Coagulopathy after hemorrhagic traumatic brain injury, an observational study of the incidence and prognosis

The prognostic value of an age-adjusted BIG score in adult patients with traumatic brain injury

Background

The base deficit, international normalized ratio, and Glasgow Coma Scale (BIG) score was previously developed to predict the outcomes of pediatric trauma patients. We designed this study to explore and improve the prognostic value of the BIG score in adult patients with traumatic brain injury (TBI).

Methods

Adult patients diagnosed with TBI in a public critical care database were included in this observational study. The BIG score was calculated based on the Glasgow Coma Scale (GCS), the international normalized ratio (INR), and the base deficit. Logistic regression analysis was performed to confirm the association between the BIG score and the outcome of included patients. Receiver operating characteristic (ROC) curves were drawn to evaluate the prognostic value of the BIG score and novel constructed models.

Results

In total, 1,034 TBI patients were included in this study with a mortality of 22.8%. Non-survivors had higher BIG scores than survivors (p < 0.001). The results of multivariable logistic regression analysis showed that age (p < 0.001), pulse oxygen saturation (SpO2) (p = 0.032), glucose (p = 0.015), hemoglobin (p = 0.047), BIG score (p < 0.001), subarachnoid hemorrhage (p = 0.013), and intracerebral hematoma (p = 0.001) were associated with in-hospital mortality of included patients. The AUC (area under the ROC curves) of the BIG score was 0.669, which was not as high as in previous pediatric trauma cohorts. However, combining the BIG score with age increased the AUC to 0.764. The prognostic model composed of significant factors including BIG had the highest AUC of 0.786.

Conclusion

The age-adjusted BIG score is superior to the original BIG score in predicting mortality of adult TBI patients. The prognostic model incorporating the BIG score is beneficial for clinicians, aiding them in making early triage and treatment decisions in adult TBI patients.

Risk factors for mortality in brain injury patients who have severe hypernatremia and received continuous venovenous hemofiltration

Background and objectives

The mortality rate for people with brain injuries is increased when hypernatremia is present. Patients with severe hypernatremia, who have a significant short-term mortality rate, were shown to benefit from continuous venovenous hemofiltration (CVVH), which has been indicated to be successful. Exploring the risk factors for short-term mortality in brain injury patients who underwent CVVH and had severe hypernatremia was the aim of the current study.

Materials and methods

Retrospective screening was performed on patients with brain injuries who underwent CVVH at Xijing Hospital between 1 December 2010 and 31 December 2021 and who have a diagnosis of severe hypernatremia. The outcomes included 28-day patient mortality and hospital stay duration. The patient survival rate was examined using the Kaplan-Meier survival curve. To determine the risk factors for short-term death for patients, univariate and multivariate Cox regression analysis models were used.

Results

Our current study included a total of 83 individuals. The included patients had a median age of 49 (IQR 35-59) years. Of the included patients, 58 patients (69.9 %) died within 28 days. The median length of hospital stay for the patient was 13 (IQR 7-21) days. The APACHE II score, SOFA score, GCS, PLT count, INR, stroke, mechanical ventilation, and vasopressor reliance were related to 28-day mortality according to the univariate Cox analysis. INR (HR = 1.004, 95 % Cl: 1.001-1.006, P = 0.008), stroke (HR = 1.971, 95 % Cl: 1.031-3.768, P = 0.04), mechanical ventilation (HR = 3.948, 95 % Cl: 1.090-14.294, P = 0.036), and vasopressor dependency (HR = 2.262, 95 % Cl: 1.099-4.655, P = 0.027) were independently associated with the risk of 28-day death rates, according to multivariate Cox regression analysis.

Conclusions

Brain injuries who have severe hypernatremia requires CVVH, which has high short-term patient mortality. Mechanical ventilation, INR increase, stroke, and vasopressor dependence are independently associated with increased patient mortality risk.

Association Between Admission Ionized Calcium Level and Neurological Outcome of Patients with Isolated Severe Traumatic Brain Injury: A Retrospective Cohort Study

BACKGROUND

Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. Pathophysiological processes following initial insult are complex and not fully understood. Ionized calcium (Ca++) is an essential cofactor in the coagulation cascade and platelet aggregation, and hypocalcemia may contribute to the progression of intracranial bleeding. On the other hand, Ca++ is an important mediator of cell damage after TBI and cellular hypocalcemia may have a neuroprotective effect after brain injury. We hypothesized that early hypocalcemia might have an adverse effect on the neurological outcome of patients suffering from isolated severe TBI. In this study, we aimed to evaluate the relationship between admission Ca++ level and the neurological outcome of these patients.

METHODS

This was a retrospective, single-center, cohort study of all patients admitted between January 2014 and December 2020 due to isolated severe TBI, which was defined as head abbreviated injury score ≥ 4 and an absence of severe (abbreviated injury score > 2) extracranial injuries. The primary outcome was a favorable neurological status at discharge, defined by a modified Rankin Scale of 0-2. Multivariable logistic regression was performed to determine whether admission hypocalcemia (Ca++  < 1.16 mmol L-1) is an independent predictor of neurological status at discharge.

RESULTS

The final analysis included 201 patients. Hypocalcemia was common among patients with isolated severe TBI (73.1%). Most of the patients had mild hypocalcemia (1 < Ca++  < 1.16 mmol L-1), and only 13 (6.5%) patients had Ca++  ≤ 1.00 mmol L-1. In the entire cohort, hypocalcemia was independently associated with higher rates of good neurological status at discharge (adjusted odds ratio of 3.03, 95% confidence interval 1.11-8.33, p = 0.03). In the subgroup of 81 patients with an admission Glasgow Coma Scale > 8, 52 (64.2%) had hypocalcemia. Good neurological status at discharge was recorded in 28 (53.8%) of hypocalcemic patients compared with 14 (17.2%) of those with normal Ca++ (p = 0.002). In multivariate analyses, hypocalcemia was independently associated with good neurological status at discharge (adjusted odds ratio of 6.67, 95% confidence interval 1.39-33.33, p = 0.02).

CONCLUSIONS

Our study demonstrates that among patients with isolated severe TBI, mild admission hypocalcemia is associated with better neurological status at hospital discharge. The prognostic value of Ca++ may be greater among patients with admission Glasgow Coma Scale > 8. Trials are needed to investigate the role of hypocalcemia in brain injury.

Acute Haemostatic Depletion and Failure in Patients with Traumatic Brain Injury (TBI): Pathophysiological and Clinical Considerations

BACKGROUND

Because of the aging population, the number of low falls in elderly people with pre-existing anticoagulation is rising, often leading to traumatic brain injury (TBI) with a social and economic burden. Hemostatic disorders and disbalances seem to play a pivotal role in bleeding progression. Interrelationships between anticoagulatoric medication, coagulopathy, and bleeding progression seem to be a promising aim of therapy.

METHODS

We conducted a selective search of the literature in databases like Medline (Pubmed), Cochrane Library and current European treatment recommendations using relevant terms or their combination.

RESULTS

Patients with isolated TBI are at risk for developing coagulopathy in the clinical course. Pre-injury intake of anticoagulants is leading to a significant increase in coagulopathy, so every third patient with TBI in this population suffers from coagulopathy, leading to hemorrhagic progression and delayed traumatic intracranial hemorrhage. In an assessment of coagulopathy, viscoelastic tests such as TEG or ROTEM seem to be more beneficial than conventional coagulation assays alone, especially because of their timely and more specific gain of information about coagulopathy. Furthermore, results of point-of-care diagnostic make rapid "goal-directed therapy" possible with promising results in subgroups of patients with TBI.

CONCLUSIONS

The use of innovative technologies such as viscoelastic tests in the assessment of hemostatic disorders and implementation of treatment algorithms seem to be beneficial in patients with TBI, but further studies are needed to evaluate their impact on secondary brain injury and mortality.

Causes and risk factors of an unplanned second craniotomy in patients with traumatic brain injury

BACKGROUND

The purpose of this retrospective study was to evaluate the causes and risk factors of an unplanned second craniotomy in patients with traumatic brain injury (TBI).

METHODS

A total of 219 patients with TBI who underwent initial unilateral intracranial supratentorial surgery between January 2016 to November 2021 were included. We evaluated the causes of an unplanned second craniotomy in 40 patients, and analyzed the risk factors for a contralateral second craniotomy in 21 patients using a multivariate logistic regression analysis.

RESULTS

The most common cause for an unplanned second craniotomy was delayed or enlarged hematoma in the non-operation area (26/40; 65%), followed by recurrent hematoma in the operation area (8/40; 20%), ipsilateral massive cerebral infarction (3/40; 7.5%), diffuse brain swelling (2/40; 5%) and enlarged cerebral contusion (1/40; 2.5%). Multivariate logistic regression analysis showed that a contralateral craniocerebral injury feature (CCIF) (OR = 13.175), defined on preoperative computerized tomography scanning, was independent risk factor for a contralateral second craniotomy.

CONCLUSIONS

An unplanned second craniotomy in patients with TBI was mainly related to delayed or enlarged hematoma. An increased risk of a contralateral second craniotomy occurs in patients with CCIF.

Association of Extravascular Leakage on Computed Tomography Angiography with Fibrinogen Levels at Admission in Patients with Traumatic Brain Injury

Extravascular leakage on computed tomography (CT) angiography in patients with traumatic brain injury (TBI) is associated with hematoma expansion, functional prognosis, subsequent surgery, and death. Fresh frozen plasma (FFP) administration is often necessary to treat coagulation disorders associated with TBI. This study aimed to determine the relationship between the presence of extravascular leakage on contrast-enhanced head CT, fibrinogen level at admission, and FFP administration in patients with TBI. The medical records of patients with TBI ≥18 years of age referred to our hospital between January 2010 and December 2020 were examined retrospectively. Patients who underwent contrast-enhanced CT immediately after admission were selected, and the presence or absence of extravascular leakage, fibrinogen level at admission, and percentage of patients who required FFP administration within 24 h of admission were examined; 172 patients were included. Multi-variable linear regression analysis was performed to determine the effects of contrast extravasation on fibrinogen levels at admission and was adjusted for age, sex, systolic blood pressure, time from injury to admission, Marshall CT score, Glasgow Coma Scale score at admission, Injury Severity Score, and need for emergency surgery; the regression coefficient was -19.8. The effect of extravasation on FFP administration within 24 h of admission was analyzed using logistic regression while adjusting for age, systolic blood pressure, Marshall CT score, need for emergency surgery, and fibrinogen level at admission. The odds ratio of contrast extravasation was 7.08 after adjustment. Extravascular leakage is associated with fibrinogen levels at admission and FFP administration within 24 h of admission.

High Dimensional Multiomics Reveals Unique Characteristics of Early Plasma Administration in Polytrauma Patients With TBI

OBJECTIVES

The authors sought to identify causal factors that explain the selective benefit of prehospital administration of thawed plasma (TP) in traumatic brain injury (TBI) patients using mediation analysis of a multiomic database.

BACKGROUND

The Prehospital Air Medical Plasma (PAMPer) Trial showed that patients with TBI and a pronounced systemic response to injury [defined as endotype 2 (E2)], have a survival benefit from prehospital administration of TP. An interrogation of high dimensional proteomics, lipidomics and metabolomics previously demonstrated unique patterns in circulating biomarkers in patients receiving prehospital TP, suggesting that a deeper analysis could reveal causal features specific to TBI patients.

METHODS

A novel proteomic database (SomaLogic Inc., aptamer-based assay, 7K platform) was generated using admission blood samples from a subset of patients (n=149) from the PAMPer Trial. This proteomic dataset was combined with previously reported metabolomic and lipidomic datasets from these same patients. A 2-step analysis was performed to identify factors that promote survival in E2-TBI patients who had received early TP. First, features were selected using both linear and multivariate-latent-factor regression analyses. Then, the selected features were entered into the causal mediation analysis.

RESULTS

Causal mediation analysis of observable features identified 16 proteins and 41 lipids with a high proportion of mediated effect (>50%) to explain the survival benefit of early TP in E2-TBI patients. The multivariate latent-factor regression analyses also uncovered 5 latent clusters of features with a proportion effect >30%, many in common with the observable features. Among the observable and latent features were protease inhibitors known to inhibit activated protein C and block fibrinolysis (SERPINA5 and CPB2), a clotting factor (factor XI), as well as proteins involved in lipid transport and metabolism (APOE3 and sPLA(2)-XIIA).

CONCLUSIONS

These findings suggest that severely injured patients with TBI process exogenous plasma differently than those without TBI. The beneficial effects of early TP in E2-TBI patients may be the result of improved blood clotting and the effect of brain protective factors independent of coagulation.

Development and Verification of Prognostic Prediction Models for Patients with Brain Trauma Based on Coagulation Function Indexes

Objective

To assess the effect of adding coagulation indices to the currently existing prognostic prediction models of traumatic brain injury (TBI) in the prediction of outcome.

Methods

A total of 210 TBI patients from 2017 to 2019 and 131 TBI patients in 2020 were selected for development and internal verification of the new model. The primary outcomes include death at 14 days and Glasgow Outcome Score (GOS) at 6 months. The performance of each model is evaluated by means of discrimination (area under the curve (AUC)), calibration (Hosmer-Lemeshow (H-L) goodness-of-fit test), and precision (Brier score).

Results

The IMPACT Core model showed better prediction ability than the CRASH Basic model. Adding one coagulation index at a time to the IMPACT Core model, the new combined models IMPACT Core+FIB and IMPACT Core+APTT are optimal for the 6-month unfavorable outcome and 6-month mortality, respectively (AUC, 0.830 and 0.878). The new models were built based on the regression coefficients of the models. Internal verification indicated that for the prediction of 6-month unfavorable outcome and 6-month mortality, both the IMPACT Core+FIB model and the IMPACT Core+APTT model show better discrimination (AUC, 0.823 vs. 0.818 and 0.853 vs. 0.837), better calibration (HL, p = 0.114 and p = 0.317) and higher precision (Brier score, 0.148 vs. 0.141 and 0.147 vs. 0.164), respectively, than the original models.

Conclusion

Our research shows that the combination of the traumatic brain injury prognostic models and coagulation indices can improve the 6-month outcome prediction of patients with TBI.

Persistent coagulopathy after gunshot traumatic brain injury: the importance of INR and the SPIN score

INTRODUCTION

Penetrating ballistic brain injury (gunshot traumatic brain injury or GTBI) is associated with a high mortality. Admission Glascow Coma Scale (GCS), injury severity score and neurological findings, cardiopulmonary instability, coagulopathy and radiological finding such as bullet trajectory and mass effect are shown to predict survival after GTBI. We aimed to examine the dynamics of the observed coagulopathy and its association with outcome.

METHODS

In this single-centered retrospective cohort study, we examined 88 patients with GTBI between 2015 and 2021. Variables analyzed include patient age; temperature, hemodynamic and respiratory variables, admission Glasgow Coma Scale (GCS); injury severity score (ISS); head abbreviated injury scale (AIS); Marshall, Rotterdam, SPIN and Baylor scores, and laboratory data including PTT, INR and platelet count. Receiver operating characteristic analysis was conducted to evaluate the performance of the predictive models.

RESULTS

The average age of our sample was 28.5 years and a majority were male subjects (92%). Fifty-four (62%) of the patients survived to discharge. The GCS score, as well as the motor, verbal, and eye-opening sub-scores were higher in survivors (P < 0.001). As was expected, radiologic findings including the Marshall and Rotterdam Scores were also associated with survival (P < 0.001). Although the ISS and Head AIS scores were higher (P < 0.001), extracranial injuries were not more prevalent in non-survivors (P= 0.567). Non-survivors had lower platelet counts and elevated PTT and INR (P < 0.001) on admission. PTT normalized within 24 h but INR continued to increase in non-survivors. SPIN score, which includes INR, was a better predictor for mortality than Rotterdam, Marshall, and Baylor etc. CONCLUSION: Progressively increasing INR after GTBI is associated with poor outcome and may indicate consumption coagulopathy from activation of the extrinsic pathway of coagulation and metabolic derangements that are triggered and sustained by the brain injury. The SPIN score, which incorporates INR as a major survival score component, outperforms other available prediction models for predicting outcome after GTBI.

XGBoost machine learning algorism performed better than regression models in predicting mortality of moderate to severe traumatic brain injury

BACKGROUND

Traumatic brain injury (TBI) brings severe mortality and morbidity risk to patients. Predicting outcome of these patients is necessary for physicians to make suitable treatments to improve prognosis. The aim of this study is to develop a mortality prediction approach using the XGBoost (extreme gradient boosting) in moderate to severe TBI.

METHODS

368 patients hospitalized in West China hospital for TBI with GCS below 13 were identified. To construct XGBoost prediction approach, patients were divided into training set and test set with ratio of 7:3. Logistic regression prediction model was also constructed and compared with XGBoost model. Area under the receiver operating characteristic curve (AUC), accuracy, sensitivity and specificity were calculated to compare the prognostic value between XGBoost and logistic regression.

RESULTS

205 patients suffered poor outcome with mortality of 55.7%. Non-survivors had lower Glasgow Coma Scale (GCS) (5 vs 7, p<0.001) and higher Injury Severit Score (ISS) than survivors (25 vs 16, p<0.001). Platelet (p<0.001), albumin (p<0.001), hemoglobin (p<0.001) were significantly lower in non-survivors while glucose (p<0.001) and prothrombin time (PT) (p<0.001)was significantly higher in non-survivors. Among the XGBoost approach, GCS, PT and glucose had the most significant feature importance. The AUC (0.955 vs 0.805) and accuracy (0.955 vs 0.70) of XGBoost were both higher than logistic regression.

CONCLUSION

Predicting mortality of moderate to severe TBI patients using XGBoost algorism is more effective and precise than logistic regression. The XGBoost prediction approach is beneficial for physicians to evaluate TBI patients at high risk of poor outcome.

Factors Associated with the Development of Coagulopathy after Open Traumatic Brain Injury

Background: The incidence of coagulopathy after open traumatic brain injury (TBI) is high. Coagulopathy can aggravate intracranial hemorrhage and further increase morbidity and mortality. The purpose of this study was to determine the clinical characteristics of coagulopathy after open TBI and its relationship with the prognosis. Methods: This study retrospectively evaluated patients with isolated open TBI from December 2018 to December 2020. Coagulopathy was defined as international normalized ratio (INR) > 1.2, activated thromboplastin time (APTT) > 35 s, or platelet count <100,000/μL. We compared the relationship between the clinical, radiological, and laboratory parameters of patients with and without coagulopathy, and the outcome at discharge. Logistic regression analysis was used to evaluate the risk factors associated with coagulopathy. We then compared the effects of treatment with and without TXA in open TBI patients with coagulopathy. Results: A total of 132 patients were included in the study; 46 patients developed coagulopathy. Patients with coagulopathy had significantly lower platelet levels (170.5 × 10⁹/L vs. 216.5 × 10⁹/L, p < 0.001), and significantly higher INR (1.14 vs. 1.02, p < 0.001) and APTT (30.5 s vs. 24.5 s, p < 0.001) compared to those with no coagulopathy. A Low Glasgow Coma Scale (GCS) score, high neutrophil/lymphocyte ratio (NLR), low platelet/lymphocyte ratio (PLR), and hyperglycemia at admission were significantly associated with the occurrence of coagulopathy. Conclusions: Coagulopathy often occurs after open TBI. Patients with a low GCS score, high NLR, low PLR, and hyperglycemia at admission are at greater risk of coagulopathy, and therefore of poor prognosis. The efficacy of TXA in open TBI patients with coagulopathy is unclear. In addition, these findings demonstrate that PLR may be a novel indicator for predicting coagulopathy.

Contribution of factor VII polymorphisms to coagulopathy in patients with isolated traumatic brain injury

BACKGROUND

Coagulopathy is a severe complication of traumatic brain injury (TBI) and can cause secondary injuries and death. Decrease of FVII activity contributes to the coagulopathy and progressive hemorrhagic injury (PHI) in patients with isolated TBI. Some polymorphic loci of coagulation factor VII (FVII) are shown to be essential for FVII activity. However, the relationship between FVII gene polymorphisms and coagulopathy in patients with isolated TBI is still unknown. Therefore, the present study aimed to investigate the relationship between FVII gene polymorphisms and plasma FVIIa levels, and assess whether FVII polymorphisms were associated with TBI-related coagulopathy, PHI, and 6 months GOS in patients with isolated TBI.

METHODS

One-hundred-forty-nine patients with isolated TBI (from East of China) admitted to Huashan Hospital's Neurological Trauma Center from March 2012 to March 2016 were enrolled in this study. The Polymorphism-Polymerase Chain Reaction (PCR) method was used to analyze the five FVII polymorphism loci (-323P0/P10, R353Q, -401G/T, -402G/A, and -670A/C) of these patients. Patients' blood was collected to test the activated partial thromboplastin time, international normalized ratio, platelet, and FVIIa concentrations. Other clinical characteristics were also recorded.

RESULTS

The minor alleles of three genotypes of -323 P0/P10, R353Q, and -401G/T each independently associated with 23.3%, 28.6%, and 27.6% lower FVIIa levels, respectively. These polymorphisms explained 21% of the total variance of FVIIa levels (adjusted R²:0.206). The genotype of -323P0/P10 was an independent risk factor for coagulopathy (OR = 2.77, p = 0.043) and PHI (OR = 3.47, p = 0.03) after adjustment for confounding factors in the logistic regression model. Polymorphisms of FVII were not independently associated with 6 months Glasgow Outcome Scale (GOS) of isolated TBI patients.

CONCLUSION

-323P0/P10, R353Q, and -401 G/T genotypes were associated with FVIIa levels. -323P0/P10 genotype was independently associated with traumatic coagulopathy and PHI in isolated TBI patients.

Prospective Analysis of Coagulopathy Associated with Isolated Traumatic Brain Injury and Clinical Outcome

Introduction Traumatic brain injury (TBI) affects the coagulation pathway in a distinct way than does extracranial trauma. The extent of coagulation abnormalities varies from bleeding diathesis to disseminated thrombosis.

Design Prospective study.

Methods The study included 50 patients of isolated TBI with cohorts of moderate (MHI) and severe head injury (SHI). Coagulopathy was graded according to the values of parameters in single laboratory. The incidence of coagulopathy according to the severity of TBI and correlation with disseminated intravascular coagulation (DIC) score, platelets, prothrombin time (PT), activated partial thromboplastin time (APTT), D-dimer, and fibrinogen was observed. The comparison was also made between expired and discharged patients within each group. It also compared coagulation derailments with clinical presentation (Glasgow Coma Scale [GCS]) and outcome (Glasgow Outcome Scale [GOS]).

Results Road traffic accident was the primary (72%) mode of injury. Fifty-two percent had MHI and rest had SHI. Eighty-four percent of cases were managed conservatively. The mean GCS was 12.23 and 5.75 in MHI and SHI, respectively. Sixty-two percent of MHI and 96% of the patients with SHI had coagulation abnormalities. On statistical analysis, DIC score (p < 0.001) strongly correlated with the severity of head injury and GOS. PT and APTT were also significantly associated with the severity of TBI. In patients with moderate TBI, D-dimer and platelet counts showed association with clinical outcome. Fibrinogen levels did not show any statistical significance. The mean platelet counts remained normal in both the groups of TBI. The mean GOS was 1.54 and 4.62 in SHI and MHI, respectively.

Conclusion Coagulopathy is common in isolated TBI. The basic laboratory parameters are reliable predictors of coagulation abnormalities in TBI. Coagulopathy is directly associated with the severity of TBI, GCS, and poor outcome.

Fibrinolysis in Traumatic Brain Injury: Diagnosis, Management, and Clinical Considerations

Posttraumatic coagulopathy involves disruption of both the coagulation and fibrinolytic pathways secondary to tissue damage, hypotension, and inflammatory upregulation. This phenomenon contributes to delayed complications after traumatic brain injury (TBI), including intracranial hemorrhage progression and systemic disseminated intravascular coagulopathy. Development of an early hyperfibrinolytic state may result in uncontrolled bleeding and is associated with increased mortality in patients with TBI. Although fibrinolytic assays are not routinely performed in the assessment of posttraumatic coagulopathy, circulating biomarkers such as D-dimer and fibrin degradation products have demonstrated potential utility in outcome prediction. Unfortunately, the relatively delayed nature of these tests limits their clinical utility. In contrast, viscoelastic tests are able to provide a rapid global assessment of coagulopathy, although their ability to reliably identify disruptions in the fibrinolytic cascade remains unclear. Limited evidence supports the use of hypertonic saline, cryoprecipitate, and plasma to correct fibrinolytic disruption; however, some studies suggest more harm than benefit. Recently, early use of tranexamic acid in patients with TBI and confirmed hyperfibrinolysis has been proposed as a strategy to further improve clinical outcomes. Moving forward, further delineation of TBI phenotypes and the clinical implications of fibrinolysis based on phenotypic variation is needed. In this review, we summarize the clinical aspects of fibrinolysis in TBI, including diagnosis, treatment, and clinical correlates, with identification of targeted areas for future research efforts.

Platelet Dysfunction after Traumatic Brain Injury: A Review

Coagulopathy is a known sequela of traumatic brain injury (TBI) and can lead to increased morbidity and mortality. Platelet dysfunction has been identified as one of several etiologies of coagulopathy following TBI and has been associated with poor outcomes. Regardless of whether the platelet dysfunction occurs as a direct consequence of the injury or because of pre-existing medical comorbidities or medication use, accurate detection and monitoring of response to therapy is key to optimal patient care. Platelet transfusion has been proposed as a potential therapeutic intervention to treat platelet dysfunction, with several studies using platelet function assays to monitor response. The development of increasingly precise diagnostic testing is providing enhanced understanding of the specific derangement in the hemostatic process, allowing clinicians to provide patient-specific treatment plans. There is wide variability in the currently available literature on the incidence and clinical significance of platelet dysfunction following TBI, which creates challenges with developing evidence-based management guidelines. The relatively high prevalence of platelet inhibitor therapy serves as an additional confounding factor. In addition, the data are largely retrospective in nature. We performed a literature review to provide clarity on this clinical issue. We reviewed 348 abstracts, and included 97 manuscripts in our final literature review. Based on the currently available research, platelet dysfunction has been consistently demonstrated in patients with moderate-severe TBI. We recommend the use of platelet functional assays to evaluate patients with TBI. Platelet transfusion directed at platelet dysfunction may lead to improved clinical outcome. A randomized trial guided by implementation science could improve the applicability of these practices.

New Uses for Thromboelastography and Other Forms of Viscoelastic Monitoring in the Emergency Department: A Narrative Review

Patients frequently visit the emergency department with conditions that place them at risk of worse outcomes when accompanied by coagulopathy. Routine tests of coagulation-prothrombin time, partial thromboplastin time, platelets, and fibrinogen-have shortcomings that limit their use in providing emergency care. One alternative is to investigate coagulation disturbance with viscoelastic monitoring (VEM), a coagulation test that measures the timing and strength of blood clot development in real time. VEM is widely used and studied in cardiac surgery, liver transplant surgery, anesthesia, and trauma. In this article, we review the technique of VEM and the biologic rationale of using it in addition to routine tests of coagulation in emergency clinical situations. Then, we review the evidence (or lack thereof) for using VEM in the diagnosis and treatment of specific conditions. Finally, we describe the limitations of the test and future directions for clinical use and research in emergency medicine.

Optimal surgical indications of endoscopic surgery for traumatic acute subdural hematoma in elderly patients based on a single-institution experience

Recently, treatment of acute subdural hematoma (ASDH) by minimally invasive surgery with endoscopy has been successfully demonstrated. However, few case series are available on this procedure for ASDH, and the surgical indication has not been established. We retrospectively analyzed the data of patients (n = 26) aged 65 years or older who underwent endoscopic surgery (ES) for ASDH at our institution between January 2011 and March 2019. We then evaluated the surgical outcomes and procedure-related complications in patients who underwent ES. The mean hematoma reduction rate was over 90%. Percentage of favorable outcomes at discharge was 69.2% in ES-treated patients. The presence of a skull fracture, subarachnoid hemorrhage, midline shift/subdural hematoma thickness ratio > 1.0, and early surgery were associated with postoperative IPHs in patients who underwent ES or conventional surgery for ASDH. The present study revealed that ES for elderly patients with ASDH is likely to be an efficient and safe procedure when patients are selected appropriately. However, ES is not recommended in patients with significant IPHs on initial CT scan. Additionally, ES should be carefully considered in cases with the factors, where IPHs may progress following surgery.