Time course of coagulopathy in isolated severe traumatic brain injury

Background

Time aspects of coagulopathy following severe traumatic brain injury (sTBI) are ill defined throughout the literature. Thus, the aim of this study was to evaluate the time course of coagulopathy following isolated sTBI and its relationship to in-hospital outcomes.

Methods

Retrospective analysis of patients sustaining isolated sTBI (head AIS ≥ 3, extracranial injuries AIS < 3). TBI coagulopathy was defined as thrombocytopenia and/or elevated international normalised ratio (INR) and/or prolonged activated partial thromboplastin time (aPTT). Incidence, onset and duration of sTBI-coagulopathy and its impact on morbidity and mortality were analysed.

Results

Overall, 45.7% (n = 127) of the 278 patients included developed coagulopathy. Coagulopathy occurred 23.1 ± 2.2 h [range: 0.1-108.2 h (0-4.5 days)] post-admission with a mean duration of 68.0 ± 7.4 h [range: 2.6-531.4 h (0.1-22.1 days)]. The time interval to onset of coagulopathy decreased significantly with increasing head injury severity (p = 0.015). Early coagulation abnormalities occurring within 12 h of admission along with markers of devastating head injury including head AIS 5, penetrating injury mechanism, subdural hematoma, and a low GCS on admission proved to be independent risk factors for mortality.

Conclusions

The sTBI-associated coagulopathy may ensue as late as 5 days after injury with a prolonged duration (>72 h) in 30% of patients. Early coagulopathy occurring within 12 h after injury is a marker of increased morbidity and poor outcomes. Pertinent prolonged screening of this sequela is warranted.     

Acute traumatic coagulopathy in the setting of isolated traumatic brain injury: A systematic review and meta-analysis

Background and objectives

Acute traumatic coagulopathy (ATC) has been reported in the setting of isolated traumatic brain injury (iTBI) and associated with high mortality and poor outcomes. The aim of this systematic review was to examine the incidence and outcome of patients with ATC in the setting of iTBI.

Methods

We conducted a search of the MEDLINE database and Cochrane library, focused on subject headings and keywords involving coagulopathy and TBI. Design and results of each study were described. Studies were assessed for heterogeneity and the pooled incidence of ATC in the setting of iTBI determined. Reported outcomes were described.

Results

There were 22 studies selected for analysis. A statistically significant heterogeneity among the studies was observed (p < 0.01). Using the random effects model the pooled proportion of patients with ATC in the setting of iTBI was 35.2% (95% CI: 29.0–41.4). Mortality of patients with ATC and iTBI ranged between 17% and 86%. Higher blood transfusion rates, longer hospital stays, longer ICU stays, decreased ventilator free days, higher rates of single and multiple organ failure and higher incidence of delayed injury and disability at discharge were reported among patients with ATC.

Conclusions

ATC is commonly associated with iTBI and almost uniformly associated with worse outcomes. Any disorder of coagulation above the normal range appears to be associated with worse outcomes and therefore a clinically important target for management. Earlier identification of patients with ATC and iTBI, for recruitment into prospective trials, presents avenues for further research.     

Relationship between trauma-induced coagulopathy and progressive hemorrhagic injury in patients with traumatic brain injury

Progressive hemorrhagic injury (PHI) can be divided into coagulopathy-related PHI and normal coagulation PHI. Coagulation disorders after traumatic brain injuries can be included in trauma-induced coagulopathy (TIC). Some studies showed that TIC is associated with PHI and increases the rates of disability and mortality. In this review, we discussed some mechanisms in TIC, which is of great importance in the development of PHI, including tissue factor (TF) hypothesis, protein C pathway and thrombocytopenia. The main mechanism in the relation of TIC to PHI is hypocoagulability. We also reviewed some coagulopathy parameters and proposed some possible risk factors, predictors andtherapies.     

Quantitative CT improves outcome prediction in acute traumatic brain injury

The admission noncontrast head computed tomography (CT) scan has been demonstrated to be one of several key early clinical and imaging features in the challenging problem of prediction of long-term outcome after acute traumatic brain injury (TBI). In this study, we employ two novel approaches to the problem of imaging classification and outcome prediction in acute TBI. First, we employ the novel technique of quantitative CT (qCT) image analysis to provide more objective, reproducible measures of the abnormal features of the admission head CT in acute TBI. We show that the incorporation of quantitative, rather than qualitative, CT features results in a significant improvement in prediction of the 6-month Extended Glasgow Outcome Scale (GOS-E) score over a wide spectrum of injury severity. Second, we employ principal components analysis (PCA) to demonstrate the interdependence of certain predictive variables. Relatively few prior studies of outcome prediction in acute TBI have used a multivariate approach that explicitly takes into account the potential covariance among clinical and CT predictive variables. We demonstrate that several predictors, including midline shift, cistern effacement, subdural hematoma volume, and Glasgow Coma Scale (GCS) score are related to one another. Rather than being independent features, their importance may be related to their status as surrogate measures of a more fundamental underlying clinical feature, such as the severity of intracranial mass effect. We believe that objective computational tools and data-driven analytical methods hold great promise for neurotrauma research, and may ultimately have a role in image analysis for clinical care.     

One-year outcome and course of recovery after severe traumatic brain injury

Goal  

To describe the outcome of patients with severe traumatic brain injury (TBI) 3, 6 and 12 months after trauma.     

Patients with mild traumatic brain injury: immediate and long-term outcome compared to intra-cranial injuries on CT scan

Background: Mild traumatic brain injury (MTBI) defined as Glasgow Coma Scale (GCS) 14 or 15 has shown contradictory short- and long-term outcomes. The objective of this study was to correlate intra-cranial injuries (ICI) on CT scan to neurocognitive tests at admission and to complaints after 1 year.

Methods: Two hundred and five patients with MTBI underwent a CT scan and were examined with neurocognitive tests. After 1 year complaints were assessed by phone interviews.

Results: The neurocognitive tests in 51% of the patients showed significant deficits; there was no difference for patients with GCS 14-15, nor was there a difference between patients with ICI to patients without. After 1 year patients with ICI had significantly more complaints than patients without ICI, the most frequent complaint was headache and memory deficits.

Conclusions: No correlation was found between GCS or ICI and the neurocognitive tests upon admission. After 1 year, patients with ICI have significantly more complaints than patients without ICI. No cost savings resulted by doing immediate CT scan on all.     

Gender differences in outcome in patients with hypotension and severe traumatic brain injury

BACKGROUND: Animal studies have identified hormonal influences on responses to injury and recovery, creating a potential gender effect on outcome. Progesterone and oestrogen are thought to afford protection in the immediate post-injury period, suggesting females have an advantage, although there has been limited evidence of this in human outcome studies. METHODS: This study examined the influence of gender on outcome in 229 adults (151 males), aged >17 years, with severe blunt head trauma, initial GCS <9 and hypotension, recruited into a randomised controlled trial of pre-hospital hypertonic saline resuscitation versus conventional fluid management. Outcome was measured by survival and Glasgow Outcome Scale-Extended version (GOS-E) scores at 6 months post-injury. RESULTS: Females recruited into the study had a higher mean age. Females were more likely to be injured as passengers and pedestrians and males as drivers or motorcyclists. There were no gender differences in GCS or injury severity scores, ICP, cerebral perfusion pressure, gas exchange (PaO2/FiO2 ratio), or duration of mechanical ventilation. After controlling for GCS, age and cause of injury, females had a lower rate of survival. They also showed a lower rate of good outcome (GOS-E score >4) at 6 months, but this appeared to reflect the lower rate of initial survival. Those females surviving had similar outcomes to males. CONCLUSIONS: The study provides no evidence that females fare better than males following severe TBI, suggesting rather that females may fare worse.     

Long-time outcome after transient transtentorial herniation in patients with traumatic brain injury

BACKGROUND: This study investigates mortality and morbidity in patients with traumatic brain injury (TBI) who developed episode(s) of transtentorial herniation. The transtentorial herniation was defined as a deterioration of consciousness accompanied by uni- or bilateral pupil dilatation. METHODS: The medical records of all patients with traumatic brain injury admitted during 1999 to the Neuro- or General Intensive Care Units at Sahlgrenska University Hospital were analyzed, and patients with at least one episode of transtentoryal herniation were included. Information regarding patient age, gender, type of trauma, initial GCS, precipitating reason for herniation, uni-/bilateral pupil dilatation, treatment(s) and outcome after at least 6 months, assessed with the Glasgow Outcome Scale (GOS), was collected from medical records. RESULTS: The study included 27 patients, average age 44 years (range 6-81), with a male proportion of 81%. The majority of the patients were victims of traffic accidents and falls. The results demonstrated that 16/27(59%) of the patients had a favorable outcome (GOS 4/5), 4/27(15%) were severely disabled (GOS 3), none was vegetative (GOS 2) and 7/27(26%) died (GOS 1). When analyzing patient subgroups, best outcome was found in children where 3/4 (75%) had a GOS 4/5. CONCLUSION: Transtentorial herniation is a serious consequence of supratentorial edema/mass lesions in patients with TBI. However, with aggressive neurointensive care and neurosurgical treatments we found a 59% patient incidence of a favorable outcome.     

Clinical predictors and neuropsychological outcome in severe traumatic brain injury patients

Summary Background. The aim of the study was to evaluate the possible significant role of some clinical factors in predicting cognitive outcome in a group of severe traumatic brain injury (TBI) patients, with Glasgow Coma Scale (GCS) lower than 8 and duration of unconsciousness for at least 15 days (prolonged coma).Method. A consecutive sample of 25 survivors of severe TBI attending the Physical and Cognitive Rehabilitation program participated in this study. The neuropsychological test battery included: Word-list Learning, Prose recall, Rey Figure Delayed recall, Word fluency, Ravens Progressive Matrices 47. The clinical variables evaluated in correlation with the neuropsychological outcome were the following: age, duration of unconsciousness, duration of post-traumatic amnesia, interval from head trauma to neuropsychological evaluation, interval from head trauma to recovery of oral feeding, and finally interval from head trauma to first verbal communication.Findings. The clinical variable with a significant predictive value on most neuropsychological scores was the interval from head trauma to the recovery of oral feeding.Conclusions. If this result is confirmed in larger samples, time interval of oral feeding recovery from head trauma should be considered as a possible predictor of neuropsychological outcome in TBI patients with prolonged coma.     

The effect of cocaine on traumatic brain injury outcome: a preliminary evaluation

The effect of acute cocaine use on the functional and neuropsychological outcome of persons with traumatic brain injury, (TBI) was examined by comparing persons with TBI who tested positive for cocaine at the time of admission with persons with negative drug and alcohol screens. Subjects were matched for age, admission GCS score, level of education, and aetiology of injury (closed vs penetrating head injury). Dependent measures were: the Disability Rating Scale, the Functional Independence Measure, and selected neuropsychological tests. No group differences were found in DRS, FIM, FIM subsets, or FIM change. However, the cocaine group scored significantly lower than the no-drug group on the Rey Auditory Verbal Learning Test, but did not differ on any of the other neuropsychological tests.     

Ethanol intoxication is associated with a lower incidence of admission coagulopathy in severe traumatic brain injury patients

The aim of this study was to determine the impact of ethanol (ETOH) on the incidence of severe traumatic brain injury (sTBI)-associated coagulopathy and to examine the effect of ETOH on in-hospital outcomes in patients sustaining sTBI. Patients admitted to the surgical intensive care unit from June 2005 through December 2008 following sTBI, defined as a head Abbreviated Injury Scale (AIS) score ≥3, were retrospectively identified. Patients with a chest, abdomen, or extremity AIS score >3 were excluded to minimize the impact of extracranial injuries. Criteria for sTBI-associated coagulopathy included thrombocytopenia and/or elevated International Normalized Ratio (INR) and/or prolonged activated partial thromboplastin time (aPTT). The incidence of admission coagulopathy, in-hospital complications, and mortality were compared between patients who were ETOH positive [ETOH (+)] and ETOH negative [ETOH (-)]. During the study period, there were 439 patients with ETOH levels available for analysis. Overall, 46.5% (n=204) of these patients were ETOH (+), while 53.5% (n=235) were ETOH (-). Coagulopathy was significantly less frequent in the ETOH (+) patients compared to their ETOH (-) counterparts (5.4% versus 15.3%; adjusted p<0.001). In the forward logistic regression analysis, a positive ETOH level proved to be an independent protective factor for admission coagulopathy [OR (95% CI)=0.24 (0.10,0.54; p=0.001]. ETOH (+) patients had a significantly lower in-hospital mortality rate than ETOH (-) patients [9.8% versus 16.6%; adjusted p=0.011; adjusted OR (95% CI)=0.39 (0.19,0.81)]. For brain-injured patients arriving alive to the hospital, ETOH intoxication is associated with a significantly lower incidence of early coagulopathy and in-hospital mortality. Further research to establish the pathophysiologic mechanisms underlying any potential beneficial effect of ETOH on the coagulation system following sTBI is warranted.     

Thrombelastography-identified coagulopathy is associated with increased morbidity and mortality after traumatic brain injury

BackgroundThe purpose of this study was to determine the relationship between coagulopathy and outcome after traumatic brain injury.MethodsPatients admitted with a traumatic brain injury were enrolled prospectively and admission blood samples were obtained for kaolin-activated thrombelastogram and standard coagulation assays. Demographic and clinical data were obtained for analysis.ResultsSixty-nine patients were included in the analysis. A total of 8.7% of subjects showed hypocoagulability based on a prolonged time to clot formation (R time, > 9 min). The mortality rate was significantly higher in subjects with a prolonged R time at admission (50.0% vs 11.7%). Patients with a prolonged R time also had significantly fewer intensive care unit–free days (8 vs 27 d), hospital-free days (5 vs 24 d), and increased incidence of neurosurgical intervention (83.3% vs 34.9%).ConclusionsHypocoagulability as shown by thrombelastography after traumatic brain injury is associated with worse outcomes and an increased incidence of neurosurgical intervention.     

Fiberoptic endoscopic evaluation of swallowing in patients with acute traumatic brain injury

Dysphagia and aspiration in intensive care unit patients with acute traumatic brain injury (TBI) is a frequent and potentially life-threatening problem. Any diagnostic technique used with this population, therefore, must be able to be performed in a timely and efficient manner while providing objective information on the nature of the swallowing problem. The purpose of the present study was to investigate the utility of using the fiberoptic endoscopic evaluation of swallowing (FEES) technique to diagnosis pharyngeal stage dysphagia and determine aspiration status in patients who presented with acute TBI. A total of 47 subjects were assessed with FEES. Thirty of 47 (64%) subjects swallowed successfully and were able to take an oral diet: 2 of 30 (7%) thickened liquids and purée consistencies, 8 of 30 (27%) a soft diet, and 20 of 30 (67%) a regular diet. Seventeen of 47 (36%) subjects exhibited pharyngeal stage dysphagia with aspiration and were not permitted an oral diet based on objective results provided by FEES. Of the 17 subjects who aspirated, 9 of 17 (53%) exhibited silent aspiration. Younger subjects (mean age 34 years, 3 months) aspirated significantly less often than older subjects (mean age 51 years, 8 months). No significant age difference was observed for gender or between overt and silent aspirators. It was concluded that FEES is an objective and sensitive tool that can be used successfully to diagnose pharyngeal stage dysphagia, determine aspiration status, and make recommendations for oral or nonoral feeding in patients with acute TBI.     

Prehospital hypoxia affects outcome in patients with traumatic brain injury: a prospective multicenter study

BACKGROUND: The goals of this study were to determine the incidence and duration of hypotension and hypoxia in the prehospital setting in patients with potentially survivable brain injuries, and to prospectively examine the association of these secondary insults with mortality and disability at hospital discharge. METHODS: Trauma patients with suspected brain injuries underwent continuous blood pressure and pulse oximetry monitoring during helicopter transport. Postadmission inclusion criteria were (1) diagnosis of acute traumatic brain injury (TBI) confirmed by computed tomography (CT) scan, operative findings, or autopsy findings; and (2) Head Abbreviated Injury Scale (AIS) score of > or = 3 or Glasgow Coma Scale (GCS) score of < or = 12 within the first 24 hours of admission. Patients were excluded with (1) no abnormal intracranial findings on the patient's CT scan; (2) determination of a nonsurvivable injury (based on an AIS score of 6 for any body region; or, (3) death in less than 12 hours after injury. Primary outcome measures included mortality and Disability Rating Scale score at discharge. RESULTS: We enrolled 150 patients into the study. Fifty-seven patients had at least one secondary insult; 37 had only hypoxic episodes, 14 had only hypotensive episodes, and 6 patients had both. Demographics and injury characteristics did not differ between those with and those without secondary insults. The mortality for patients without secondary insults was 20%, compared with 37% for patients with hypoxic episodes, 8% for patients with hypotensive episodes, and 24% for patients with both. The Disability Rating Scale score at discharge was significantly higher in patients with secondary insults. Using multivariate analysis, the calculated odds ratio of mortality caused by prehospital hypoxia after head injury was 2.66 (p < 0.05). CONCLUSIONS: Secondary insults after TBI are common, and these insults are associated with disability. Hypoxia in the prehospital setting significantly increases the odds of mortality after brain injury controlled for multiple variables.