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Borbas BZ, Whitfield P, King N. The safety of early pharmacological venous thromboembolism prophylaxis in patients with traumatic intracranial haemorrhage: a systematic review and meta-analysis. Br J Neurosurg 2024:1-11. [PMID: 38688329 DOI: 10.1080/02688697.2024.2339357] [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: 10/14/2022] [Accepted: 04/01/2024] [Indexed: 05/02/2024]
Abstract
INTRODUCTION In patients with traumatic intracranial haemorrhage (tICH) there is significant risk of both venous thromboembolism (VTE) and haemorrhage progression. There is a paucity of literature to inform the timing of pharmacological thromboprophylaxis (PTP) initiation. AIM This meta-analysis aims to summarise the current literature on the timing of PTP initiation in tICH. METHODS This meta-analysis followed the Methodological Expectations of Cochrane Intervention Reviews checklist and the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Following the literature search, studies were matched against the criteria for inclusion. Data from included studies was pooled, analysed using random-effect analysis and presented as forest plots of risk ratios, except one result reported as difference of means. The ROBINS-I tool was used to assess the risk of bias in the studies. The GRADE approach was taken to assess the quality of included studies. Heterogeneity of studies was assessed using Tau∧2. Funnel plots were generated and used in conjunction with Harbord's test and Rucker's arcsine to assess for small-study effect including publication bias. RESULTS A total of 9927 ICH patients who received PTP were included from 15 retrospective observational cohort studies, 4807 patients received early PTP, the remaining 5120 received late PTP. The definition of early was dependent on the study but no more than 72-hours after admission. The mean age of the included cohort was 45.3 (std dev ±9.5) years, and the proportion of males was 71%. Meta-analysis indicated that there was a significant difference between early and late groups for the rate of VTE (RR, 0.544; p = 0.000), pulmonary embolus (RR, 0.538; p = 0.004), deep vein thrombosis (RR, 0.484; p = 0.000) and the intensive care unit length of stay (difference of means, -2.021; 95% CI, -2.250, -1.792; p = 0.000; Tau∧2 = 0.000), favouring the early group. However, the meta-analysis showed no significant difference between the groups for the rate of mortality (RR, 1.008; p = 0.936), tICH progression (RR, 0.853; p = 0.157), and neurosurgical intervention (RR, 0.870; p = 0.480). CONCLUSION These findings indicated that early PTP appears to be safe and effective in patients with tICH.
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Affiliation(s)
| | - Peter Whitfield
- Neurosurgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
- Peninsula Medical School, University of Plymouth, Plymouth, UK
| | - Nicola King
- School of Biomedical Sciences, Faculty of Health, University of Plymouth, Plymouth, UK
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2
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Ratnasekera AM, Seng SS, Kim D, Ji W, Jacovides CL, Kaufman EJ, Sadek HM, Perea LL, Poloni CM, Shnaydman I, Lee AJ, Sharp V, Miciura A, Trevizo E, Rosenthal MG, Lottenberg L, Zhao W, Keininger A, Hunt M, Cull J, Balentine C, Egodage T, Mohamed AT, Kincaid M, Doris S, Cotterman R, Seegert S, Jacobson LE, Williams J, Moncrief M, Palmer B, Mentzer C, Tackett N, Hranjec T, Dougherty T, Morrissey S, Donatelli-Seyler L, Rushing A, Tatebe LC, Nevill TJ, Aboutanos MB, Hamilton D, Redmond D, Cullinane DC, Falank C, McMellen M, Duran C, Daniels J, Ballow S, Schuster KM, Ferrada P. Propensity weighted analysis of chemical venous thromboembolism prophylaxis agents in isolated severe traumatic brain injury: An EAST sponsored multicenter study. Injury 2024:111523. [PMID: 38614835 DOI: 10.1016/j.injury.2024.111523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 03/09/2024] [Accepted: 04/01/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND In patients with severe traumatic brain injury (TBI), clinicians must balance preventing venous thromboembolism (VTE) with the risk of intracranial hemorrhagic expansion (ICHE). We hypothesized that low molecular weight heparin (LMWH) would not increase risk of ICHE or VTE as compared to unfractionated heparin (UH) in patients with severe TBI. METHODS Patients ≥ 18 years of age with isolated severe TBI (AIS ≥ 3), admitted to 24 level I and II trauma centers between January 1, 2014 to December 31, 2020 and who received subcutaneous UH and LMWH injections for chemical venous thromboembolism prophylaxis (VTEP) were included. Primary outcomes were VTE and ICHE after VTEP initiation. Secondary outcomes were mortality and neurosurgical interventions. Entropy balancing (EBAL) weighted competing risk or logistic regression models were estimated for all outcomes with chemical VTEP agent as the predictor of interest. RESULTS 984 patients received chemical VTEP, 482 UH and 502 LMWH. Patients on LMWH more often had pre-existing conditions such as liver disease (UH vs LMWH 1.7 % vs. 4.4 %, p = 0.01), and coagulopathy (UH vs LMWH 0.4 % vs. 4.2 %, p < 0.001). There were no differences in VTE or ICHE after VTEP initiation. There were no differences in neurosurgical interventions performed. There were a total of 29 VTE events (3 %) in the cohort who received VTEP. A Cox proportional hazards model with a random effect for facility demonstrated no statistically significant differences in time to VTE across the two agents (p = 0.44). The LMWH group had a 43 % lower risk of overall ICHE compared to the UH group (HR = 0.57: 95 % CI = 0.32-1.03, p = 0.062), however was not statistically significant. CONCLUSION In this multi-center analysis, patients who received LMWH had a decreased risk of ICHE, with no differences in VTE, ICHE after VTEP initiation and neurosurgical interventions compared to those who received UH. There were no safety concerns when using LMWH compared to UH. LEVEL OF EVIDENCE Level III, Therapeutic Care Management.
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Affiliation(s)
- Asanthi M Ratnasekera
- Department of Surgery, Division of Trauma and Surgical Critical Care, Associate Professor of Surgery, Drexel College of Medicine, Philadelphia, PA, United States; Crozer Health Upland PA, Currently at Christianacare Health, Newark, DE, United States.
| | - Sirivan S Seng
- Department of Surgery, Crozer Health, Upland, PA, United States
| | - Daniel Kim
- Department of Surgery, Crozer Health, Upland, PA, United States
| | - Wenyan Ji
- Center for Biostatistics and Health Data Science, Department of Statistics, Virginia Polytechnic Institute and State University, Roanoke, VA, United States
| | - Christina L Jacovides
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, United States; Currently at Temple University, Philadelphia, PA, United States
| | - Elinore J Kaufman
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Hannah M Sadek
- Department of Surgery, Virginia Commonwealth University, Richmond, VA, United States
| | - Lindsey L Perea
- Department of Surgery, Penn Medicine Lancaster General Health, Lancaster, PA, United States
| | - Christina Monaco Poloni
- Department of Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, United States
| | - Ilya Shnaydman
- Department of Surgery, Medical Director, Surgical Intensive Care Unit, New York Medical College, West Chester Medical Center, Valhalla, NY, United States
| | | | - Victoria Sharp
- Department of Surgery, Trinity Health Ann Arbor, Ypsilanti, MI, United States
| | - Angela Miciura
- Department of Surgery, Trinity Health Ann Arbor, Ypsilanti, MI, United States
| | - Eric Trevizo
- Department of Surgery, Loma Linda University Medical Center, Loma Linda, CA, United States
| | - Martin G Rosenthal
- Department of Surgery, Loma Linda University Medical Center, Loma Linda, CA, United States
| | - Lawrence Lottenberg
- Department of Surgery, St. Mary's Medical Center, West Palm Beach, FL, United States; Florida Atlantic University, Boca Raton, FL, United States
| | - William Zhao
- Department of Surgery, St. Mary's Medical Center, West Palm Beach, FL, United States; Florida Atlantic University, Boca Raton, FL, United States
| | - Alicia Keininger
- Department of Surgery, Trinity Health Oakland, Pontiac, MI, United States
| | - Michele Hunt
- Department of Surgery, Trinity Health Oakland, Pontiac, MI, United States
| | - John Cull
- Department of Surgery, Prisma Health Upstate, Greenville, SC, United States
| | - Chassidy Balentine
- Department of Surgery, Prisma Health Upstate, Greenville, SC, United States
| | - Tanya Egodage
- Department of Surgery, Cooper University Hospital, Camden, NJ, United States
| | - Aleem T Mohamed
- Department of Surgery, Cooper University Hospital, Camden, NJ, United States
| | - Michelle Kincaid
- Department of Surgery, Ohio Health Grant Medical Center, Columbus, OH, United States
| | - Stephanie Doris
- Department of Surgery, Ohio Health Grant Medical Center, Columbus, OH, United States
| | - Robert Cotterman
- Department of Surgery, Promedica Toledo Hospital, Toledo, OH, United States
| | - Sara Seegert
- Department of Research, Promedica Toledo Hospital, Toledo, OH, United States
| | - Lewis E Jacobson
- Department of Surgery, Ascension St. Vincent Hospital, Indianapolis, IN, United States
| | - Jamie Williams
- Department of Surgery, Ascension St. Vincent Hospital, Indianapolis, IN, United States
| | - Melissa Moncrief
- Department of Trauma & Acute Care Surgery, Kettering Health Main Campus, Kettering, OH, United States
| | - Brandi Palmer
- Department of Trauma & Acute Care Surgery, Kettering Health Main Campus, Kettering, OH, United States
| | - Caleb Mentzer
- Department of Surgery, Spartanburg Medical Center, Spartanburg, SC, United States
| | - Nichole Tackett
- Department of Surgery, Spartanburg Medical Center, Spartanburg, SC, United States
| | - Tjasa Hranjec
- Department of Surgery, Memorial Healthcare System, Hollywood, FL, United States
| | - Thomas Dougherty
- Department of Surgery, Memorial Healthcare System, Hollywood, FL, United States
| | - Shawna Morrissey
- Department of Surgery, Conemaugh Memorial Medical Center, Johnstown, PA, United States
| | - Lauren Donatelli-Seyler
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Amy Rushing
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Leah C Tatebe
- Department of Surgery, Cook County Hospital, Chicago, IL, United States; Currently at Northwestern Memorial Hospital, Chicago, IL, United States
| | - Tiffany J Nevill
- Department of Surgery, Cook County Hospital, Chicago, IL, United States
| | - Michel B Aboutanos
- Department of Surgery, Virginia Commonwealth University, Richmond, VA, United States
| | - David Hamilton
- Department of Surgery, Penrose Hospital, Colorado Springs, CO, United States
| | - Diane Redmond
- Department of Surgery, Penrose Hospital, Colorado Springs, CO, United States
| | - Daniel C Cullinane
- Department of Surgery, Maine Medical Center, Portland, ME, United States
| | - Carolyne Falank
- Department of Surgery, Maine Medical Center, Portland, ME, United States
| | - Mark McMellen
- Department of Surgery, St. Anthony Hospital, Lakewood, CO, United States
| | - Chris Duran
- Department of Surgery, St. Anthony Hospital, Lakewood, CO, United States
| | - Jennifer Daniels
- Department of Surgery, University of California San Francisco, Fresno, CA, United States
| | - Shana Ballow
- Department of Surgery, University of California San Francisco, Fresno, CA, United States
| | - Kevin M Schuster
- Department of Surgery, Yale School of Medicine, New Haven, CT, United States
| | - Paula Ferrada
- Department of Surgery, INOVA Fairfax Health System, Fairfax, VA, United States
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Ang D, Pierre K, Armstrong J, Dunne J, Flaherty S, Gonzalez E, McKenney M, Offner P, Plurad D, Liu H, Ziglar M. Timing and Type of Venous Thromboembolic Chemoprophylaxis Is Associated with Acute Traumatic Brain Injury Outcomes. Neurotrauma Rep 2022; 3:511-521. [DOI: 10.1089/neur.2022.0048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Darwin Ang
- Department of Trauma, HCA Florida Ocala Hospital, Ocala, Florida, USA
- Department of Surgery, University of South Florida, Tampa, Florida, USA
- College of Medicine, University of Central Florida, Orlando, Florida, USA
| | - Kevin Pierre
- Department of Trauma, HCA Florida Ocala Hospital, Ocala, Florida, USA
- College of Medicine, University of Central Florida, Orlando, Florida, USA
| | - John Armstrong
- Department of Surgery, University of South Florida, Tampa, Florida, USA
| | - James Dunne
- Department of Surgery, Medical Center, Memorial Health University, Savannah, Georgia, USA
| | - Stephen Flaherty
- Department of Trauma, Del Sol Medical Center, El Paso, Texas, USA
| | - Ernest Gonzalez
- Department of Trauma, South Austin Medical Center, Austin, Texas, USA
| | - Mark McKenney
- Department of Trauma, Kendall Regional Medical Center, Miami, Florida, USA
| | - Patrick Offner
- Department of Trauma, Sky Ridge Medical Center, Lone Tree, Colorado, USA
| | - David Plurad
- Department of Trauma, Riverside Community Hospital, Riverside, California, USA
| | - Huazhi Liu
- Department of Trauma, HCA Florida Ocala Hospital, Ocala, Florida, USA
| | - Michele Ziglar
- Clinical Services Group, Hospital Corporation of America, Nashville, Tennessee, USA
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Al-Dorzi H, Al-Yami G, Al-Daker F, Alqirnas M, Alhamadh M, Khan R. The association of timing of pharmacological prophylaxis and venous thromboembolism in patients with moderate-to-severe traumatic brain injury: A retrospective cohort study. Ann Thorac Med 2022; 17:102-109. [PMID: 35651893 PMCID: PMC9150664 DOI: 10.4103/atm.atm_174_21] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 05/12/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES: Patients with traumatic brain injury (TBI) have an increased risk for venous thromboembolism (VTE). The current guidelines recommend pharmacologic prophylaxis, but its timing remains unclear. METHODS: In this retrospective cohort study, patients with moderate-to-severe TBI admitted to a tertiary care intensive care unit between 2016 and 2019 were categorized into two groups according to the timing of pharmacologic prophylaxis: early if prophylaxis was given within 72 h from hospital admission and late if after 72 h. RESULTS: Of the 322 patients in the cohort, 46 (14.3%) did not receive pharmacological prophylaxis, mainly due to early brain death; 152 (47.2%) received early pharmacologic prophylaxis and 124 (38.5%) received late prophylaxis. Predictors of late pharmacologic prophylaxis were lower body mass index, intracerebral hemorrhage (odds ratio [OR], 3.361; 95% confidence interval [CI], 1.269–8.904), hemorrhagic contusion (OR, 3.469; 95% CI, 1.039–11.576), and lower platelet count. VTE was diagnosed in 43 patients on a median of 10 days after trauma (Q1, Q3: 5, 15): 6.6% of the early prophylaxis group and 26.6% of the late group (P < 0.001). On multivariable logistic regression analysis, the predictors of VTE were Acute Physiology and Chronic Health Evaluation II score, subarachnoid hemorrhage, and late versus early pharmacologic prophylaxis (OR, 3.858; 95% CI, 1.687–8.825). The late prophylaxis group had higher rate of tracheostomy, longer duration of mechanical ventilation and stay in the hospital, lower discharge Glasgow coma scale, but similar survival, compared with the early group. CONCLUSIONS: Late prophylaxis (>72 h) was associated with higher VTE rate in patients with moderate-to-severe TBI, but not with higher mortality.
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5
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Timing of venous thromboembolic pharmacological prophylaxis in traumatic combined subdural and subarachnoid hemorrhage. Am J Surg 2021; 223:1194-1199. [PMID: 34809908 DOI: 10.1016/j.amjsurg.2021.11.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 11/13/2021] [Accepted: 11/15/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND The combination of subdural and subarachnoid hemorrhage is the most common intracranial bleeding. The present study evaluated the timing and type of venous thromboembolic chemoprophylaxis (VTEp) for efficacy and safety in patients with blunt head trauma with combined acute subdural and subarachnoid hemorrhage. METHODS Patients with isolated combined acute subdural and subarachnoid hemorrhage were extracted from the ACS-TQIP database (2013-2017). After 1:1 cohort matching of patients receiving early prophylaxis (EP, ≤48 h) versus late prophylaxis (LP, >48 h) outcomes were compared with univariable and multivariable regression analysis. RESULTS Multivariable regression analysis identified EP as an independent protective factor for VTE complications (OR 0.468, CI 0.293-0.748) but not mortality (p = 0.485). The adjusted risk for delayed craniectomy was not associated with EP compared to LP (p = 0.283). The type of VTEp was not associated with VTE complications (p = 0.301), mortality (p = 0.391) or delayed craniectomy (p = 0.126). CONCLUSIONS Early VTEp (≤48 h) was associated with fewer VTE complications in patients and did not increase the risk for craniectomies in patients with combined acute subdural and subarachnoid hemorrhage.
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6
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Maegele M. Coagulopathy and Progression of Intracranial Hemorrhage in Traumatic Brain Injury: Mechanisms, Impact, and Therapeutic Considerations. Neurosurgery 2021; 89:954-966. [PMID: 34676410 DOI: 10.1093/neuros/nyab358] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 07/31/2021] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Marc Maegele
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Center, University Witten/Herdecke, Cologne, Germany.,Institute for Research in Operative Medicine, University Witten/Herdecke, Cologne, Germany.,Treatment Center for Traumatic Injuries, Third Affiliated Hospital of Southern Medical University, Guangzhou, China
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7
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Jakob DA, Benjamin ER, Recinos G, Cremonini C, Lewis M, Demetriades D. Venous thromboembolic pharmacological prophylaxis in severe traumatic acute subdural hematomas: Early prophylaxis is effective and safe. Am J Surg 2021; 223:1004-1009. [PMID: 34364655 DOI: 10.1016/j.amjsurg.2021.07.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 07/26/2021] [Accepted: 07/27/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate the optimal timing and type of pharmacological venous thromboembolism prophylaxis (VTEp) in patients with severe blunt head trauma with acute subdural hematomas (ASDH). METHODS Matched cohort study using ACS-TQIP database (2013-2016) including patients with isolated ASDH. Outcomes of matched patients receiving early prophylaxis (EP, ≤48 h) and late prophylaxis (LP, >48 h) were compared with univariable and multivariable regression analysis. RESULTS In 1,660 matched cases VTE complications (3.1% vs 0.5%, p < 0.001) were more common in the LP compared to the EP group. Multivariable regression analysis identified EP as an independent protective factor for VTE complications (OR 0.169, p < 0.001) but not mortality (p = 0.260). The adjusted risk for delayed craniectomy was not associated with EP compared to LP (p = 0.095). LMWH was independently associated with a lower mortality (OR 0.480, p = 0.008) compared to UH. CONCLUSIONS Early VTEp (≤48 h) does not increase the risk for craniectomies and is independently associated with fewer VTE complications in patients with isolated ASDH. LMWH was independently associated with a lower mortality compared to UH.
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Affiliation(s)
- Dominik A Jakob
- Division of Trauma and Critical Care, University of Southern California, Los Angeles, CA, USA.
| | - Elizabeth R Benjamin
- Division of Trauma and Critical Care, University of Southern California, Los Angeles, CA, USA.
| | - Gustavo Recinos
- Division of Trauma and Critical Care, University of Southern California, Los Angeles, CA, USA.
| | - Camilla Cremonini
- Division of Trauma and Critical Care, University of Southern California, Los Angeles, CA, USA.
| | - Meghan Lewis
- Division of Trauma and Critical Care, University of Southern California, Los Angeles, CA, USA.
| | - Demetrios Demetriades
- Division of Trauma and Critical Care, University of Southern California, Los Angeles, CA, USA.
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8
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Fletcher-Sandersjöö A, Thelin EP, Maegele M, Svensson M, Bellander BM. Time Course of Hemostatic Disruptions After Traumatic Brain Injury: A Systematic Review of the Literature. Neurocrit Care 2021; 34:635-656. [PMID: 32607969 PMCID: PMC8128788 DOI: 10.1007/s12028-020-01037-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Almost two-thirds of patients with severe traumatic brain injury (TBI) develop some form of hemostatic disturbance, which contributes to poor outcome. While the initial head injury often leads to impaired clot formation, TBI is also associated with an increased risk of thrombosis. Most likely there is a progression from early bleeding to a later prothrombotic state. In this paper, we systematically review the literature on the time course of hemostatic disruptions following TBI. A MEDLINE search was performed for TBI studies reporting the trajectory of hemostatic assays over time. The search yielded 5,049 articles, of which 4,910 were excluded following duplicate removal as well as title and abstract review. Full-text assessment of the remaining articles yielded 33 studies that were included in the final review. We found that the first hours after TBI are characterized by coagulation cascade dysfunction and hyperfibrinolysis, both of which likely contribute to lesion progression. This is then followed by platelet dysfunction and decreased platelet count, the clinical implication of which remains unclear. Later, a poorly defined prothrombotic state emerges, partly due to fibrinolysis shutdown and hyperactive platelets. In the clinical setting, early administration of the antifibrinolytic agent tranexamic acid has proved effective in reducing head-injury-related mortality in a subgroup of TBI patients. Further studies evaluating the time course of hemostatic disruptions after TBI are warranted in order to identify windows of opportunity for potential treatment options.
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Affiliation(s)
- Alexander Fletcher-Sandersjöö
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden.
- Department of Clinical Neuroscience, Karolinska Institutet, Bioclinicum J5:20, 171 64, Solna, Stockholm, Sweden.
| | - Eric Peter Thelin
- Department of Clinical Neuroscience, Karolinska Institutet, Bioclinicum J5:20, 171 64, Solna, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Marc Maegele
- Department for Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
- Institute for Research in Operative Medicine, University Witten/Herdecke, Cologne, Germany
| | - Mikael Svensson
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Bioclinicum J5:20, 171 64, Solna, Stockholm, Sweden
| | - Bo-Michael Bellander
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Bioclinicum J5:20, 171 64, Solna, Stockholm, Sweden
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9
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Rivas L, Vella M, Ju T, Fernandez-Moure JS, Sparks A, Seamon MJ, Sarani B. Early Chemoprophylaxis Against Venous Thromboembolism in Patients With Traumatic Brain Injury. Am Surg 2021; 88:187-193. [PMID: 33502231 DOI: 10.1177/0003134820983171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Timing to start of chemoprophylaxis for venous thromboembolism (VTE) in patients with traumatic brain injury (TBI) remains controversial. We hypothesize that early administration is not associated with increased intracranial hemorrhage. METHODS A retrospective study of adult patients with TBI following blunt injury was performed. Patients with penetrating brain injury, any moderate/severe organ injury other than the brain, need for craniotomy/craniectomy, death within 24 hours of admission, or progression of bleed on 6 hour follow-up head computed tomography scan were excluded. Patients were divided into early (≤24 hours) and late (>24 hours) cohorts based on time to initiation of chemoprophylaxis. Progression of bleed was the primary outcome. RESULTS 264 patients were enrolled, 40% of whom were in the early cohort. The average time to VTE prophylaxis initiation was 17 hours and 47 hours in the early and late groups, respectively (P < .0001). There was no difference in progression of bleed (5.6% vs. 7%, P = .67), craniectomy/-craniotomy rate (1.9% vs. 2.5%, P = .81), or VTE rate (0% vs. 2.5%, P = .1). CONCLUSION Early chemoprophylaxis is not associated with progression of hemorrhage or need for neurosurgical intervention in patients with TBI and a stable head CT 7 hours following injury.
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Affiliation(s)
- Lisbi Rivas
- Center for Trauma and Critical Care, Department of Surgery, 50430George Washington University, Washington, DC, USA
| | - Michael Vella
- Department of Surgery, Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania, Philadelphia, PA, USA.,Department of Surgery at the University of Rochester Medical Center, Rochester, NY, USA
| | - Tammy Ju
- Center for Trauma and Critical Care, Department of Surgery, 50430George Washington University, Washington, DC, USA
| | - Joseph S Fernandez-Moure
- Department of Surgery, Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania, Philadelphia, PA, USA.,Department of Surgery at Duke Medical Center, 14640University of Pennsylvania Perelman School of Medicine, Durham, NC, USA
| | - Andrew Sparks
- Center for Trauma and Critical Care, Department of Surgery, 50430George Washington University, Washington, DC, USA
| | - Mark J Seamon
- Department of Surgery, Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Babak Sarani
- Center for Trauma and Critical Care, Department of Surgery, 50430George Washington University, Washington, DC, USA
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10
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Coleman JR, Carmichael H, Zangara T, Dunn J, Schroeppel TJ, Campion E, Goodman M, Hosokawa P, Sauaia A, Moore EE, Bunn B, Floren M, Ferrigno L. A Stitch in Time Saves Clots: Venous Thromboembolism Chemoprophylaxis in Traumatic Brain Injury. J Surg Res 2020; 258:289-298. [PMID: 33039638 DOI: 10.1016/j.jss.2020.08.076] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 08/20/2020] [Accepted: 08/26/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Venous thromboembolism chemoprophylaxis (VTE-CHEMO) is often delayed in patients with traumatic brain injury because of the concern for intracranial hemorrhage (ICH) progression. We hypothesize that (1) late time to VTE-CHEMO (≥48 h) is associated with higher incidence of VTE, and (2) VTE-CHEMO use does not correlate with ICH progression. MATERIALS AND METHODS This is a multiinstitutional retrospective study of patients with traumatic brain injury admitted between 2014 and 2016. Inclusion criteria were head Abbreviated Injury Code ≥2, ICH present on initial head computed tomography, and two or more head computed tomography scans after admission. The primary outcome was VTE, and the secondary outcome was ICH progression. Patients were classified as receiving VTE-CHEMO early (<48 h) or late (≥48 h). Multivariable analysis with Cox proportional hazards regression was performed. RESULTS Overall, 1803 patients were included. Patients with VTE (n = 137) were more likely to have spinal cord injury, blunt cerebrovascular injury, pelvic or femur fractures, and missed VTE-CHEMO doses. After multivariable regression, body mass index >30 (hazard ratio [HR], 1.05; P = 0.002), Injury Severity Score (HR, 1.004; P < 0.001), pelvic or femur fractures (HR, 1.05; P < 0.0001), spinal cord injury (HR, 1.28; P = 0.02), and missed VTE-CHEMO doses (HR, 1.08; P = 0.01) were significant predictors of VTE. In those who required neurosurgery, late VTE-CHEMO predicted VTE (HR, 1.21; P = 0.0001). Overall, 32% patients experienced ICH progression, which did not correlate with VTE-CHEMO use or timing. CONCLUSIONS This multicenter study highlights benefits from early VTE-CHEMO and identifies high-risk groups who may benefit from more aggressive prophylaxis. These data also emphasize risk to patients by withholding VTE-CHEMO.
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Affiliation(s)
- Julia R Coleman
- Department of Surgery, University of Colorado-Denver, Aurora, Colorado.
| | | | - Tessa Zangara
- University of Colorado School of Medicine, Aurora, Colorado
| | - Julie Dunn
- Department of Surgery, UCHealth Medical Center of the Rockies, Loveland, Colorado
| | - Thomas J Schroeppel
- Department of Surgery, UCHealth Memorial Hospital, Colorado Springs, Colorado
| | - Eric Campion
- Department of Surgery, Denver Health Medical Center, Denver, Colorado
| | - Michael Goodman
- Department of Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Patrick Hosokawa
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado, Aurora, Colorado
| | - Angela Sauaia
- Department of Surgery, University of Colorado-Denver, Aurora, Colorado; Department of Health Systems, Management and Policy, School of Public Health, University of Colorado-Denver, Aurora, Colorado
| | - Ernest E Moore
- Department of Surgery, University of Colorado-Denver, Aurora, Colorado; Department of Surgery, Denver Health Medical Center, Denver, Colorado
| | - Bryce Bunn
- Rocky Vista University School of Medicine, Parker, Colorado
| | - Michael Floren
- Department of Mathematics and Statistics, Misericordia University, Dallas, Pennsylvania
| | - Lisa Ferrigno
- Department of Surgery, University of Colorado-Denver, Aurora, Colorado
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11
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Rakhit S, Nordness MF, Lombardo SR, Cook M, Smith L, Patel MB. Management and Challenges of Severe Traumatic Brain Injury. Semin Respir Crit Care Med 2020; 42:127-144. [PMID: 32916746 DOI: 10.1055/s-0040-1716493] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Traumatic brain injury (TBI) is the leading cause of death and disability in trauma patients, and can be classified into mild, moderate, and severe by the Glasgow coma scale (GCS). Prehospital, initial emergency department, and subsequent intensive care unit (ICU) management of severe TBI should focus on avoiding secondary brain injury from hypotension and hypoxia, with appropriate reversal of anticoagulation and surgical evacuation of mass lesions as indicated. Utilizing principles based on the Monro-Kellie doctrine and cerebral perfusion pressure (CPP), a surrogate for cerebral blood flow (CBF) should be maintained by optimizing mean arterial pressure (MAP), through fluids and vasopressors, and/or decreasing intracranial pressure (ICP), through bedside maneuvers, sedation, hyperosmolar therapy, cerebrospinal fluid (CSF) drainage, and, in refractory cases, barbiturate coma or decompressive craniectomy (DC). While controversial, direct ICP monitoring, in conjunction with clinical examination and imaging as indicated, should help guide severe TBI therapy, although new modalities, such as brain tissue oxygen (PbtO2) monitoring, show great promise in providing strategies to optimize CBF. Optimization of the acute care of severe TBI should include recognition and treatment of paroxysmal sympathetic hyperactivity (PSH), early seizure prophylaxis, venous thromboembolism (VTE) prophylaxis, and nutrition optimization. Despite this, severe TBI remains a devastating injury and palliative care principles should be applied early. To better affect the challenging long-term outcomes of severe TBI, more and continued high quality research is required.
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Affiliation(s)
- Shayan Rakhit
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mina F Nordness
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sarah R Lombardo
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Madison Cook
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Meharry Medical College, Nashville, Tennessee
| | - Laney Smith
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Washington and Lee University, Lexington, Virginia
| | - Mayur B Patel
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Neurosurgery and Hearing and Speech Sciences, Vanderbilt Brain Institute, Vanderbilt University Medical Center, Nashville, Tennessee.,Surgical Service, Nashville VA Medical Center, Tennessee Valley Healthcare System, US Department of Veterans Affairs, Nashville, Tennessee.,Geriatric Research, Education, and Clinical Center Service, Nashville VA Medical Center, Tennessee Valley Healthcare System, US Department of Veterans Affairs, Nashville, Tennessee
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12
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Yeates EO, Grigorian A, Schubl SD, Kuza CM, Joe V, Lekawa M, Borazjani B, Nahmias J. Chemoprophylaxis and Venous Thromboembolism in Traumatic Brain Injury at Different Trauma Centers. Am Surg 2020. [DOI: 10.1177/000313482008600433] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Patients with severe traumatic brain injury (TBI) are at an increased risk of venous thromboembolism (VTE). Because of concerns of worsening intracranial hemorrhage, clinicians are hesitant to start VTE chemoprophylaxis in this population. We hypothesized that ACS Level I trauma centers would be more aggressive with VTE chemoprophylaxis in adults with severe TBI than Level II centers. We also predicted that Level I centers would have a lower risk of VTE. We queried the Trauma Quality Improvement Program (2010–2016) database for patients with Abbreviated Injury Scale scores of 4 and 5 of the head and compared them based on treating the hospital trauma level. Of 204,895 patients with severe TBI, 143,818 (70.2%) were treated at Level I centers and 61,077 (29.8%) at Level II centers. The Level I cohort had a higher rate of VTE chemoprophylaxis use (43.2% vs 23.3%, P < 0.001) and a shorter median time to chemoprophylaxis (61.9 vs 85.9 hours, P < 0.001). Although Level I trauma centers started VTE chemoprophylaxis more often and earlier than Level II centers, there was no difference in the risk of VTE ( P = 0.414) after controlling for covariates. Future prospective studies are warranted to evaluate the timing, safety, and efficacy of early VTE chemoprophylaxis in severe TBI patients.
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Affiliation(s)
- Eric O. Yeates
- Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California; and
| | - Areg Grigorian
- Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California; and
| | - Sebastian D. Schubl
- Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California; and
| | - Catherine M. Kuza
- Department of Anesthesiology, University of Southern California Medical Center, Los Angeles, California
| | - Victor Joe
- Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California; and
| | - Michael Lekawa
- Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California; and
| | - Boris Borazjani
- Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California; and
| | - Jeffry Nahmias
- Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California; and
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13
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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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14
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Anticoagulant chemoprophylaxis in patients with traumatic brain injuries: A systematic review. J Trauma Acute Care Surg 2020; 88:454-460. [DOI: 10.1097/ta.0000000000002580] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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15
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Hoffman H, Jalal MS, Chin LS. The risk factors, outcomes, and costs associated with venous thromboembolism after traumatic brain injury: a nationwide analysis. Brain Inj 2019; 33:1671-1678. [DOI: 10.1080/02699052.2019.1667536] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Haydn Hoffman
- Department of Neurosurgery, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Muhammad S. Jalal
- Department of Neurosurgery, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Lawrence S. Chin
- Department of Neurosurgery, State University of New York Upstate Medical University, Syracuse, NY, USA
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16
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Management of Head Trauma in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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17
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Morris MC, Kassam F, Bercz A, Beckmann N, Schumacher F, Gulbins E, Makley AT, Goodman MD. The Role of Chemoprophylactic Agents in Modulating Platelet Aggregability After Traumatic Brain Injury. J Surg Res 2019; 244:1-8. [PMID: 31279258 DOI: 10.1016/j.jss.2019.06.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 04/22/2019] [Accepted: 06/06/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND The pathophysiology behind the subacute but persistent hypercoagulable state after traumatic brain injury (TBI) is poorly understood but contributes to morbidity induced by venous thromboembolism. Because platelets and their microvesicles have been hypothesized to play a role in post-traumatic hypercoagulability, administration of commonly used agents may ameliorate this coagulability. We hypothesized that utilization of aspirin, ketorolac, amitriptyline, unfractionated heparin, or enoxaparin would modulate the platelet aggregation response after TBI. METHODS Concussive TBI was induced by weight drop. Mice were then randomized to receive aspirin, ketorolac, amitriptyline, heparin, enoxaparin, or saline control at 2 and 8 h after TBI. Mice were sacrificed at 6 or 24 h after injury to determine coagulability by rotational thromboelastometry (ROTEM), platelet function testing with impedance aggregometry, and microvesicle enumeration. Platelet sphingolipid metabolites were analyzed by mass spectrometry. RESULTS ROTEM demonstrated increased platelet contribution to maximum clot firmness at 6 h after TBI in mice that received aspirin or amitriptyline, but this did not persist at 24 h. By contrast, adenosine diphosphate- and arachidonic acid-induced platelet aggregation at 6 h was significantly lower in mice receiving ketorolac, aspirin, and amitriptyline compared with mice receiving saline at 6 h after injury and only arachidonic acid-initiated platelet aggregation was decreased by aspirin at 24 h. There were no differences in microvesicle production at either time point. Platelet sphingosine-1-phosphate levels were decreased at 6 h in the group receiving amitriptyline and increased at 24 h along with platelet ceramide levels at 24 h in the amitriptyline group. CONCLUSION After TBI, amitriptyline decreased platelet aggregability and increased contribution to clot in a manner similar to aspirin. The amitriptyline effects on platelet function and sphingolipid metabolites may represent a possible role of the acid sphingomyelinase in the hypercoagulability observed after injury. In addition, inhibition of platelet reactivity may be an underappreciated benefit of low molecular weight heparins, such as enoxaparin.
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Affiliation(s)
| | - Farzaan Kassam
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Aron Bercz
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Nadine Beckmann
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Fabian Schumacher
- Department of Molecular Biology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany; Institute of Nutritional Science, University of Potsdam, Potsdam, Germany
| | - Erich Gulbins
- Department of Molecular Biology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Amy T Makley
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
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