Thrombelastography-identified coagulopathy is associated with increased morbidity and mortality after traumatic brain injury
ABSTRACT The purpose of this study was to determine the relationship between coagulopathy and outcome after traumatic brain injury.
Patients 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.
Sixty-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%).
Hypocoagulability as shown by thrombelastography after traumatic brain injury is associated with worse outcomes and an increased incidence of neurosurgical intervention.
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ABSTRACT: Careful course observation is necessary for cases of mild to moderate traumatic brain injury even when disturbed consciousness is mild on admission. This is because delayed enlargement of hematoma and progression of cerebral swelling may occur and result in an emergency craniotomy. Here, we investigated coagulopathy and abnormal fibrinolysis as a predictive factor of “deterioration requiring surgery” in mild to moderate traumatic brain injury.Patients and methodsSixty-one patients with mild to moderate (Glasgow Coma Scale (GCS) score 9–15) traumatic brain injury were admitted between June 2009 and October 2010. There were 54 subjects in the study, excluding those treated with oral antiplatelet agents and anticoagulants. Patients were classified into those with deterioration requiring surgery [op(+)] or those without deterioration requiring surgery [op(−)]. This was based on whether surgical treatment was performed for hematoma expansion, and exacerbated consciousness level within 3 days after admission. Age, GCS score on admission and blood test findings (platelet count, PT-INR, APTT, fibrinogen, FDP, and d-dimer) on admission were compared.ResultsThe op(+) and op(−) groups comprised 7 (13.0%) and 47 patients (87.0%), respectively. Platelet counts (24.8 vs 18.5 × 104/μl) were decreased, and PT-INR (1.0 vs 1.2) was higher in the op(+) group. Specially, APTT (28.6 vs 39.1 s), FDP (28.9 vs 112.9 μg/ml), and d-dimer (17.3 vs 69.6 μg/ml) values were significantly higher in the op(+) group.Conclusions Coagulopathy and abnormal fibrinolysis, which are measurable in routine medical practice, is associated with deterioration requiring surgery in mild to moderate traumatic brain injury, indicating that careful course observation is necessary.Clinical Neurology and Neurosurgery 10/2014; 127. DOI:10.1016/j.clineuro.2014.10.007 · 1.25 Impact Factor
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ABSTRACT: Impaired haemostasis represents a major risk factor for bleeding complications in neurosurgical patients. Coagulopathy commonly occurs after (brain) trauma and major haemorrhage or originates from antithrombotic medication. Point of care (POC) devices for bedside assessment of haemostatic parameters are increasingly used in various medical specialties. Results can be instantly implemented into treatment modalities as results are delivered within a very short period. POC coagulation testing has also shown beneficial effects in the treatment of neurosurgical patients. Identification of hyperfibrinolysis is achieved through viscoelastic testing of haemostasis and bedside coagulometry hastens the management of anticoagulated patients in need of urgent neurosurgical procedures. Results of POC testing of platelet function have been correlated with patient outcomes after traumatic brain injury and furthermore, quantification of antiplatelet medication effects on platelet activity is made possible through the use of these devices. Further studies are needed to characterise the potential of POC testing of platelet function. Antiplatelet medication plays an important role in regard to haemorrhagic and thromboembolic risks. Therefore, POC testing of platelet activity may improve treatment modalities in patients undergoing neurosurgical procedures as well as neurointerventional procedures (such as intracranial stent placement). In this article we summarise the available data of POC testing in neurosurgical patients and discuss the potential of these devices in this field. POC technologies have improved patient care in various medical fields and in our view it is likely that this will also apply to the field of neurosurgery.Journal of Clinical Neuroscience 11/2014; 22(2). DOI:10.1016/j.jocn.2014.07.029 · 1.32 Impact Factor
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ABSTRACT: IntroductionData on the incidence of a hypercoagulable state in trauma, as measured by thromboelastometry (ROTEM), is limited and the prognostic value of hypercoagulability after trauma on outcome is unclear. We aimed to determine the incidence of hypercoagulability after trauma, and to assess whether early hypercoagulability has prognostic value on the occurrence of multiple organ failure (MOF) and mortality.Methods This was a prospective observational cohort study in trauma patients who met highest trauma level team activation. Hypercoagulability was defined as a G value of ¿11.7 dynes/cm2 and hypocoagulability as a G value of <5.0 dynes/cm2. ROTEM was performed on admission and 24 hours later.ResultsA total of 1010 patients were enrolled and 948 patients were analyzed. Median age was 38 (interquartile range (IQR) 26 to 53), 77% were male and median injury severity score was 13 (IQR 8 to 25). On admission, 7% of the patients were hypercoagulable and 8% were hypocoagulable. Altogether, 10% of patients showed hypercoagulability within the first 24 hours of trauma. Hypocoagulability, but not hypercoagulability, was associated with higher sequential organ failure assessment scores, indicating more severe MOF. Mortality in patients with hypercoagulability was 0%, compared to 7% in normocoagulable and 24% in hypocoagulable patients (P <0.001). EXTEM CT, alpha and G were predictors for occurrence of MOF and mortality.Conclusion The incidence of a hypercoagulable state after trauma is 10% up to 24 hours after admission, which is broadly comparable to the rate of hypocoagulability. Further work in larger studies should define the clinical consequences of identifying hypercoagulability and a possible role for very early, targeted use of anticoagulants.Critical care (London, England) 12/2014; 18(6):687. DOI:10.1186/s13054-014-0687-6