Coagulopathy in the Acute Phase of Traumatic Brain Injury

Acute traumatic brain injury (TBI) can be accompanied by coagulopathy. In TBI, when an increased risk of hemorrhagic lesions in the brain tissue exists, keeping the normal hemostasis is crucial.The aim: to determine the incidence of coagulopathy in the acute phase of isolated TBI and identify the correlation between the types of hemostasis disorders and the severity of TBI.Materials and methods. We analyzed 323 case records of patients with TBI hospitalized to the Neurosurgery Center ICU from 2008 to 2016, 118 of them were included in the study. Criteria for inclusion were acute isolated TBI, hospitalization in the ﬁrst 72 hours after injury, young and middle-aged patients. On admission to the hospital, all patients were assessed according to the Glasgow Coma Scale (GCS) and divided into two groups: group I with severe TBI, group 2 with mild and moderate TBI. All patients underwent blood coagulation testing (APTT, PTI, ﬁbrinogen concentration, platelet count).Results. In 63.6% of patients with acute TBI coagulopathy were found, most of them (55.1%) had hypocoagulability state and were observed in the group of severe PMT (62.5%). The most frequent signs of coagulopathy were reduced PTI of less than 70% and thrombocytopenia of less than 150×109/l. A weak correlation (R=0.276; P=0.002) was found between the development of thrombocytopenia and adverse outcomes (1–3 points according to GOS).Conclusion. on hospital admission coagulopathy was diagnosed in 63,6% of patients in the acute phase of TBI, hypocoagulability state prevailed. Coagulopathy was signiﬁcantly more common in patients in the acute phase of severe TBI (GCS8 points).The mechanisms of TBI-associated coagulopathy have not yet been fully clariﬁed. Further studies of the role of platelet, plasma and ﬁbrinolytic components in the development of coagulopathy are warranted, which require more comprehensive methods of hemostasis investigation.

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Chemoprophylaxis and Venous Thromboembolism in Traumatic Brain Injury at Different Trauma Centers

The American Surgeon ◽

10.1177/000313482008600433 ◽

2020 ◽

Vol 86 (4) ◽

pp. 362-368

Author(s):

Eric O. Yeates ◽

Areg Grigorian ◽

Sebastian D. Schubl ◽

Catherine M. Kuza ◽

Victor Joe ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Venous Thromboembolism ◽

Brain Injury ◽

Trauma Centers ◽

Improvement Program ◽

Level Ii ◽

Increased Risk ◽

Scale Scores ◽

Severe Tbi ◽

Level I

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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Parallel recovery of consciousness and sleep in acute traumatic brain injury

Neurology ◽

10.1212/wnl.0000000000003508 ◽

2016 ◽

Vol 88 (3) ◽

pp. 268-275 ◽

Cited By ~ 20

Author(s):

Catherine Duclos ◽

Marie Dumont ◽

Caroline Arbour ◽

Jean Paquet ◽

Hélène Blais ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Cognitive Functioning ◽

Acute Phase ◽

Mixed Model ◽

Hospitalized Patients ◽

Wrist Actigraphy ◽

Severe Tbi ◽

Acute Traumatic Brain Injury ◽

Nighttime Sleep

Objective:To investigate whether the progressive recuperation of consciousness was associated with the reconsolidation of sleep and wake states in hospitalized patients with acute traumatic brain injury (TBI).Methods:This study comprised 30 hospitalized patients (age 29.1 ± 13.5 years) in the acute phase of moderate or severe TBI. Testing started 21.0 ± 13.7 days postinjury. Consciousness level and cognitive functioning were assessed daily with the Rancho Los Amigos scale of cognitive functioning (RLA). Sleep and wake cycle characteristics were estimated with continuous wrist actigraphy. Mixed model analyses were performed on 233 days with the RLA (fixed effect) and sleep-wake variables (random effects). Linear contrast analyses were performed in order to verify if consolidation of the sleep and wake states improved linearly with increasing RLA score.Results:Associations were found between scores on the consciousness/cognitive functioning scale and measures of sleep-wake cycle consolidation (p < 0.001), nighttime sleep duration (p = 0.018), and nighttime fragmentation index (p < 0.001). These associations showed strong linear relationships (p < 0.01 for all), revealing that consciousness and cognition improved in parallel with sleep-wake quality. Consolidated 24-hour sleep-wake cycle occurred when patients were able to give context-appropriate, goal-directed responses.Conclusions:Our results showed that when the brain has not sufficiently recovered a certain level of consciousness, it is also unable to generate a 24-hour sleep-wake cycle and consolidated nighttime sleep. This study contributes to elucidating the pathophysiology of severe sleep-wake cycle alterations in the acute phase of moderate to severe TBI.

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Mortality risk stratification in isolated severe traumatic brain injury using the revised cardiac risk index

European Journal of Trauma and Emergency Surgery ◽

10.1007/s00068-021-01841-7 ◽

2021 ◽

Author(s):

Maximilian Peter Forssten ◽

Gary Alan Bass ◽

Kai-Michael Scheufler ◽

Ahmad Mohammad Ismail ◽

Yang Cao ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Risk Stratification ◽

Hospital Mortality ◽

Severe Traumatic Brain Injury ◽

Mortality Risk ◽

Risk Index ◽

Cardiac Risk ◽

Increased Risk ◽

Severe Tbi

Abstract Purpose Traumatic brain injury (TBI) continues to be a significant cause of mortality and morbidity worldwide. As cardiovascular events are among the most common extracranial causes of death after a severe TBI, the Revised Cardiac Risk Index (RCRI) could potentially aid in the risk stratification of this patient population. This investigation aimed to determine the association between the RCRI and in-hospital deaths among isolated severe TBI patients. Methods All adult patients registered in the TQIP database between 2013 and 2017 who suffered an isolated severe TBI, defined as a head AIS ≥ 3 with an AIS ≤ 1 in all other body regions, were included. Patients were excluded if they had a head AIS of 6. The association between different RCRI scores (0, 1, 2, 3, ≥ 4) and in-hospital mortality was analyzed using a Poisson regression model with robust standard errors while adjusting for potential confounders, with RCRI 0 as the reference. Results 259,399 patients met the study’s inclusion criteria. RCRI 2 was associated with a 6% increase in mortality risk [adjusted IRR (95% CI) 1.06 (1.01–1.12), p = 0.027], RCRI 3 was associated with a 17% increased risk of mortality [adjusted IRR (95% CI) 1.17 (1.05–1.31), p = 0.004], and RCRI ≥ 4 was associated with a 46% increased risk of in-hospital mortality [adjusted IRR(95% CI) 1.46 (1.11–1.90), p = 0.006], compared to RCRI 0. Conclusion An elevated RCRI ≥ 2 is significantly associated with an increased risk of in-hospital mortality among patients with an isolated severe traumatic brain injury. The simplicity and bedside applicability of the index makes it an attractive choice for risk stratification in this patient population.

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Accuracy of Self-report as a Method of Screening for Lifetime Occurrence of Traumatic Brain Injury Events that Resulted in Hospitalization

Journal of the International Neuropsychological Society ◽

10.1017/s1355617716000497 ◽

2016 ◽

Vol 22 (7) ◽

pp. 717-723 ◽

Cited By ~ 13

Author(s):

Audrey McKinlay ◽

L. John Horwood ◽

David M. Fergusson

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Injury Severity ◽

Early Adulthood ◽

Self Report ◽

Increased Risk ◽

History Of ◽

Severe Tbi ◽

Health And Development ◽

At Risk Populations

AbstractBackgroundTraumatic brain injury (TBI) occurs frequently during child and early adulthood, and is associated with negative outcomes including increased risk of drug abuse, mental health disorders and criminal offending. Identification of previous TBI for at-risk populations in clinical settings often relies on self-report, despite little information regarding self-report accuracy. This study examines the accuracy of adult self-report of hospitalized TBI events and the factors that enhance recall.MethodsThe Christchurch Health and Development Study is a birth cohort of 1265 children born in Christchurch, New Zealand, in 1977. A history of TBI events was prospectively gathered at each follow-up (yearly intervals 0–16, 18, 21, 25 years) using parental/self-report, verified using hospital records.ResultsAt 25 years, 1003 cohort members were available, with 59/101 of all hospitalized TBI events being recalled. Recall varied depending on the age at injury and injury severity, with 10/11 of moderate/severe TBI being recalled. Logistic regression analysis indicated that a model using recorded loss of consciousness, age at injury, and injury severity, could accurately classify whether or not TBI would be reported in over 74% of cases.ConclusionsThis research demonstrates that, even when individuals are carefully cued, many instances of TBI will not recalled in adulthood despite the injury having required a period of hospitalization. Therefore, screening for TBI may require a combination of self-report and review of hospital files to ensure that all cases are identified. (JINS, 2016, 22, 717–723)

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Progressive hemorrhagic injury after severe traumatic brain injury: effect of hemoglobin transfusion thresholds

Journal of Neurosurgery ◽

10.3171/2015.11.jns151515 ◽

2016 ◽

Vol 125 (5) ◽

pp. 1229-1234 ◽

Cited By ~ 21

Author(s):

Aditya Vedantam ◽

Jose-Miguel Yamal ◽

Maria Laura Rubin ◽

Claudia S. Robertson ◽

Shankar P. Gopinath

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Severe Traumatic Brain Injury ◽

Time Interval ◽

Transfusion Threshold ◽

Cox Regression Analysis ◽

Diffuse Brain Injury ◽

Progressive Hemorrhagic Injury ◽

Increased Risk ◽

Severe Tbi

OBJECT There is limited literature available to guide transfusion practices for patients with severe traumatic brain injury (TBI). Recent studies have shown that maintaining a higher hemoglobin threshold after severe TBI offers no clinical benefit. The present study aimed to determine if a higher transfusion threshold was independently associated with an increased risk of progressive hemorrhagic injury (PHI), thereby contributing to higher rates of morbidity and mortality. METHODS The authors performed a secondary analysis of data obtained from a recently performed randomized clinical trial studying the effects of erythropoietin and blood transfusions on neurological recovery after severe TBI. Assigned hemoglobin thresholds (10 g/dl vs 7 g/dl) were maintained with packed red blood cell transfusions during the acute phase after injury. PHI was defined as the presence of new or enlarging intracranial hematomas on CT as long as 10 days after injury. A severe PHI was defined as an event that required an escalation of medical management or surgical intervention. Clinical and imaging parameters and transfusion thresholds were used in a multivariate Cox regression analysis to identify independent risk factors for PHI. RESULTS Among 200 patients enrolled in the trial, PHI was detected in 61 patients (30.5%). The majority of patients with PHI had a new, delayed contusion (n = 29) or an increase in contusion size (n = 15). The mean time interval between injury and identification of PHI was 17.2 ± 15.8 hours. The adjusted risk of severe PHI was 2.3 times higher for patients with a transfusion threshold of 10 g/dl (95% confidence interval 1.1–4.7; p = 0.02). Diffuse brain injury was associated with a lower risk of PHI events, whereas higher initial intracranial pressure increased the risk of PHI (p < 0.001). PHI was associated with a longer median length of stay in the intensive care unit (18.3 vs 14.4 days, respectively; p = 0.04) and poorer Glasgow Outcome Scale scores (42.9% vs 25.5%, respectively; p = 0.02) at 6 months. CONCLUSIONS A higher transfusion threshold of 10 g/dl after severe TBI increased the risk of severe PHI events. These results indicate the potential adverse effect of using a higher hemoglobin transfusion threshold after severe TBI.

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Is Routine Continuous EEG for Traumatic Brain Injury Beneficial?

The American Surgeon ◽

10.1177/000313481708301232 ◽

2017 ◽

Vol 83 (12) ◽

pp. 1433-1437 ◽

Cited By ~ 2

Author(s):

Lia Aquino ◽

Christopher Y. Kang ◽

Megan Y. Harada ◽

Ara Ko ◽

Amy Do-nguyen ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Injury Severity ◽

Trauma Patients ◽

Injury Score ◽

Increased Risk ◽

Continuous Eeg ◽

Severe Tbi ◽

Level I ◽

Abbreviated Injury Score

Severe traumatic brain injury (TBI) is associated with increased risk for early clinical and sub-clinical seizures. The use of continuous electroencephalography (cEEG) monitoring after TBI allows for identification and treatment of seizures that may otherwise occur undetected. Benefits of “routine” cEEG after TBI remain controversial. We examined the rate of subclinical seizures identified by cEEG in TBI patients admitted to a Level I trauma center. We analyzed a cohort of trauma patients with moderate to severe TBI (head Abbreviated Injury Score ≥3) who received cEEG within seven days of admission between October 2011 and May 2015. Demographics, clinical data, injury severity, and costs were recorded. Clinical characteristics were compared between those with and without seizures as identified by cEEG. A total of 106 TBI patients with moderate to severe TBI received a cEEG during the study period. Most were male (74%) with a mean age of 55 years. Subclinical seizures were identified by cEEG in only 3.8 per cent of patients. Ninety-three per cent were on antiseizure prophylaxis at the time of cEEG. Patients who had subclinical seizures were significantly older than their counterparts (80 vs 54 years, P = 0.03) with a higher mean head Abbreviated Injury Score (5.0 vs 4.0, P = 0.01). Mortality and intensive care unit stay were similar in both groups. Of all TBI patients who were monitored with cEEG, seizures were identified in only 3.8 per cent. Seizures were more likely to occur in older patients with severe head injury. Given the high cost of routine cEEG and the low incidence of subclinical seizures, we recommend cEEG monitoring only when clinically indicated.

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An Approach to Determining Intracranial Pressure Variability Capable of Predicting Decreased Intracranial Adaptive Capacity in Patients With Traumatic Brain Injury

Biological Research For Nursing ◽

10.1177/1099800409349164 ◽

2010 ◽

Vol 11 (4) ◽

pp. 317-324 ◽

Cited By ~ 10

Author(s):

Jun-Yu Fan ◽

Catherine Kirkness ◽

Paolo Vicini ◽

Robert Burr ◽

Pamela Mitchell

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Intracranial Pressure ◽

Adaptive Capacity ◽

Controlled Trial ◽

Relevant Information ◽

Data Set ◽

Bedside Monitoring ◽

Increased Risk ◽

Severe Tbi

Nurses caring for traumatic brain injury (TBI) patients with intracranial hypertension (ICH) recognize that patients whose intracranial adaptive capacity is reduced are susceptible to periods of disproportionate increase in intracranial pressure (DIICP) in response to a variety of stimuli. It is possible that DIICP signals potential secondary brain damage due to sustained or intermittent ICH. However, there are few clinically accessible intracranial pressure (ICP) measurement parameters that allow nurses and other critical care clinicians to identify patients at risk of DIICP. The purpose of this study was to investigate whether there are specific minute-to-minute trends in ICP variability during the first 48 hr of monitoring that might accurately predict DIICP in patients with severe TBI. A total of 38 patients with severe TBI were sampled from the data set of a randomized controlled trial testing bedside monitoring displays and cerebral perfusion pressure management in individuals with TBI or sub-arachnoid hemorrhage. The investigators retrospectively examined the rates of change (slope) in mean, standard deviation, and variance of ICP on a 1-min basis for 30 consecutive min prior to a specified DIICP event. There was a significantly increasing linear and quadratic slope in mean ICP prior to the development of DIICP, compared with the comparison data set (p < .05). It is feasible to display moving averages in modern bedside monitoring. Such an arrangement may be useful to provide visual displays that provide immediate clinically relevant information regarding the patients with decreased adaptive capacity and therefore increased risk of DIICP.

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Traumatic Brain Injury as a Risk Factor for Dementia: An Eighteen-Year Two Institution Clinical Experience

Neurosurgery ◽

10.1093/neuros/nyz310_124 ◽

2019 ◽

Vol 66 (Supplement_1) ◽

Cited By ~ 1

Author(s):

Brittany M Stopa ◽

Elisabetta Mezzalira ◽

Ajaz Khawaja ◽

Saef Izzy ◽

William B Gormley

Keyword(s):

Traumatic Brain Injury ◽

Risk Factor ◽

Brain Injury ◽

The United States ◽

Age Group ◽

Academic Medical ◽

Increased Risk ◽

Control And Prevention ◽

Severe Tbi

Abstract INTRODUCTION The Centers for Disease Control and Prevention (CDC) reports that there were 2.87 million cases of traumatic brain injury (TBI) in the United States in 2014. Some studies suggest a connection between TBI and increased risk of dementia, but it remains unclear whether the risk increases with age and TBI severity. Given our aging population, it is essential to better characterize the link between TBI and dementia. METHODS We conducted a retrospective cohort study of 2 major academic medical centers for years 2000 to 2015. We identified all patients with TBI, aged 45 and older. Variables included age, TBI severity, pre-existing dementia, dementia diagnosed after TBI, years to dementia, and follow-up time. TBI severity was determined by head/neck AIS score, using ICD-PIC software. Mild TBI was defined as AIS 0 to 2, and moderate/severe as AIS 3 to 6. Analysis was done in R.v.3.0.1 software. RESULTS Overall, there were 14 199 patients with TBI, of which 9938 (70%) were mild and 4261 (30%) were moderate/severe. Mean age was 70.5 (± 14.0). There were 1422 cases (10%) of pre-existing dementia, and 850 (6%) cases of dementia diagnosed after TBI. The mean follow-up time was 1129 (± 1,474) d. The 75 to 84 age group had the highest incidence of TBI (28%). When compared by age group and TBI severity, the proportion of moderate/severe TBI increased with increasing age. The proportion of pre-existing dementia increased with age, as expected. Notably, there is increased incidence of dementia after TBI in patients aged 65 and older (7%-10%, P < .001). There was no observed effect of TBI severity on the risk of dementia after TBI. CONCLUSION Our results indicate that TBI is a risk factor for the development of dementia, especially in patients aged 65 and older. This points to the need for public health measures to mitigate the risk of TBI in this patient population.

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Challenges and Opportunities for Neuroimaging in Young Patients with Traumatic Brain Injury: a Coordinated Effort towards Advancing Discovery from the ENIGMA Pediatric Moderate/Severe TBI Group

10.31234/osf.io/y2txh ◽

2019 ◽

Cited By ~ 4

Author(s):

Emily L. Dennis ◽

Karen Caeyenberghs ◽

Robert F. Asarnow ◽

Talin Babikian ◽

Brenda Bartnik-Olson ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Meta Analysis ◽

Young Patients ◽

Future Research ◽

Childhood And Adolescence ◽

Developmental Issues ◽

Challenges And Opportunities ◽

Severe Tbi ◽

Advance Research

Traumatic brain injury (TBI) is a major cause of death and disability in children in both developed and developing nations. Children and adolescents suffer from TBI at a higher rate than the general population; however, research in this population lags behind research in adults. This may be due, in part, to the smaller number of investigators engaged in research with this population and may also be related to changes in safety laws and clinical practice that have altered length of hospital stays, treatment, and access to this population. Specific developmental issues also warrant attention in studies of children, and the ever-changing context of childhood and adolescence may require larger sample sizes than are commonly available to adequately address remaining questions related to TBI. The ENIGMA (Enhancing NeuroImaging Genetics through Meta-Analysis) Pediatric Moderate-Severe TBI (msTBI) group aims to advance research in this area through global collaborative meta-analysis. In this paper we discuss important challenges in pediatric TBI research and opportunities that we believe the ENIGMA Pediatric msTBI group can provide to address them. We conclude with recommendations for future research in this field of study.

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