregon Health and Science University, Portland, Oregon
| | - David H Farrell
- School of Medicine, Division of Trauma, Critical Care and Acute Care Surgery, Oregon Health and Science University, Portland, Oregon
| | - Susan E Rowell
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
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Lv K, Yuan Q, Fu P, Wu G, Wu X, Du Z, Yu J, Li Z, Hu J. Impact of fibrinogen level on the prognosis of patients with traumatic brain injury: a single-center analysis of 2570 patients. World J Emerg Surg 2020; 15:54. [PMID: 32977824 PMCID: PMC7517804 DOI: 10.1186/s13017-020-00332-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 08/27/2020] [Indexed: 11/19/2022] Open
Abstract
Background Fibrinogen may play an important role in the survival of trauma patients; however, its role in traumatic brain injury (TBI) and its correlation with disease prognosis remain poorly understood. The aims of this study were to determine the incidence of TBI-associated hypofibrinogenemia in patients with TBI and to evaluate the prognostic value of fibrinogen level with respect to mortality and clinical outcomes. Methods A total of 2570 consecutive TBI patients were retrospectively studied. Prognostic evaluations were determined using the Glasgow Outcome Score (GOS) assessment 3 months after injury. The shape of the relationship between fibrinogen level and mortality or outcome was examined using cubic spline functions. Logistic regression analyses were conducted to identify the association between fibrinogen level and 3-month functional outcomes. Results Fibrinogen concentrations < 2 g/L were observed in 992 (38.6%) patients at the time of admission. Multivariate analyses showed that for patients with fibrinogen levels < 2.0 g/L, those levels were an independent prognostic factor for 3-month mortality (odds ratio [OR], 0.91; 95% confidence interval [CI], 0.89–0.93; P < .001). By contrast, for patients with fibrinogen levels < 2.5 g/L, the levels were an independent prognostic factor for favorable outcomes at 3 months (OR, 1.654; 95% CI, 1.186–2.306; P = .003). Similar results were also seen for patients with fibrinogen levels > 3.0 g/L, with the levels being an independent prognostic factor for favorable outcomes at 3 months (OR, 0.771; 95% CI, 0.607–0.979; P = .033). Conclusions Fibrinogen is an independent prognostic factor for clinical outcomes in TBI patients. Maintaining the level of fibrinogen between 2.5 and 3 g/L may improve clinical outcomes in patients with TBI.
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Affiliation(s)
- Ke Lv
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Middle Road, Shanghai, China
| | - Qiang Yuan
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Middle Road, Shanghai, China
| | - Pengfei Fu
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Middle Road, Shanghai, China
| | - Gang Wu
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Middle Road, Shanghai, China
| | - Xing Wu
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Middle Road, Shanghai, China
| | - Zhuoying Du
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Middle Road, Shanghai, China
| | - Jian Yu
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Middle Road, Shanghai, China
| | - Zhiqi Li
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Middle Road, Shanghai, China
| | - Jin Hu
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Middle Road, Shanghai, China.
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Farrell DH, Rick EA, Dewey EN, Schreiber MA, Rowell SE. γ' fibrinogen levels are associated with blood clot strength in traumatic brain injury patients. Am J Surg 2020; 220:459-463. [PMID: 31948701 PMCID: PMC7641475 DOI: 10.1016/j.amjsurg.2019.12.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 11/20/2019] [Accepted: 12/23/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND γ' fibrinogen is an alternatively-spliced fibrinogen variant that displays different coagulation parameters in vitro than the major form of fibrinogen. Purified γ' fibrinogen has slower clotting kinetics than unfractionated fibrinogen, but forms clots that are stronger and resistant to fibrinolysis. However, these properties have only been investigated in human populations in a limited number of studies. We therefore performed a retrospective analysis to test the hypothesis that γ' fibrinogen levels influence coagulation in vivo. METHODS In the present study, we utilized blood samples that were collected from traumatic brain injury patients to probe the relationship between γ' fibrinogen levels and traditional coagulation parameters. RESULTS The results show that the levels of γ' fibrinogen were inversely associated with clotting kinetics, indicated by a shortened INR. In addition, the levels of γ' fibrinogen were associated with stronger clots by thrombelastography. However, these changes were not associated with significant changes in hemorrhage progression. CONCLUSIONS These findings verify that γ' fibrinogen properties observed in purified systems result in similar properties in a clinical setting, and may affect coagulation.
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Affiliation(s)
- David H Farrell
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health & Science University, Portland, OR, USA.
| | - Elizabeth A Rick
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Elizabeth N Dewey
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Martin A Schreiber
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Susan E Rowell
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Duke University School of Medicine, Durham, NC, USA
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Slavoaca D, Muresanu D, Birle C, Rosu OV, Chirila I, Dobra I, Jemna N, Strilciuc S, Vos P. Biomarkers in traumatic brain injury: new concepts. Neurol Sci 2020; 41:2033-2044. [PMID: 32157587 DOI: 10.1007/s10072-019-04238-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Accepted: 12/30/2019] [Indexed: 12/21/2022]
Abstract
Traumatic brain injury is a multifaceted condition that encompasses a spectrum of injuries: contusions, axonal injuries in specific brain regions, edema, and hemorrhage. Brain injury determines a broad clinical and disability spectrum due to the implication of various cellular pathways, genetic phenotypes, and environmental factors. It is challenging to predict patient outcomes, to appropriately evaluate the patients, to determine a suitable treatment strategy and rehabilitation program, and to communicate with patient relatives. Biomarkers detected from body fluids are potential evaluation tools for traumatic brain injury patients. These may serve as internal indicators of cerebral damage, delivering valuable information about the dynamic cellular, biochemical, and molecular environments. The diagnostic and prognostic value of biomarkers tested both in animal models of traumatic brain injury is still under question, despite a considerable scientific literature. Recent publications emphasize that a more realistic approach involves combining multiple types of biomarkers with other investigative tools (imaging, outcome scales, and genetic polymorphisms). Additionally, there is increasing interest in the use of biomarkers as tools for treatment monitoring and as surrogate outcome variables to facilitate the design of distinct randomized controlled trials. This review highlights the latest available evidence regarding biomarkers in adults after traumatic brain injury and discusses new approaches in the evaluation of this patient group.
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Affiliation(s)
- Dana Slavoaca
- Department of Neurosciences, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
- RoNeuro Institute for Neurological Research and Diagnostic, No. 37 Mircea Eliade Street, 400486, Cluj-Napoca, Romania
| | - Dafin Muresanu
- Department of Neurosciences, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania.
- RoNeuro Institute for Neurological Research and Diagnostic, No. 37 Mircea Eliade Street, 400486, Cluj-Napoca, Romania.
| | - Codruta Birle
- Department of Neurosciences, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
- RoNeuro Institute for Neurological Research and Diagnostic, No. 37 Mircea Eliade Street, 400486, Cluj-Napoca, Romania
| | - Olivia Verisezan Rosu
- Department of Neurosciences, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
- RoNeuro Institute for Neurological Research and Diagnostic, No. 37 Mircea Eliade Street, 400486, Cluj-Napoca, Romania
| | - Ioana Chirila
- Neurology Clinic, Cluj Emergency County Hospital, Cluj-Napoca, Romania
| | - Iulia Dobra
- Neurology Clinic, Cluj Emergency County Hospital, Cluj-Napoca, Romania
| | - Nicoleta Jemna
- Department of Neurosciences, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
- RoNeuro Institute for Neurological Research and Diagnostic, No. 37 Mircea Eliade Street, 400486, Cluj-Napoca, Romania
| | - Stefan Strilciuc
- Department of Neurosciences, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
- RoNeuro Institute for Neurological Research and Diagnostic, No. 37 Mircea Eliade Street, 400486, Cluj-Napoca, Romania
| | - Pieter Vos
- Department of Neurology, Slingeland Hospital, Doetinchem, The Netherlands
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Response to the Comment on “The S100A10 Pathway Mediates an Occult Hyperfibrinolytic Subtype in Trauma Patients”. Ann Surg 2020; 271:e111-e112. [DOI: 10.1097/sla.0000000000003691] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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22
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Does Complement-Mediated Hemostatic Disturbance Occur in Traumatic Brain Injury? A Literature Review and Observational Study Protocol. Int J Mol Sci 2020; 21:ijms21051596. [PMID: 32111078 PMCID: PMC7084711 DOI: 10.3390/ijms21051596] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 02/07/2020] [Accepted: 02/25/2020] [Indexed: 12/11/2022] Open
Abstract
Despite improvements in medical triage and tertiary care, traumatic brain injury (TBI) remains associated with significant morbidity and mortality. Almost two-thirds of patients with severe TBI develop some form of hemostatic disturbance, which contributes to poor outcome. In addition, the complement system, which is abundant in the healthy brain, undergoes significant intra- and extracranial amplification following TBI. Previously considered to be structurally similar but separate systems, evidence of an interaction between the complement and coagulation systems in non-TBI cohorts has accumulated, with the activation of one system amplifying the activation of the other, independent of their established pathways. However, it is not known whether this interaction exists in TBI. In this review we summarize the available literature on complement activation following TBI, and the crosstalk between the complement and coagulation systems. We demonstrate how the complement system interacts with the coagulation cascade by activating the intrinsic coagulation pathway and by bypassing the initial cascade and directly producing thrombin as well. This crosstalk also effects platelets, where evidence points to a relationship with the complement system on multiple levels, with complement anaphylatoxins being able to induce disproportionate platelet activation and adhesion. The complement system also stimulates thrombosis by inhibiting fibrinolysis and stimulating endothelial cells to release prothrombotic microparticles. These interactions see clinical relevance in several disorders where a deficiency in complement regulation seems to result in a prothrombotic clinical presentation. Finally, based on these observations, we present the outline of an observational cohort study that is currently under preparation and aimed at assessing how complement influences coagulation in patients with isolated TBI.
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