Acute traumatic coagulopathy in the setting of isolated traumatic brain injury: Definition, incidence and outcomes

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

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

Efficacy and safety of tranexamic acid in acute traumatic brain injury: A meta-analysis of randomized controlled trials

INTRODUCTION

Tranexamic acid (TXA) holds a pivotal role in the therapeutic approach to traumatic conditions. Nevertheless, its precise influence on diminishing mortality and limiting the progression of intracranial hemorrhage (ICH) during the treatment of traumatic brain injury (TBI) remains indeterminate.

METHODS

PubMed, EMBASE, Cochrane Library, and Web of Science were searched for randomized controlled trials that compared TXA and a placebo in adults with TBI up to September 31, 2023. Two authors independently abstracted the data and assessed the quality of evidence. Additionally, subgroup analyses were performed to assess outcomes with low heterogenety.

RESULTS

Our search strategy yielded 11,299 patients from 11 studies. The result showed that TXA had no effect on mortality (RR 0.93 [0.86, 1.00], p = 0.06; I2: 0%, p = 0.79), poor clinical outcomes (RR 0.92 [0.78, 1.09], p = 0.34; I2: 0%, p = 0.40), adverse events (RR 0.94 [0.83, 1.07], p = 0.34; I2: 48%, p = 0.10), vascular occlusive events (RR 0.85 [0.68, 1.06], p = 0.16; I2: 32%, p = 0.22), pulmonary embolism (RR 0.76 [0.47, 1.22], p = 0.26; I2: 0%, p = 0.83), seizure (RR 1.11 [0.92, 1.35], p = 0.27; I2: 0%, p = 0.49) and hemorrhagic complications (RR 0.78 [0.55, 1.09], p = 0.14; I2: 0%, p = 0.42). TXA might reduce the rate of hemorrhagic expansion (RR 0.83 [0.70, 0.99], p = 0.03; I2: 18%, p = 0.29) and mean hemorrhage volume (SMD -0.39 [-0.60, -0.18], p <0.001; I2: 44%, p = 0.13).When the time interval from symptom onset to treatment was <3 h, TXA reduced mean hemorrhage volume (SMD -0.51 [-0.81, -0.20], p = 0.001; I2: 0%, p = 0.94).

CONCLUSIONS

TXA did not elevate the risk of adverse event, however, the lack of reduction in mortality and the poor clinical outcomes constrain the value of clinical application. Early administration of TXA (within 3 h) may significantly decrease the likelihood of ICH growth in patients with TBI.

Emergent Management of Severe Hypothermia, Acidemia, and Coagulopathy in Operative Penetrating Ballistic Cranial Trauma

Hypothermia in a trauma patient has been associated with increased morbidity and mortality and is more frequently seen in those sustaining traumatic brain injuries (TBIs). Acidosis is an important consequence of hypothermia that leads to derangements across the spectrum of the coagulation cascade. Here, we present a case of a 31-year-old male presented after suffering a right parietal penetrating ballistic injury with an associated subdural hematoma and 7 mm midline shift requiring decompressive craniectomy and external ventricular drain (EVD) placement in the setting of severe hypothermia (28°C) and acidosis (pH 7.12). With aggressive rewarming intraoperatively, the use of full-body forced-air warming, warmed IV fluids, and increasing the ambient room temperature, the patient's acidosis and hypothermia improved to pH 7.20 and 34°C. Despite these aggressive attempts to rewarm the patient, he developed coagulopathy in the setting of concurrent hypothermia and acidosis. This case highlights the importance of prompt reversal of hypothermia due to its potentially fatal effects, particularly in the setting of severe TBIs. We discuss the critical aspects of surgical management of the injury and anesthetic management of hypothermia, acidosis, and coagulopathy perioperatively.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Coagulopathy in Isolated Traumatic Brain Injury: Myth or Reality

INTRODUCTION

Traumatic Brain Injury (TBI) has been shown to be associated with altered hemostasis and coagulopathy, that correlates with worsening secondary injury and clinical outcomes. Isolated Traumatic Brain Injury (iTBI), that is TBI without significant extracranial injuries, has also been shown to be associated with systemic coagulopathy and derangements in hemostasis.

METHODS

Literature Review.

RESULTS

Present your results in logical sequence in the text, tables, and figures, giving the main or most important findings first. Do not repeat all the data in the tables or figures in the text; emphasize or summarize only the most important observations. Provide data on all primary and secondary outcomes identified in the Methods section. Give numeric results not only as derivatives (e.g. percentages) but also as the absolute numbers from which the derivatives were calculated, and specify the statistical significance attached to them, if any.

DISCUSSION

In this review, we provide an overview of the pathophysiology of the hemostatic disturbances caused by iTBI, review key clinical findings and discrepancies in the way this question has been approached, describe the use and role of global viscoelastic assays such as the thromboelastrogram, and detail principles for reversal of pre-injury blood thinners.

CONCLUSIONS

iTBI is clearly associated with the development of coagulopathy, but the extent to which it occurs is confounded by the fact that many of the studies have included patients with moderate extracranial trauma into the iTBI category. The coagulopathy itself has been better studied in preclinical models, and the mechanisms driving it suggest a pattern consistent with disseminated intravascular coagulation with hyperfibrinolysis. We provide pragmatic clinical takeaways and suggestions for future research.

A predictive model for postoperative progressive haemorrhagic injury in traumatic brain injuries

Background

Progressive haemorrhagic injury after surgery in patients with traumatic brain injury often results in poor patient outcomes. This study aimed to develop and validate a practical predictive tool that can reliably estimate the risk of postoperative progressive haemorrhagic injury (PHI) in patients with traumatic brain injury (TBI).

Methods

Data from 645 patients who underwent surgery for TBI between March 2018 and December 2020 were collected. The outcome was postoperative intracranial PHI, which was assessed on postoperative computed tomography. The least absolute shrinkage and selection operator (LASSO) regression model, univariate analysis, and Delphi method were applied to select the most relevant prognostic predictors. We combined conventional coagulation test (CCT) data, thromboelastography (TEG) variables, and several predictors to develop a predictive model using binary logistic regression and then presented the results as a nomogram. The predictive performance of the model was assessed with calibration and discrimination. Internal validation was assessed.

Results

The signature, which consisted of 11 selected features, was significantly associated with intracranial PHI (p < 0.05, for both primary and validation cohorts). Predictors in the prediction nomogram included age, S-pressure, D-pressure, pulse, temperature, reaction time, PLT, prothrombin time, activated partial thromboplastin time, FIB, and kinetics values. The model showed good discrimination, with an area under the curve of 0.8694 (95% CI, 0.8083–0.9304), and good calibration.

Conclusion

This model is based on a nomogram incorporating CCT and TEG variables, which can be conveniently derived at hospital admission. It allows determination of this individual risk for postoperative intracranial PHI and will facilitate a timely intervention to improve outcomes.

Coagulopathy and Progression of Intracranial Hemorrhage in Traumatic Brain Injury: Mechanisms, Impact, and Therapeutic Considerations

BACKGROUND

Traumatic brain injury (TBI) remains one of the most challenging health and socioeconomic problems of our times. Clinical courses may be complicated by hemostatic abnormalities either pre-existing or developing with TBI.

OBJECTIVE

To review frequencies, patterns, mechanisms, novel approaches to diagnostics, treatment, and outcomes of hemorrhagic progression and coagulopathy after TBI.

METHODS

Selective review of the literature in the databases Medline (PubMed) and Cochrane Reviews using different combinations of the relevant search terms was conducted.

RESULTS

Of the patients, 20% with isolated TBI display laboratory coagulopathy upon hospital admission with profound effect on morbidity and mortality. Preinjury use of antithrombotic agents may be associated with higher rates of hemorrhagic progression and delayed traumatic intracranial hemorrhage. Further testing may display various changes affecting platelet function/numbers, pro- and/or anticoagulant factors, and fibrinolysis as well as interactions between brain tissues, vascular endothelium, mechanisms of inflammation, and blood flow dynamics. The nature of hemostatic disruptions after TBI remains elusive but current evidence suggests the presence of both a hyper- and hypocoagulable state with possible overlap and lack of distinction between phases and states. More "global" hemostatic assays, eg, viscoelastic and thrombin generation tests, may provide more detailed and timely information on the overall hemostatic potential thereby allowing early "goal-directed" therapies.

CONCLUSION

Whether timely and targeted management of hemostatic abnormalities after TBI can protect against secondary brain injury and thereby improve outcomes remains elusive. Innovative technologies for diagnostics and monitoring offer windows of opportunities for precision medicine approaches to managing TBI.

Age-related differences in the impact of coagulopathy in patients with isolated traumatic brain injury: An observational cohort study

BACKGROUND

Although age and coagulopathy are well-known predictors of poor outcome after traumatic brain injury (TBI), the interaction effect of these two predictors remains unclear.

OBJECTIVES

We assessed age-related differences in the impact of coagulopathy on the outcome following isolated TBI.

METHODS

We conducted a retrospective observational study in two tertiary emergency critical care medical centers in Japan from 2013 to 2018. A total of 1036 patients with isolated TBI (head Abbreviated Injury Scale ≥ 3 and other Abbreviated Injury Scale < 3) were selected and divided into the nonelderly (n = 501, 16-64 years) and elderly group (n = 535, age ≥65 years). We further evaluated the impact of coagulopathy (international normalized ratio, >1.2) on the outcomes (Glasgow Outcome Scale-Extended [GOS-E] scores, in-hospital mortality, and ventilation-free days) in both groups using univariate and multivariate models. Further, we conducted an age-based assessment of the impact of TBI-associated coagulopathy on GOS-E using a generalized additive model.

RESULTS

The multivariate model showed a significant association of age and TBI-associated coagulopathy with lower GOS-E scores, in-hospital mortality, and shorter ventilation-free days in the nonelderly group; however, significant impact of coagulopathy was not observed for all the outcomes in the elderly group. There was a decrease in the correlation degree between coagulopathy and GOS-E scores decreased with those older than 65 years.

CONCLUSION

There was a low impact of coagulopathy on functional and survival outcomes in geriatric patients with isolated TBI.

LEVEL OF EVIDENCE

Therapeutic study, Level IV.

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.

Computed tomographic parameters correlate with coagulation disorders in isolated traumatic brain injury

BACKGROUND AND OBJECTIVE

The imbalanced hemostatic equilibrium caused by brain tissue or vessel damage underlies the pathophysiology of traumatic brain injury (TBI)-induced coagulopathy, and cranial computed tomography (CT) is the gold standard for evaluating brain injury. The present study aimed to explore the correlation between quantitative cranial CT parameters and coagulopathy after TBI.

METHODS

We retrospectively collected the medical records of TBI patients with extracranial abbreviated injury scale (AIS) scores <3 who were admitted to our institution. The quantitative cranial CT parameters of patients with and without coagulopathy were compared, and univariate correlation analysis between CT parameters and coagulation subtest values and platelet counts was performed. The predictors for each subtest of coagulation function were probed by multivariate regression.

RESULTS

TBI patients with coagulopathy had a larger intracerebral haematoma/contusion (ICH/C) volume (p < 0.001), a higher incidence of compressed basal cisterns (p = 0.015), a higher Graeb score (p < 0.001) and subarachnoid haematoma (Fisher's scaling score) (p = 0.019) than those without coagulopathy. IH/C volume was identified as an independent risk factor for predicting coagulopathy. ICH/C volume showed a significantly positive correlation with APTT (Pearson's correlation = 0.333, p < 0.001), while a significant negative correlation with PLT (Pearson's correlation = - 0.312, p < 0.001).

CONCLUSION

ICH/C volume was a main quantitative cranial CT parameter for predicting coagulopathy, suggesting that parenchymal brain damage and vessel injury were closely associated with coagulopathy after TBI.

Effect of Red Blood Cell Storage Duration on Outcomes of Isolated Traumatic Brain Injury

Background

The aim of this study was to investigate the effects of red blood cell (RBC) storage duration on the outcomes of adult isolated traumatic brain injury (iTBI) patients after transfusion.

Material/Methods

A total of 1252 adult iTBI patients who received the fresh RBCs (stored for ≤14 days) or old RBCs (stored for >14 days) were finally enrolled in this study. The primary outcome was 90-day mortality. The secondary outcomes were in-hospital mortality, nosocomial infection, and complications.

Results

By 90 days after RBC transfusion, 89 patients (17.0%) had died in the fresh RBC group, and 107 had died (14.7%) in the old RBC group, with no significant difference in 90-day mortality between the 2 groups (OR=1.192, 95% CI: 0.877–1.620, P=0.261). According to ISS score, no differences were discovered in mild injury (OR=1.079, 95% CI: 0.682–1.707, P=0.746), severe injury (OR=1.055, 95% CI: 0.634–1.755, P=0.838), and more severe injury (OR=1.940, 95% CI: 0.955–3.943, P=0.064). For GCS score, there were no differences in mild injury (OR=1.546, 95% CI: 0.893–2.676, P=0.118), moderate injury (OR=0.965, 95% CI: 0.616–1.513, P=0.877), and severe injury (OR=1.332, 95% CI: 0.677–2.620, P=0.406). We also observed no significant differences in secondary outcomes.

Conclusions

Use of old RBCs did not increase the 90-day mortality in adult iTBI patients.

Factors associated with the progression of traumatic intracranial hematoma during interventional radiology to establish hemostasis of extracranial hemorrhagic injury in severe multiple trauma patients

Aim

To identify factors affecting the progression of traumatic intracranial hemorrhagic injury (t‐ICH) during interventional radiology (IVR) for the hemostasis of extracranial hemorrhagic injury.

Methods

This was a retrospective comparative study. Fifty‐two patients with t‐ICH who underwent hemostasis using IVR for extracranial trauma at our institute were included. Clinical and computed tomography scan data were collected to investigate factors associated with t‐ICH progression.

Results

Fifty‐two subjects (36 men/16 women) with a mean age of 70.9 ± 19.2 years were analyzed. The mean Injury Severity Score was 34.9 ± 11.2. In 29 patients (55.7%), t‐ICH progressed during IVR. Hematoma progression frequently occurred in patients with acute subdural hematoma (56.2%) and traumatic intracerebral hematoma/hemorrhagic brain contusion (66.6%). Factors associated with t‐ICH progression included age (P = 0.029), consciousness level at admission (P = 0.001), Revised Trauma Scale (P = 0.036), probability of survival (P = 0.043), platelet count (P = 0.005), fibrinogen level (P = 0.016), hemoglobin level (P = 0.003), D‐dimer level (P = 0.046), and red blood cell transfusion volume (P = 0.023).

Conclusion

Aggressive correction of anemia, thrombocytopenia, and low fibrinogen levels in severe consciousness disturbance patients with acute subdural hematoma and traumatic intracerebral hematoma/hemorrhagic brain contusion could improve the prognosis after IVR for hemostasis of extracranial hemorrhagic injuries.

Bloodletting Puncture at Hand Twelve Jing-Well Points Improves Neurological Recovery by Ameliorating Acute Traumatic Brain Injury-Induced Coagulopathy in Mice

Traumatic brain injury (TBI) contributes to hypocoagulopathy associated with prolonged bleeding and hemorrhagic progression. Bloodletting puncture therapy at hand twelve Jing-well points (BL-HTWP) has been applied as a first aid measure in various emergent neurological diseases, but the detailed mechanisms of the modulation between the central nervous system and systemic circulation after acute TBI in rodents remain unclear. To investigate whether BL-HTWP stimulation modulates hypocoagulable state and exerts neuroprotective effect, experimental TBI model of mice was produced by the controlled cortical impactor (CCI), and treatment with BL-HTWP was immediately made after CCI. Then, the effects of BL-HTWP on the neurological function, cerebral perfusion state, coagulable state, and cerebrovascular histopathology post-acute TBI were determined, respectively. Results showed that BL-HTWP treatment attenuated cerebral hypoperfusion and improve neurological recovery post-acute TBI. Furthermore, BL-HTWP stimulation reversed acute TBI-induced hypocoagulable state, reduced vasogenic edema and cytotoxic edema by regulating multiple hallmarks of coagulopathy in TBI. Therefore, we conclude for the first time that hypocoagulopathic state occurs after acute experimental TBI, and the neuroprotective effect of BL-HTWP relies on, at least in part, the modulation of hypocoagulable state. BL-HTWP therapy may be a promising strategy for acute severe TBI in the future.

Higher age is a major driver of in-hospital adverse events independent of comorbid diseases among patients with isolated mild traumatic brain injury

PURPOSE

The goal of this study was to investigate if and to what extent age, independent of comorbid diseases, is a risk factor for negative in-hospital outcome with mTBI.

METHODS

In a retrospective cohort study, we identified 1589 adult patients treated for isolated mTBI in our level-1 trauma center between 2008 and 2015. We used logistic regression analyses to assess the odds of any adverse event by age group (< 65, 65-75, 76-85, and 85+), adjusting for gender and chronic diseases.

RESULTS

The prevalence of any adverse event during in-hospital care among mTBI patients was 3.2% overall, 1.8% among those younger than age 65 years, 2.1% among those age 65-75 years, 8% among those age 75-85 years, and 19% among those age 85+ years. The odds of any adverse event were similar in patients aged 65-75 years, but increased among senior patients 4.4-fold for age 75-85 years (OR 4.4, 95%CI 2.0-9.8, p < 0.001), and 18-fold for age 85+ years (OR 18.0, 95%CI 8.7-37, p < 0.001). Additionally, chronic alcohol abuse (OR 7.0, 95%CI 3.2-15, p < 0.001), diseases of the musculoskeletal system (OR 4.3, 95%CI 1.5-13, p = 0.008), and diabetes mellitus (OR 2.7, 95%CI 1.2-6.5, p = 0.023) increased the odds of any adverse events independent of age and all other covariates.

CONCLUSIONS

The odds of sustaining an adverse event increased exponentially after age 75 independent of gender and any comorbid diseases. Our data support international efforts to manage senior patients in interdisciplinary geriatric trauma units.

Elevated plasma levels of TIMP-3 are associated with a higher risk of acute respiratory distress syndrome and death following severe isolated traumatic brain injury

Background:

Complications after injury, such as acute respiratory distress syndrome (ARDS), are common after traumatic brain injury (TBI) and associated with poor clinical outcomes. The mechanisms driving non-neurologic organ dysfunction after TBI are not well understood. Tissue inhibitor of matrix metalloproteinase-3 (TIMP-3) is a regulator of matrix metalloproteinase activity, inflammation, and vascular permeability, and hence has plausibility as a biomarker for the systemic response to TBI.

Methods:

In a retrospective study of 182 patients with severe isolated TBI, we measured TIMP-3 in plasma obtained on emergency department arrival. We used non-parametric tests and logistic regression analyses to test the association of TIMP-3 with the incidence of ARDS within 8 days of admission and in-hospital mortality.

Results:

TIMP-3 was significantly higher among subjects who developed ARDS compared with those who did not (median 2810 pg/mL vs. 2260 pg/mL, p=0.008), and significantly higher among subjects who died than among those who survived to discharge (median 2960 pg/mL vs. 2080 pg/mL, p<0.001). In an unadjusted logistic regression model, for each SD increase in plasma TIMP-3, the odds of ARDS increased significantly, OR 1.5 (95% CI 1.1 to 2.1). This association was only attenuated in multivariate models, OR 1.4 (95% CI 1.0 to 2.0). In an unadjusted logistic regression model, for each SD increase in plasma TIMP-3, the odds of death increased significantly, OR 1.7 (95% CI 1.2 to 2.3). The magnitude of this association was greater in a multivariate model adjusted for markers of injury severity, OR 1.9 (95% CI 1.2 to 2.8).

Discussion:

TIMP-3 may play an important role in the biology of the systemic response to brain injury in humans. Along with clinical and demographic data, early measurements of plasma biomarkers such as TIMP-3 may help identify patients at higher risk of ARDS and death after severe isolated TBI.

Level of evidence

III.

Prognostic value of coagulation tests for in-hospital mortality in patients with traumatic brain injury

BACKGROUND

Coagulopathy is commonly observed after traumatic brain injury (TBI). However, it is not known whether using the standard independent predictors in conjunction with coagulation tests would improve their prognostic value. We determined the incidence of TBI-associated coagulopathy in patients with isolated TBI (iTBI), evaluated the prognostic value of coagulation tests for in-hospital mortality, and tested their predictive power for in-hospital mortality in patients with iTBI.

METHODS

We conducted a retrospective, observational database study on 2319 consecutive patients with iTBI who attended the Huashan Hospital Department of the Neurosurgery Neurotrauma Center at Fudan University in China between December 2004 and June 2015. Two models based on the admission characteristics were developed: model A included predictors such as age, Glasgow Coma Scale (GCS) score, pupil reactivity, type of injury, and hemoglobin and glucose levels, while model B included the predictors from model A as well as coagulation test results. A total of 1643 patients enrolled between December 2004 and December 2011 were used to derive the prognostic models, and 676 patients enrolled between January 2012 and June 2015 were used to validate the models.

RESULTS

Overall, 18.6% (n = 432) of the patients developed coagulopathy after iTBI. The prevalence of acute traumatic coagulopathy is associated with the severity of brain injury. The percentage of platelet count <100 × 109/L, international normalized ratio (INR) > 1.25, the prothrombin time (PT) > 14 s, activated partial thromboplastin time (APTT) > 36 s, D-dimer >5 mg/L and fibrinogen (FIB) < 1.5 g/L was also closely related to the severity of brain injury, significance being found among three groups. Age, pupillary reactivity, GCS score, epidural hematoma (EDH), and glucose levels were independent prognostic factors for in-hospital mortality in model A, whereas age, pupillary reactivity, GCS score, EDH, glucose levels, INR >1.25, and APTT >36 s exhibited strong prognostic effects in model B. Discrimination and calibration were good for the development group in both prediction models. However, the external validation test showed that calibration was better in model B than in model A for patients from the validation population (Hosmer-Lemeshow test, p = 0.152 vs. p = 0.046, respectively).

CONCLUSIONS

Coagulation tests can improve the predictive power of the standard model for in-hospital mortality after TBI.

Use of Idarucizumab for dabigatran reversal: Emergency department experience in two cases with subdural haematoma

Introduction

Idarucizumab is the first effective humanized monoclonal antibody fragment developed specifically as a reversal agent for dabigatran, a Direct Oral Anticoagulant. Despite recent trials demonstrating reversal of clinically relevant bleeding, there is a paucity of data on use outside the trial setting. This manuscript describes the use of Idarucizumab to reverse dabigatran in two patients presenting to the emergency department of a major tertiary hospital with acute traumatic subdural haematomas (SDH).

Methods

Patients were identified through retrospective review of medication dispensing systems and electronic medical records.

Results

Two cases of Idarucizumab use were identified. Case 1 was of a 63-year-old male who presented following a motorcycle crash. Case 2 was of a 77-year-old male who presented with a 3-week history of ataxia and recurrent falls. Both patients were taking dabigatran for atrial fibrillation (AF). CT Brain revealed acute SDH with clinical indications for urgent surgical evacuation. Serum dabigatran levels were obtained on arrival in the emergency department with levels of 155 ng/ml and 110 ng/ml (reference range 117–275 ng/ml). Idarucizumab for dabigatran reversal was commenced; Case 1 received 5 g Idarucizumab as an intravenous bolus dose, while Case 2 received 5 g Idarucizumab as two 2.5 g intravenous infusions. Serum dabigatran levels for Cases 1 and 2 were 0 ng/ml at 75 min and 340 min post Idarucizumab administration respectively. Both patients proceeded to craniotomy with evacuation of the SDH. There was no extension of the SDH in either case. Anticoagulation was withheld until outpatient clinic review, and both patients transferred for rehabilitation prior to discharge home.

Conclusion

Idarucizumab was clinically effective for reversing dabigatran, resulting in undetectable serum levels, and should be considered in patients presenting to hospital with clinically significant bleeding associated with dabigatran therapy.

Assessment of Haemostasis in patients undergoing emergent neurosurgery by rotational Elastometry and standard coagulation tests: a prospective observational study

BACKGROUND

Rotational elastometry (ROTEM) has been shown useful to monitor coagulation in trauma patients and in major elective surgery. In this study, we aimed to evaluate the utility of ROTEM to identify hemostatic disturbances and to predict the need for transfusion, compared with standard coagulation tests (SCTs) in patients undergoing emergent neurosurgery.

METHODS

Over a four-year period, adult patients who met criteria for emergent neurosurgery lasting more than 90 min were included in the study. Blood was collected preoperatively and analyzed with SCTs (international normalized ratio [INR], fibrinogen concentration, prothrombin time [PT or Quick], partial thromboplastine time [PTT], fibrinogen concentration and platelet count), and ROTEM assays. Correlations between SCTs and ROTEM parameters as well as receiver operating characteristic curves were performed to detect a coagulopathic pattern based on standard criteria and the need for transfusing at least 3 units of packed red blood cells (PRBCs).

RESULTS

In a cohort of 92 patients, 39 (42%) required ≥3 PRBCs and a coagulopathic pattern was identified in 32 patients based on SCTs and in 19 based on ROTEM. There was a strong correlation between PTT and INTEM coagulation time (R = 0.76) as well as between fibrinogen concentrations and FIBTEM maximal clot firmess (R = 0.70). The need for transfusion (≥ 3 PRBCs) was best predicted by the maximal clot firmess of EXTEM and FIBTEM (AUC of 0.72 and 0.71, respectively) and by fibrinogen concentration (AUC of 0.70).

CONCLUSIONS

In patients undergoing emergent neurosurgery, ROTEM analysis provides valid markers of early coagulopathy and predictors of blood transfusion requirements.

Acute Traumatic Coagulopathy Accompanying Isolated Traumatic Brain Injury is Associated with Worse Long-Term Functional and Cognitive Outcomes

BACKGROUND

Approximately one-third of patients with isolated traumatic brain injury (iTBI) present with acute traumatic coagulopathy (ATC). ATC is associated with increased morbidity and mortality. Its effects on long-term functional and cognitive outcomes are not as well characterized.

METHODS

Data from the Citicoline Brain Injury Treatment Trial (COBRIT) were analyzed retrospectively. Exclusion criteria were renal failure or malignancy, and any extracranial injury severity score >3. ATC was defined as INR > 1.3, PTT > 38 s, or platelets < 100 K, determined at baseline, and during the first 7 days of hospitalization.

RESULTS

Six hundred forty-seven patients were included; 21 % were found to have ATC. Highest incidence occurred at baseline, and Day Two. Forty-two percent of ATC patients had a GCS < 8, compared with 11.3 % of non-ATC patients (p < 0.001). A significantly higher proportion of ATC patients was transfused blood products, required greater than 4L of fluids, demonstrated hyperthermia and hypothermia, were hypotensive and demonstrated elevated lactate when compared to non-ATC patients. In-hospital mortality, mean hospital length of stay, incidence of DVT and seizures were also significantly higher in ATC patients. A significantly lower portion of ATC patients had good outcomes on the GOS-E (i.e., score > 6), and the DRS (i.e., score < 2) at 180 days, for which ATC was found to be an independent predictor with binary logistic regression. ATC patients also performed significantly worse on several components of the CVLT-II at 180 days.

CONCLUSIONS

ATC accompanying iTBI is associated with worse functional and cognitive outcomes at 180 days.

Prehospital plasma resuscitation associated with improved neurologic outcomes after traumatic brain injury

BACKGROUND

Trauma-related hypotension and coagulopathy worsen secondary brain injury in patients with traumatic brain injuries (TBIs). Early damage control resuscitation with blood products may mitigate hypotension and coagulopathy. Preliminary data suggest resuscitation with plasma in large animals improves neurologic function after TBI; however, data in humans are lacking.

METHODS

We retrospectively identified all patients with multiple injuries age >15 years with head injuries undergoing prehospital resuscitation with blood products at a single Level I trauma center from January 2002 to December 2013. Inclusion criteria were prehospital resuscitation with either packed red blood cells (pRBCs) or thawed plasma as sole colloid resuscitation. Patients who died in hospital and those using anticoagulants were excluded. Primary outcomes were Glasgow Outcomes Score Extended (GOSE) and Disability Rating Score (DRS) at dismissal and during follow-up.

RESULTS

Of 76 patients meeting inclusion criteria, 53% (n = 40) received prehospital pRBCs and 47% (n = 36) received thawed plasma. Age, gender, injury severity or TBI severity, arrival laboratory values, and number of prehospital units were similar (all p > 0.05). Patients who received thawed plasma had an improved neurologic outcome compared to those receiving pRBCs (median GOSE 7 [7-8] vs. 5.5 [3-7], p < 0.001). Additionally, patients who received thawed plasma had improved functionality compared to pRBCs (median DRS 2 [1-3.5] vs. 9 [3-13], p < 0.001). Calculated GOSE and DRS scores during follow-up, median 6 [5-7] months, demonstrated increased function in those resuscitated with thawed plasma compared to pRBCs by both median GOSE (8 [7-8] vs. 6 [6-7], p < 0.001) and DRS (0 [0-1] vs. 4 [2-8], p < 0.001).

CONCLUSION

In critically injured trauma patients with TBI, early resuscitation with thawed plasma is associated with improved neurologic and functional outcomes at discharge and during follow-up compared to pRBCs alone. These preliminary data support the further investigation and use of plasma in the resuscitation of critically injured TBI patients.

LEVEL OF EVIDENCE

Therapeutic, level V.

Blood transfusion and coagulopathy in geriatric trauma patients

Background

Trauma resuscitation has undergone a paradigm shift with new emphasis on the early use of blood products and increased proportions of plasma and platelets. However, it is unclear how this strategy is applied or how effective it is in the elderly population. The study aim is to identify differences in transfusion practices and the coagulopathy of trauma in the elderly.

Methods

Data was prospectively collected on all consecutive patients that met trauma activation criteria at a Level I trauma centre. Data fields included patient demographics, co-morbidities, injury and resuscitation data, laboratory values, thromboelastography (TEG) results, and outcome measures. Elderly patients were defined as those 55 and older. Propensity-score matched analysis was completed for patients receiving blood product transfusion. Patients were matched by gender, mechanism, injury severity score (ISS), head injury, and time from injury.

Results

Total of 628 patients were included, of which 142 (23%) were elderly. Elderly patients were more likely to be female (41% vs. 24%), suffer blunt mechanism of trauma (96% vs. 80%), have higher ISS scores (mean 25.4 vs. 21.6) and mortality (19% vs. 8%). Elderly patients were significantly more likely to receive a blood transfusion (42% vs. 30%), specifically for red cells and plasma. Propensity-matched analysis resulted in no difference in red cell transfusion or mortality. Despite the broad similarities between the matched cohorts, trauma coagulopathy as measured by TEG was less commonly observed in the elderly.

Discussion

Our results suggest that elderly trauma patients are more likely to receive blood products when admitted to a trauma centre, though this may be attributed to under-triage. The results also suggest an altered coagulopathic response to traumatic injury which is partially influenced by increased anticoagulant and antiplatelet medication use in the geriatric population.

Conclusion

It is not clear whether the acute coagulopathy of trauma is equivalent in geriatric patients, and further study is therefore warranted.

The effect of tranexamic acid in traumatic brain injury: A randomized controlled trial

PURPOSE

Traumatic brain injury (TBI) is a leading cause of death and disability. Intracranial hemorrhage (ICH) secondary to TBI is associated with a high risk of coagulopathy which leads to increasing risk of hemorrhage growth and higher mortality rate. Therefore, antifibrinolytic agents such as tranexamic acid (TA) might reduce traumatic ICH. The aim of the present study was to investigate the extent of ICH growth after TA administration in TBI patients.

METHODS

This single-blind randomized controlled trial was conducted on patients with traumatic ICH (with less than 30 ml) referring to the emergency department of Vali-Asr Hospital, Arak, Iran in 2014. Patients, based on the inclusion and exclusion criteria, were divided into intervention and control groups (40 patients each). All patients received a conservative treatment for ICH, as well as either intravenous TA or placebo. The extent of ICH growth as the primary outcome was measured by brain CT scan after 48 h.

RESULTS

Although brain CT scan showed a significant increase in hemorrhage volume in both groups after 48 h, it was significantly less in the TA group than in the control group (p = 0.04). The mean total hemorrhage expansion was (1.7 ± 9.7) ml and (4.3 ± 12.9) ml in TA and placebo groups, respectively (p < 0.001).

CONCLUSION

It has been established that TA, as an effective hospital-based treatment for acute TBI, could reduce ICH growth. Larger studies are needed to compare the effectiveness of different doses.

Current concepts in penetrating and blast injury to the central nervous system

Aim

To review the current management, prognostic factors and outcomes of penetrating and blast injuries to the central nervous system and highlight the differences between gunshot wound, blast injury and stabbing.

Methods

A review of the current literature was performed.

Results

Of patients with craniocerebral GSW, 66–90 % die before reaching hospital. Of those who are admitted to hospital, up to 51 % survive. The patient age, GCS, pupil size and reaction, ballistics and CT features are important factors in the decision to operate and in prognostication. Blast injury to the brain is a component of multisystem polytrauma and has become a common injury encountered in war zones and following urban terrorist events. GSW to the spine account for 13–17 % of all gunshot injuries.

Conclusions

Urgent resuscitation, correction of coagulopathy and early surgery with wide cranial decompression may improve the outcome in selected patients with severe craniocerebral GSW. More limited surgery is undertaken for focal brain injury due to GSW. A non-operative approach may be taken if the clinical status is very poor (GCS 3, fixed dilated pupils) or GCS 4–5 with adverse CT findings or where there is a high likelihood of death or poor outcome. Civilian spinal GSWs are usually stable neurologically and biomechanically and do not require exploration. The indications for exploration are as follows: (1) compressive lesions with partial spinal cord or cauda equina injury, (2) mechanical instability and (3) complications. The principles of management of blast injury to the head and spine are the same as for GSW. Multidisciplinary specialist management is required for these complex injuries.

Microparticles impact coagulation after traumatic brain injury

BACKGROUND

The pathophysiology that drives the subacute hypercoagulable state commonly seen after traumatic brain injury (TBI) is not well understood. Alterations caused by TBI in platelet and microparticle (MP) numbers and function have been suggested as possible causes; however, the contributions of platelets and MPs are currently unknown.

MATERIALS AND METHODS

A weight-drop technique of TBI using a murine model of moderate head injury was used. Blood was collected at intervals after injury. MP enumeration and characterization were performed using Nanoparticle Tracking Analysis, and platelet counts and coagulation parameters were determined using thromboelastometry. A MP procoagulant assay was used to compare activity between injured and sham mice.

RESULTS

At 24 h after injury, there were no changes in circulating platelet numbers. However, there was a decrease in platelet contribution to clot formation. In contrast, there was a decline in circulating total MP numbers. When MPs from sham mice were added to the blood from head-injured animals, there was a normalization of platelet contribution to clot formation. Conversely, when MPs from TBI mice were added to sham blood, there was a significant decrease in platelet contribution to clot formation. Notably, there was an increase in MP procoagulant activity in head-injured mice.

CONCLUSIONS

MPs generated after TBI likely contribute to altered coagulation after head injury and may play a key role in the development of a posttraumatic hypercoagulable state in TBI patients.