The influence of hemocoagulation disorders on the development of posttraumatic cerebral infarction and outcome in patients with moderate or severe head trauma

Antithrombin activity levels for predicting long-term outcomes in the early phase of isolated traumatic brain injury

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.

Surgical Outcomes in Patients with Simultaneous Traumatic Brain and Torso Injuries in a Single Regional Trauma Center over a 5-Year Period

Purpose The purpose of the study is to analyze the results of surgical treatment of patients with brain and torso injury for 5 years in a single regional trauma center. Methods We analyzed multiple trauma patients who underwent brain surgery and torso surgery for chest or abdominal injury simultaneously or sequentially among all 14,175 trauma patients who visited Dankook University Hospital Regional Trauma Center from January 2015 to December 2019. Results A total of 25 patients underwent brain surgery and chest or abdominal surgery, with an average age of 55.4 years, 17 men and eight women. As a result of surgical treatment, there were 14 patients who underwent the surgery on the same day (resuscitative surgery), of which five patients underwent surgery simultaneously, four patients underwent brain surgery first, and one patient underwent chest surgery first, four patients underwent abdominal surgery first. Among the 25 treated patients, the 10 patients died, which the cause of death was five severe brain injuries and four hemorrhagic shocks. Conclusions In multiple damaged patients require both torso surgery and head surgery, poor prognosis was associated with low initial Glasgow Coma Scale and high Injury Severity Score. On the other hand, patients had good prognosis when blood pressure was maintained and operation for traumatic brain injury was performed first. At the same time, patients who had operation on head and torso simultaneously had extremely low survival rates. This may be associated with secondary brain injury due to low perfusion pressure or continuous hypotension and the traumatic coagulopathy caused by massive bleeding.

A Machine Learning Approach for the Prediction of Traumatic Brain Injury Induced Coagulopathy

Background: Traumatic brain injury-induced coagulopathy (TBI-IC), is a disease with poor prognosis and increased mortality rate.

Objectives: Our study aimed to identify predictors as well as develop machine learning (ML) models to predict the risk of coagulopathy in this population.

Methods: ML models were developed and validated based on two public databases named Medical Information Mart for Intensive Care (MIMIC)-IV and the eICU Collaborative Research Database (eICU-CRD). Candidate predictors, including demographics, family history, comorbidities, vital signs, laboratory findings, injury type, therapy strategy and scoring system were included. Models were compared on area under the curve (AUC), accuracy, sensitivity, specificity, positive and negative predictive values, and decision curve analysis (DCA) curve.

Results: Of 999 patients in MIMIC-IV included in the final cohort, a total of 493 (49.35%) patients developed coagulopathy following TBI. Recursive feature elimination (RFE) selected 15 variables, including international normalized ratio (INR), prothrombin time (PT), sepsis related organ failure assessment (SOFA), activated partial thromboplastin time (APTT), platelet (PLT), hematocrit (HCT), red blood cell (RBC), hemoglobin (HGB), blood urea nitrogen (BUN), red blood cell volume distribution width (RDW), creatinine (CRE), congestive heart failure, myocardial infarction, sodium, and blood transfusion. The external validation in eICU-CRD demonstrated that adapting boosting (Ada) model had the highest AUC of 0.924 (95% CI: 0.902–0.943). Furthermore, in the DCA curve, the Ada model and the extreme Gradient Boosting (XGB) model had relatively higher net benefits (ie, the correct classification of coagulopathy considering a trade-off between false- negatives and false-positives)—over other models across a range of threshold probability values.

Conclusions: The ML models, as indicated by our study, can be used to predict the incidence of TBI-IC in the intensive care unit (ICU).

The Association Between D-dimer Levels and Long-Term Neurological Outcomes of Patients with Traumatic Brain Injury: An Analysis of a Nationwide Observational Neurotrauma Database in Japan

BACKGROUND

We evaluated the association between D-dimer (DD) levels and long-term neurological prognoses among patients with isolated traumatic brain injury.

METHODS

Using data from multiple centers in the Japanese Neurotrauma Data Bank, we conducted an observational retrospective cohort study. Patients with isolated traumatic brain injury (head Abbreviated Injury Scale score > 2; any other Abbreviated Injury Scale score < 3) who were registered in the Japanese Neurotrauma Data Bank from 2015 to 2017 were recruited. We excluded patients younger than age 16 years and those who developed cardiac arrest at hospital admission. We also excluded patients with unknown Glasgow Outcome Scale (GOS) scores at 6 months after injury and those with unknown DD levels. The primary outcome was the association of DD levels with GOS scores at 6 months. We defined GOS scores 1 to 3 as poor and GOS scores 4 and 5 as good. The secondary outcome was the association of DD levels with mortality at 6 months after injury. We conducted multivariate logistic regression analyses to calculate the adjusted odds ratios of DD levels at hospital admission and GOS scores at 6 months as tertiles with 95% confidence intervals (CIs). A total of 293 patients were enrolled (median age 67 years; interquartile range 51-79 years). The median DD level was 27.1 mg/L (interquartile range 9.7-70.8 mg/L), and 58.0% (n = 170) had poor GOS scores at 6 months.

RESULTS

The multivariable logistic regression analysis indicated that the adjusted odds ratios were 2.52 (95% CI 1.10-5.77) for middle DD levels with poor GOS scores at 6 months and 5.81 (95% CI 2.37-14.2) for high DD levels with poor GOS scores at 6 months.

CONCLUSIONS

We revealed an association between DD levels and poor long-term neurological outcomes among patients with isolated traumatic brain injury.

Global Characterisation of Coagulopathy in Isolated Traumatic Brain Injury (iTBI): A CENTER-TBI Analysis

BACKGROUND

Trauma-induced coagulopathy in patients with traumatic brain injury (TBI) is associated with high rates of complications, unfavourable outcomes and mortality. The mechanism of the development of TBI-associated coagulopathy is poorly understood.

METHODS

This analysis, embedded in the prospective, multi-centred, observational Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study, aimed to characterise the coagulopathy of TBI. Emphasis was placed on the acute phase following TBI, primary on subgroups of patients with abnormal coagulation profile within 4 h of admission, and the impact of pre-injury anticoagulant and/or antiplatelet therapy. In order to minimise confounding factors, patients with isolated TBI (iTBI) (n = 598) were selected for this analysis.

RESULTS

Haemostatic disorders were observed in approximately 20% of iTBI patients. In a subgroup analysis, patients with pre-injury anticoagulant and/or antiplatelet therapy had a twice exacerbated coagulation profile as likely as those without premedication. This was in turn associated with increased rates of mortality and unfavourable outcome post-injury. A multivariate analysis of iTBI patients without pre-injury anticoagulant therapy identified several independent risk factors for coagulopathy which were present at hospital admission. Glasgow Coma Scale (GCS) less than or equal to 8, base excess (BE) less than or equal to - 6, hypothermia and hypotension increased risk significantly.

CONCLUSION

Consideration of these factors enables early prediction and risk stratification of acute coagulopathy after TBI, thus guiding clinical management.

Upregulation of C Terminus of Hsc70-Interacting Protein Attenuates Apoptosis and Procoagulant Activity and Facilitates Brain Repair After Traumatic Brain Injury

Traumatic brain injury (TBI) could highly induce coagulopathy through breaking the dynamic balance between coagulation and fibrinolysis systems, which may be a major contributor to the progressive secondary injury cascade that occurs after TBI. Phosphatase and tensin homolog deleted on chromosome 10 (PTEN) inhibition is reported to exert neuroprotection in TBI, making it a potential regulatory target involved in TBI-induced coagulation disorder. PTEN level is controlled in a major way by E3 ligase-mediated degradation through the ubiquitin-proteasome system. The C terminus of Hsc70-interacting protein (CHIP) has been shown to regulate proteasomal degradation and ubiquitination level of PTEN. In the present study, CHIP was overexpressed and knocked down in mouse brain microvascular endothelial cells (bEnd.3) and tissues during the early phase of TBI. In vitro cell proliferation, cell apoptosis, migration capacity, and invasion capacity were determined. The changes of procoagulant and apoptosis molecules after TBI were also detected as well as the micrangium density and blood-brain barrier permeability after in vivo TBI. In vitro results demonstrated that CHIP overexpression facilitated bEnd.3 cell proliferation, migration, and invasion and downregulated cell apoptosis and the expressions of procoagulant molecules through promoting PTEN ubiquitination in a simulated TBI model with stretch-induced injury treatment. In vivo experiments also demonstrated that CHIP overexpression suppressed post-TBI apoptosis and procoagulant protein expressions, as well as increased microvessel density, reduced hemorrhagic injury, and blood-brain barrier permeability. These findings suggested that the upregulation of CHIP may attenuate apoptosis and procoagulant activity, facilitate brain repair, and thus exerts neuroprotective effects in TBI.

Age-Related Differences in the Time Course of Coagulation and Fibrinolytic Parameters in Patients with Traumatic Brain Injury

Coagulopathy and older age are common and well-recognized risk factors for poorer outcomes in traumatic brain injury (TBI) patients; however, the relationships between coagulopathy and age remain unclear. We hypothesized that coagulation/fibrinolytic abnormalities are more pronounced in older patients and may be a factor in poorer outcomes. We retrospectively evaluated severe TBI cases in which fibrinogen and D-dimer were measured on arrival and 3–6 h after injury. Propensity score-matched analyses were performed to adjust baseline characteristics between older patients (the “elderly group,” aged ≥75 y) and younger patients (the “non-elderly group,” aged 16–74 y). A total of 1294 cases (elderly group: 395, non-elderly group: 899) were assessed, and propensity score matching created a matched cohort of 324 pairs. Fibrinogen on admission, the degree of reduction in fibrinogen between admission and 3–6 h post-injury, and D-dimer levels between admission and 3–6 h post-injury were significantly more abnormal in the elderly group than in the non-elderly group. On multivariate logistic regression analysis, independent risk factors for poor prognosis included low fibrinogen and high D-dimer levels on admission. Posttraumatic coagulation and fibrinolytic abnormalities are more severe in older patients, and fibrinogen and D-dimer abnormalities are negative predictive factors.

Serum Exosomal Proteins F9 and TSP-1 as Potential Diagnostic Biomarkers for Newly Diagnosed Epilepsy

Epilepsy is one of the most common chronic neurological diseases in the world, with a high incidence, a high risk of sudden unexplained death, and diagnostic challenges. Exosomes are nanosized extracellular vesicles that are released into physical environments and carry a variety of biological information. Moreover, exosomes can also be synthesized and released from brain cells, passing through the blood-brain barrier, and can be detected in peripheral blood or cerebrospinal fluid. Our study using the tandem mass tag (TMT) approach showed that a total of 76 proteins were differentially expressed in serum exosomes between epilepsy patients and healthy controls, with 6 proteins increasing and 70 proteins decreasing. Analysis of large clinical samples and two mouse models of chronic epilepsy indicated that two significantly differentially expressed serum exosomal proteins, coagulation factor IX (F9) and thrombospondin-1 (TSP-1), represent promising biomarkers for the diagnosis of epilepsy, with area under the curve (AUC) values of up to 0.7776 (95% CI, 0.7306–0.8246) and 0.8534 (95% CI, 0.8152–0.8916), respectively. This is the first study of exosomal proteins in epilepsy, and it suggests that exosomes are promising new tools for the diagnosis of epilepsy.

Higher Admission D-Dimer Values Are Associated With an Increased Risk of Nonroutine Discharge in Neurosurgery Patients

Background

D-dimers are serum acute-phase proteins with a role in mediating inflammation that may be used as biomarkers for the prediction of deep vein thrombosis. Recent studies have shown that D-dimers can be used to predict prognosis and stratify risk in neurosurgical patients; however, a comparative analysis across diagnostic subtypes has yet to be performed.

Methods

A bioinformatics analysis evaluated neurosurgical patients with admission D-dimer levels between 2008 and 2017. Nonroutine disposition (e.g., skilled nursing facility, rehabilitation, other hospital, mortality) was primarily evaluated.

Results

A total of 1,854 patients (mean age 55.1±18.2 years, 55.4% male; mean admission D-dimer 4.83±7.78 μg/ml) were identified. Patient diagnoses included vascular (27.1%), trauma (16.4%), multiple diagnoses (15.7%), spine (15.6%), tumor (13.0%), and other (12.2%) causes. Univariate analysis showed that older age (p=0.0001), higher American Society of Anesthesiologists (ASA) score (p=0.0001), lower Glasgow Coma Scale (GCS) score (p=0.0001), diagnosis type (p=0.0001), longer length of stay (LOS) (p=0.0001), higher infection rate (p=0.0001), surgery in the past year (p=0.02), and higher D-dimer levels (3.4±4.9 vs. 5.4±8.7 μg/ml, p=0.0001) were associated with nonroutine disposition. Multivariate logistic regression showed that elevated D-dimers were independently associated with a greater relative risk of nonroutine disposition (relative risk [RR] 1.026, 95% CI 1.02-1.033, p=0.0001).

Conclusions

Elevated admission D-dimer values were independently associated with a 3% increased risk of nonroutine disposition per D-dimer unit after accounting for other factors. These results suggest that D-dimer values may help in stratifying patient risk models despite clinical heterogeneity. Further refinement of neurosurgical patient risk models using clinical variables and biomarkers may aid in resource allocation and early warning.

Impact of a posttraumatic cerebral infarction on outcome in patients with TBI: the Italian multicenter cohort INCEPT study

BACKGROUND

Post-traumatic cerebral infarction (PTCI) is common after traumatic brain injury (TBI). It is unclear what the occurrence of a PTCI is, how it impacts the long-term outcome, and whether it adds incremental prognostic value to established outcome predictors.

METHODS

This was a prospective multicenter cohort study of moderate and severe TBI patients. The primary objective was to evaluate if PTCI was an independent risk factor for the 6-month outcome assessed with the Glasgow Outcome Scale (GOS). We also assessed the PTCI occurrence and if it adds incremental value to the International Mission for Prognosis and Clinical Trial design in TBI (IMPACT) core and extended models.

RESULTS

We enrolled 143 patients, of whom 47 (32.9%) developed a PTCI. In the multiple ordered logistic regression, PTCI was retained in both the core and extended IMPACT models as an independent predictor of the GOS. The predictive performances increased significantly when PTCI was added to the IMPACT core model (AUC = 0.73, 95% C.I. 0.66-0.82; increased to AUC = 0.79, 95% CI 0.71-0.83, p = 0.0007) and extended model (AUC = 0.74, 95% C.I. 0.65-0.81 increased to AUC = 0.80, 95% C.I. 0.69-0.85; p = 0.00008). Patients with PTCI showed higher ICU mortality and 6-month mortality, whereas hospital mortality did not differ between the two groups.

CONCLUSIONS

PTCI is a common complication in patients suffering from a moderate or severe TBI and is an independent risk factor for long-term disability. The addition of PTCI to the IMPACT core and extended predictive models significantly increased their performance in predicting the GOS.

TRIAL REGISTRATION

The present study was registered in ClinicalTrial.gov with the ID number NCT02430324.

Management of subdural effusion and hydrocephalus following decompressive craniectomy for posttraumatic cerebral infarction in a patient with traumatic brain injury: a case report

Background

Subdural effusion with hydrocephalus (SDEH) is a rare complication of traumatic brain injury, especially following decompressive craniectomy (DC) for posttraumatic cerebral infarction. The diagnosis and treatment are still difficult and controversial for neurosurgeons.

Case presentation

A 45-year-old man developed traumatic cerebral infarction after traumatic brain injury and underwent DC because of the mass effect of cerebral infarction. Unfortunately, the complications of traumatic subdural effusion (SDE) and hydrocephalus occurred in succession following DC. Burr-hole drainage and subdural peritoneal shunt were performed in sequence because of the mass effect of SDE, which only temporarily improved the symptoms of the patient. Cranioplasty and ventriculoperitoneal shunt were performed ultimately, after which SDE disappeared completely. However, the patient remains severely disabled, with a Glasgow Outcome Scale of 3.

Conclusions

It is important for neurosurgeons to consider the presence of accompanying hydrocephalus when treating patients with SDE. Once the diagnosis of SDEH is established and the SDE has no mass effect, timely ventriculoperitoneal shunt may be needed to avoid multiple surgical procedures, which is a safe and effective surgical method to treat SDEH.

Outcomes after Traumatic Brain Injury with Concomitant Severe Extracranial Injuries

Traumatic brain injury (TBI) is a leading cause of death and disability in trauma patients. Patients with TBI frequently sustain concomitant injuries in extracranial regions. The effect of severe extracranial injury (SEI) on the outcome of TBI is controversial. For 8 years, we retrospectively enrolled 485 patients with the blunt head injury with head abbreviated injury scale (AIS) ≧ 3. SEI was defined as AIS ≧ 3 injuries in the face, chest, abdomen, and pelvis/extremities. Vital signs and coagulation parameter values were also extracted from the database. Total patients were dichotomized into isolated TBI (n = 343) and TBI associated with SEI (n = 142). The differences in severity and outcome between these two groups were analyzed. To assess the relation between outcome and any variables showing significant differences in univariate analysis, we included the parameters in univariable and multivariable logistic regression analyses. Mortality was 17.8% in the isolated TBI group and 21.8% in TBI with SEI group (P = 0.38), but the Glasgow Outcome Scale (GOS) in the TBI with SEI group was unfavorable compared to the isolated TBI group (P = 0.002). Patients with SBP ≦ 90 mmHg were frequent in the TBI with SEI group. Adjusting for age, GCS, and length of hospital stay, SEI was a strong prognostic factor for mortality with adjusted ORs of 2.30. Hypotension and coagulopathy caused by SEI are considerable factors underlying the secondary insults to TBI. It is important to manage not only the brain but the whole body in the treatment of TBI patients with SEI.

Predictors Associated With Post-Traumatic Hydrocephalus in Patients With Head Injury Undergoing Unilateral Decompressive Craniectomy

Objective

Post-traumatic hydrocephalus (PTH) makes recovery from head trauma after decompression more complicated and is associated with high risks of clinical deterioration and poor outcomes. The aim of this study was to verify the predictors associated with the development of PTH in patients with head injury undergoing unilateral decompressive craniectomy (DC).

Methods

Among traumatic brain injury (TBI) patients who underwent unilateral DC between January 2013 and December 2016, the clinical medical records, radiological information, and changes of patients’ conditions in the 3-month after injury were reviewed retrospectively.

Results

183 TBI patients after unilateral DC were analyzed, and 50 (27.32%) of them suffered PTH based on head CT scans. Univariate and multivariable analyses revealed that older age (p = 0.002), the Glasgow Coma Scale (GCS) score at admission (p < 0.001), intraventricular hemorrhage (IVH; p = 0.008), post-traumatic cerebral infarction (PCI; p = 0.007), and postoperative meningitis (p = 0.016) were independent predictors for the hydrocephalus after DC. Receiver operating characteristic curves were created and the area under the curve (AUC) were calculated to further assess the accuracy of the variables for predicting PTH. The AUC was 0.836 for the combined all five independent factors (95% confidence interval: 0.775–0.887).

Conclusion

TBI patients who undergo unilateral DC with advanced age, lower GCS score at admission, coexisting IVH, PCI, and/or postoperative meningitis should be closely monitored at follow-up assessments for earlier prediction of PTH.

Neurologic complications of polytrauma

Neurologic complications in polytrauma can be classified by etiology and clinical manifestations: neurovascular, delirium, and spinal or neuromuscular problems. Neurovascular complications include ischemic strokes, intracranial hemorrhage, or the development of traumatic arteriovenous fistulae. Delirium and encephalopathy have a reported incidence of 67-92% in mechanically ventilated polytrauma patients. Causes include sedation, analgesia/pain, medications, sleep deprivation, postoperative state, toxic ingestions, withdrawal syndromes, organ system dysfunction, electrolyte/metabolic abnormalities, and infections. Rapid identification and treatment of the underlying cause are imperative. Benzodiazepines increase the risk of delirium, and alternative agents are preferred sedatives. Pharmacologic treatment of agitated delirium can be achieved with antipsychotics. Nonconvulsive seizures and status epilepticus are not uncommon in surgical/trauma intensive care unit (ICU) patients, require electroencephalography for diagnosis, and need timely management. Spinal cord ischemia is a known complication in patients with traumatic aortic dissections or blunt aortic injury requiring surgery. Thoracic endovascular aortic repair has reduced the paralysis rate. Neuromuscular complications include nerve and plexus injuries, and ICU-acquired weakness. In polytrauma, the neurologic examination is often confounded by pain, sedation, mechanical ventilation, and distracting injuries. Regular sedation pauses for examination and maintaining a high index of suspicion for neurologic complications are warranted, particularly because early diagnosis and management can improve outcomes.

Post-traumatic thrombo-embolic complications in polytrauma patients

INTRODUCTION

Thrombo-embolic events after trauma are considered to be life-threatening complications. Our aim was to determine the incidence of arterial and venous thrombo-embolic events (TE) in severely-injured trauma patients, and its associated risk factors by using a large trauma registry.

METHODS

Patients' data from the TraumaRegister DGU® (TR-DGU) were screened for TE (DVT [symptomatic deep vein thrombosis], PE [symptomatic pulmonary embolism], MI [myocardial infarction], and stroke) through the clinical course of severely injured adult trauma patients from January 2005 to December 2012. Univariate analysis was used to compare the clinical outcomes (endpoints: mortality, ICU and hospital length of stay, ventilator days), and a multivariate regression analysis was used to assess the independent risk factors associated with each TE event.

RESULTS

From a cohort of 40,846 trauma patients, 1122 (2.8%) patients developed a TE during their post-traumatic clinical course (313, 0.8% DVT; 425, 1.0% PE; 160, 0.4% MI and 231, 0.6% stroke). ICU length of stay [LOS], total LOS, days on mechanical ventilation, and incidence of multiple organ failure (MOF) and sepsis were significantly increased in patients with TE complications. Injury severity, major pelvic injury, and one or more operations were found to be independent risk factors for the development of DVT. Age ≥ 60 years, male gender, and more than one operation were risk factors for PE development. For MI age was the only significant risk factor. The occurrence of a stroke is increased in patients with an age ≥ 60 years, major head injury (AIS head ≥ 3), and more than one operation. Finally, mortality rates were significantly higher in the TE group when compared to the non-TE cohort (21.8% vs. 12.7%; p < 0.001).

CONCLUSION

TE complications were associated with longer ICU and hospital stay as well as a higher mortality. Overall, age and repeated operations were the most important risk factors for the development of TE events.