Progressive Hemorrhagic Injury Research Articles

Classification, risk factors, and outcomes of patients with progressive hemorrhagic injury after traumatic brain injury

BackgroundAccording to the pathoanatomic classification system, progressive hemorrhagic injury (PHI) can be categorized into progressive intraparenchymal contusion or hematoma (pIPCH), epidural hematoma (pEDH), subdural hematoma (pSDH), and traumatic subarachnoid hemorrhage (ptSAH). The clinical features of each type differ greatly. The objective of this study was to determine the predictors, clinical management, and outcomes of PHI according to this classification.MethodsMultivariate logistic regression analysis was used to identify independent risk factors for PHI and each subgroup. Patients with IPCH or EDH were selected for subgroup propensity score matching (PSM) to exclude confounding factors before evaluating the association of hematoma progression with the outcomes by classification.ResultsIn the present cohort of 419 patients, 123 (29.4%) demonstrated PHI by serial CT scan. Of them, progressive ICPH (58.5%) was the most common type, followed by pEDH (28.5%), pSDH (9.8%), and ptSAH (3.2%). Old age (≥ 60 years), lower motor Glasgow Coma Scale score, larger primary lesion volume, and higher level of D-dimer were independent risk factors related to PHI. These factors were also independent predictors for pIPCH, but not for pEDH. The time to first CT scan and presence of skull linear fracture were robust risk factors for pEDH. After PSM, the 6-month mortality and unfavorable survival rates were significantly higher in the pIPCH group than the non-pIPCH group (24.2% vs. 1.8% and 12.1% vs. 7.3%, respectively, p < 0.001), but not significantly different between the pEDH group and the non-pEDH group.ConclusionsUnderstanding the specific patterns of PHI according to its classification can help early recognition and suggest targeted prevention or treatment strategies to improve patients’ neurological outcomes.

Risk factors of deterioration in patients of head injury with non-operative management on first neurosurgical consultation.

In most of the emergency trauma intensive care units (ICUs) of India, neurosurgical opinion is sought for patients presenting with head trauma after earliest possible resuscitation to determine the further line of management. This study aimed to identify common risk factors, leading to neurological deterioration in conservatively managed patients of traumatic brain injury (TBI). This retrospective study analyzed patients admitted with acute TBI and traumatic intracranial hematoma under emergency trauma care ICU who did not require neurosurgical operation within 48 h of trauma. The recorded data were analyzed to determine the predictors of neurological deterioration using univariate and binary logistic regression analysis in SPSS-16 software. Medical records of consecutive 275 patients of acute TBI presenting to the emergency department were studied. One hundred and ninety-three patients were afflicted with mild TBI (70.18%), 49 patients had moderate TBI (17.81%), and 33 had severe TBI (12%). In the outcome, 74.54% of patients were discharged, and operative decision was made on 6.18% of patients and 19.27% died. Severe TBI is the independent predictor of neurological deterioration during their stay in ICU. Progressive hemorrhagic injury (PHI) showed neurological deterioration in 86.5% of patients. Systemic inflammatory response syndrome (SIRS) was present in 93.5% of patients who had deteriorated neurologically. Dyselectrolytemia was the biochemical derangements seen in 24.36% of cases. This study revealed severe TBI, PHI, and SIRS to be strong and independent risk factors of neurological deterioration.

Blood biomarkers for predicting coagulopathy occurrence in patients with traumatic brain injury: a systematic review.

Purpose: The occurrence of coagulopathy in patients with traumatic brain injury (TBI) is related to severe complications. The authors performed the first systematic review to investigate whether biomarkers can predict the occurrence of hypocoagulopathy or progressive hemorrhagic injury in patients with TBI. Methods: The authors included studies that performed a receiver operating characteristics analysis for the biomarker and provided a clear value along with the respective sensitivity and specificity. Additionally, they attempted to classify each biomarker, taking into account its physiological role. Results: Twelve studies were included. All biomarkers were protein molecules, except in one study that examined the prognostic role of glucose. Copeptin had the highest sensitivity, and S100A12 had the highest specificity in predicting coagulopathy, while IL-33 had the highest sensitivity and GALECTIN-3 had the highest specificity in predicting progressive hemorrhagic injury. Conclusion: The study of the role of biomarkers in predicting the occurrence of coagulopathy in patients with TBI remains in its infancy.

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

BackgroundCoagulopathy 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. MethodsOne-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. ResultsThe 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.

Thromboelastography is a Marker for Clinically Significant Progressive Hemorrhagic Injury in Severe Traumatic Brain Injury.

Coagulopathy in traumatic brain injury (TBI) is associated with increased risk of poor outcomes, but accurate prediction of clinically significant progressive hemorrhagic injury (PHI) in patients with severe TBI remains a challenge. Thromboelastography (TEG) is a real-time test of whole blood coagulation that provides dynamic information about global hemostasis. This study aimed to identify differences in TEG values between patients with severe TBI who did or did not experience clinically significant PHI. This was a single-center retrospective cohort study of adult patients with severe TBI. Patients were eligible for inclusion if initial Glasgow coma scale (GCS) was ≤ 8 and baseline head computed tomography (CT) imaging and TEG were available. Exclusion criteria included receipt of hemostatic agents prior to TEG. PHI was defined as bleeding expansion on CT within 24h associated with 2-point drop in GCS, neurosurgical intervention, or mortality within 24h. The primary endpoint was TEG value differences between patients with and without PHI. Secondary endpoints included differences in conventional coagulation tests (CCTs) between groups. Of the 526 patients evaluated, 141 met inclusion criteria. The most common reason for exclusion was lack of baseline TEG and receipt of reversal product prior to TEG. Sixty-four patients experienced PHI in the first 24h after presentation. K time (2.03min vs. 1.33min, P = 0.035) and alpha angle (65° vs. 69°, P = 0.015) were found to be significantly different in patients experiencing PHI. R time (5.25min vs. 4.71min), maximum amplitude (61mm vs. 63mm), and clot lysis at 30min after maximum clot strength (3.5% vs. 1.7%) were not significantly different between groups. Of the CCTs, only activated partial thromboplastin time (30.3s vs. 27.6s, P = 0.014) was found to be different in patients with PHI. Prolonged K time and narrower alpha angle were found to be associated with developing clinically significant PHI in patients with severe TBI. Despite differences detected in alpha angle, median values in both groups were within normal reference ranges. These abnormalities may reflect pathologic hypoactivity of fibrinogen, and further study is warranted to evaluate TEG-guided cryoprecipitate administration in this patient population.

The diagnosis and prognostic value of plasma copeptin in traumatic brain injury: a systematic review and meta-analysis

The purpose of this meta-analysis was to assess the diagnosis and prognostic value of plasma copeptin levels after traumatic brain injury (TBI). The databases PubMed, Cochrane Library, OvidSP, Google Scholar, VIP, CNKI, and WFSD were systematically searched from the inception dates to May 9, 2020. The pooled analysis of relevant data was conducted by the RevMan 5.3 software. Subgroups analysis was performed to explore the impact of age, country, male ratio, follow-up time, and Glasgow coma score (GCS) on the pooled area under curve (AUC) values of assessment mortality. A total of 17 studies involving 2654 participants were included in the current meta-analysis. The pooled results demonstrated that increased plasma copeptin levels were significantly associated with TBI [SMD, 2.44; 95%CI, 1.59 ~ 3.29; P < 0.00001] and also were significantly associated with mortality [SMD, 1.37; 95%CI, 1.16 ~ 1.58; P < 0.00001], and poor functional outcomes (PFO) [SMD, 1.44; 95%CI, 1.20 ~ 1.68; P < 0.00001] in patients with TBI. Furthermore, the copeptin had a significant value in diagnosing brain concussion [AUC, 0.90; 95%CI, 0.84 ~ 0.95; P < 0.00001] and predicting progressive hemorrhagic injury [AUC, 0.83; 95%CI, 0.80 ~ 0.87; P < 0.00001], acute traumatic coagulopathy [AUC, 0.84; 95%CI, 0.79 ~ 0.89; P < 0.00001], mortality [AUC, 0.89; 95%CI, 0.87 ~ 0.92; P < 0.00001], and PFO [AUC, 0.88; 95%CI, 0.84 ~ 0.92; P < 0.00001] in patients with TBI. The subgroup analysis findings suggested that the age, country, male ratio, follow-up time, and GCS were not obvious factors influencing the pooled AUC values of assessment mortality. The authors indicate that the plasma copeptin is a potentially promising biomarker for TBI diagnosis and prognosis prediction.

1297: Thromboelastography Is a Marker for Progressive Hemorrhagic Injury in Severe Traumatic Brain Injury

1297: Thromboelastography Is a Marker for Progressive Hemorrhagic Injury in Severe Traumatic Brain Injury

Implementation of Thromboelastometry for Coagulation Management in Isolated Traumatic Brain Injury Patients Undergoing Craniotomy.

BackgroundCoagulopathy (CP) is a modifiable factor linked with secondary brain damage and poor outcome of traumatic brain injury (TBI). A shift towards goal-directed coagulation management has been observed recently. We investigated whether rotational thromboelastometry (ROTEM) based management could be successfully implemented in TBI patients and improve outcomes.Material/MethodsA prospective, case-control study was performed. Adult patients with isolated TBI requiring craniotomy were included in this study. All patients underwent standard coagulation tests (SCT). Patients were identified as either in control group or in case group. Patients in the case group were additionally tested with ROTEM to specify their coagulation status. Management of the patients in the control group was based on SCT, whereas management of patients in the case group was guided by ROTEM. Outcome measures were as follows: CP rate, protocol adhesion, blood loss, transfusions, progressive hemorrhagic injury (PHI), re-intervention, Glasgow coma score (GCS) and Glasgow outcome score (GOS) at discharge, and in-hospital mortality.ResultsThere were 134 patients enrolled (65 patients in the control group and 69 patients in the case group). Twenty-six patients in the control group (40%) were found to be coagulopathic (control-CP subgroup) and 34 patients in the case group (49.3%) were found to be coagulopathic (case-CP subgroup). Twenty-five case-CP patients had ROTEM abnormalities triggering protocolized intervention, and 24 of them were treated. Overall ROTEM-based protocol adhesion rate was 85.3%. Postoperative ROTEM parameters of case-CP patients significantly improved, and the number of coagulopathic patients decreased. The incidence of PHI (control versus case group) and neurosurgical re-intervention (control-CP versus case-CP subgroup) was in favor of ROTEM guidance (P<0.05). Mortality and GCS and GOS at discharge did not differ significantly between groups.ConclusionsROTEM led to consistent coagulation management, improved clot quality, and decreased incidence of PHI and neurosurgical re-intervention. Further studies are needed to confirm benefits of ROTEM in cases of TBI.

Serum CXC chemokine ligand-12 as a potential predictor for in-hospital major adverse events after severe traumatic brain injury

BackgroundCXC chemokine ligand-12 (CXCL12) is associated with brain inflammation. We attempted to discern whether serum CXCL12 is a promising predictor for in-hospital major adverse events (IMAEs) after traumatic brain injury (TBI), including death, acute lung injury, acute traumatic coagulopathy, progressive hemorrhagic injury and posttraumatic cerebral infarction. MethodsIn this prospective, observational study, serum CXCL12 levels were quantified among 117 severe TBI patients. We investigated the relation of CXCL12 levels to IMAEs using a multivariate analysis. ResultsMedian value of serum CXCL12 concentrations was substantially higher in patients with IMAEs than in other remainders (21.1 vs. 11.6 ng/ml). With an increasing number of IMAEs, serum CXCL12 concentrations were significantly increased (r = 0.702). Serum CXCL12 independently predicted IMAEs (odds ratio, 1.253; 95% CI, 1.100–1.428). Serum CXCL12 concentrations discriminated risk of IMAEs with area under receiver operating characteristic curve of 0.759 (95% CI, 0.672–0.834), its concentrations >16.0 ng/ml distinguished IMAEs with 83.9% sensitivity and 67.2% specificity and its combination with Glasgow coma scale scores produced the best predictive ability compared with each one alone (p = 0.0116 or 0.0004). ConclusionSerum CXCL12 concentrations are independently associated with IMAEs following TBI, substantializing serum CXCL12 as a useful prognostic biomarker for head trauma patients.

D-dimer/fibrinogen ratio for the prediction of progressive hemorrhagic injury after traumatic brain injury

BackgroundProgressive hemorrhagic injury (PHI) greatly affects prognosis of traumatic brain injury (TBI). D-dimer/fibrinogen ratio (D/F ratio) may be a potential predictor for venous thromboembolism. This study sought to describe and evaluate any relationship between D/F ratio and PHI after TBI. MethodsThis retrospective study included a cohort of 192 TBI patients. Plasma D-dimer and fibrinogen were measured, and subsequently D/F ratio was calculated. Multivariate logistic regression analysis was applied to identify predictors of PHI. Receiver operating characteristic (ROC) curve was conFig.d to analyze predictive capability for PHI. ResultsA total of 43 patients (22.4%) experienced PHI. Both Glasgow coma scale (GCS) score (odds ratio [OR], 0.565; 95% CI, 0.464–0.689) and D/F ratio (OR, 4.026; 95% CI, 2.219–7.305) were the two independent predictor for PHI. Area under ROC curve (AUC) of D/F ratio was similar to that of GCS score (AUC, 0.816; 95% CI, 0.754–0.868 vs. AUC, 0.834; 95% CI, 0.773–0.883; P = 0.699). Moreover, D/F ratio significantly improved AUC of GCS score to 0.928 (95% CI, 0.881–0.960; P < 0.001). ConclusionsD/F ratio was strongly predictive of PHI in the studied cohort and, thereby should be considered in the clinical management of TBI patients.

Incidence of progressive hemorrhagic injury in patients presenting with traumatic brain injury at a large tertiary care hospital in Karachi, Pakistan. A Case Series.

Objectives: Our study aims to determine the frequency of progressive hemorrhagic injury as observed on the CT scan from the initial scan performed at the time of presentation to a subsequent one in the 12 hours after the initial scan. Study Design: The type of study is a prospective observational case series. Setting: At Tertiary Care Hospital in Karachi, Pakistan. Period: 3 months from June 2018 to August 2018. Materials &amp; Methods: All patients over 18 years of age who presented to the Accident and Emergency Department of the hospital with traumatic brain injury and had a CT scan performed within four hours of the injury were included in the study. A predesigned proforma was used to note down patient findings. CT scan findings were classified as subdural hematoma (SDH), intraparenchymal contusion (IPC) extradural hematoma (EDH) and subarachnoid hemorrhage (SAH). A repeat CT scan was performed twelve hours after the initial CT scan. Data were analyzed using IBM SPSS version 20.0, mean and frequencies were calculated for continuous variables while frequencies and percentages were calculated for categorical variables. Results: Of the n= 110 patients in our study 79 were males and 31 were female, the mean age of the patients was 34.25 years. The Glasgow Coma Scale scores at the time of arrival were between thirteen and fifteen for n= 33 (30%) of the patients, between nine and twelve for n= 54 (49.09%) of the patients, less than and equal to eight for n= 23 (20.90%) of the patients. Subarachnoid hemorrhage was present in n= 32 (29.09%) patients, intraparenchymal hematoma was present in n= 42 (38.18%) of the patients, while subdural hematoma and epidural hematoma was present in n= 14 (12.72%) and n= 22 (20%) of the patients respectively. Progressive hemorrhagic injury was found in n= 66 (60%) of the patients, while in n= 11 (10%) of the patients there was resolution of the lesion and n= 33 (33%) of the patients showed no observable changes in the repeat CT scan. Finally, our results indicate that of the 110 patients in our study PHI was seen in n= 17 (53.12%) patients with SAH, n= 18 (81.81%) patients of EDH, n= 5 (35.71%) patients of SDH and n= 26 (61.90%) patients of IPC respectively. Conclusion: According to the results of our study PHI is observed in 60% of the patients with a traumatic brain injury observed within the initial 12 hours after injury, and epidural hematoma and intraparenchymal contusions had the highest incidences of PHI among all the different types of traumatic brain injuries.

Combination Therapy Using Prothrombin Complex Concentrate and Vitamin K in Anticoagulated Patients with Traumatic Intracranial Hemorrhage Prevents Progressive Hemorrhagic Injury: A Historically Controlled Study.

Warfarin remains crucially involved in the treatment of patients at thrombotic or thromboembolic risk. However, warfarin increases the mortality rate among patients with traumatic intracranial hemorrhage (TICH) through progressive hemorrhagic injury (PHI). Therefore, a rapid anticoagulation reversal could be required in patients with TICH to prevent PHI. Differences in the warfarin reversal effect between combination therapy of prothrombin complex concentrate (PCC) with vitamin K (VK) and VK monotherapy remain unclear. However, studies have reported that PCC has greater effectiveness and safety for warfarin reversal compared with fresh frozen plasma (FFP). This retrospective study aimed to evaluate the warfarin reversal effects of combination therapy of PCC with VK and VK monotherapy on TICH. We compared the clinical outcomes between the periods before and after the PCC introduction in our hospital. There were 13 and 7 patients who received VK monotherapy and PCC with VK, respectively. PHI predictors were evaluated using univariate regression analyses. Warfarin reversal using PCC had a significant negative association with PHI (odds ratio: 0.03, 95% confidence interval: 0.00–0.41, P = 0.004). None of the patients presented with thrombotic complications. Warfarin reversal through a combination of PCC with VK could be more effective for inhibiting post-trauma PHI compared with VK monotherapy. This could be attributed to a rapid and stable warfarin reversal. PCC should be administered to patients with TICH taking warfarin for PHI prevention.

Ability of Fibrin Monomers to Predict Progressive Hemorrhagic Injury in Patients with Severe Traumatic Brain Injury.

Progressive hemorrhagic injury (PHI) is common in patients with severe traumatic brain injury (TBI) and is associated with poor outcomes. TBI-associated coagulopathy is frequent and has been described as risk factor for PHI. This coagulopathy is a dynamic process involving hypercoagulable and hypocoagulable states either one after the other either concomitant. Fibrin monomers (FMs) are a direct marker of thrombin action and thus reflect coagulation activation. This study sought to determine the ability of FM to predict PHI after severe TBI. We conducted a prospective, observational study including all severe TBI patients admitted in the trauma center. Between September 2011 and September 2016, we enrolled patients with severe TBI into the derivation cohort. Between October 2016 and December 2018, we recruited the validation cohort on the same basis. Study protocol included FM measurements and standard coagulation test at admission and two computed tomography (CT) scans (upon arrival and at least 6h thereafter). A PHI was defined by an increment in size of initial lesion (25% or more) or the development of a new hemorrhage in the follow-up CT scan. Multivariate logistic regression analysis was applied to identify predictors of PHI. Overall, 106 patients were included in the derivation cohort. Fifty-four (50.9%) experienced PHI. FM values were higher in these patients (151 [136.8-151] vs. 120.5 [53.3-151], p < 0.0001). The ROC curve demonstrated that FM had a fair accuracy to predict the occurrence of PHI with an area under curve of 0.7 (95% CI [0.6-0.79]). The best threshold was determined at 131.7μg/ml. In the validation cohort of 54 patients, this threshold had a negative predictive value of 94% (95% CI [71-100]) and a positive predictive value of 49% (95% CI [32-66]). The multivariate logistic regression analysis identified 2 parameters associated with PHI: FM ≥ 131.7 (OR 6.8; 95% CI [2.8-18.1]) and Marshall category (OR 1.7; 95% CI [1.3-2.2]). Coagulopathy was not associated with PHI (OR 1.3; 95% CI [0.5-3.0]). The proportion of patients with an unfavorable functional neurologic outcome at 6-months follow-up was higher in patients with positive FM: 59 (62.1%) versus 16 (29.1%), p < 0.0001. FM levels at admission had a fair accuracy to predict PHI in patients with severe TBI. FM values ≥ 131.7μg/ml are independently associated with the occurrence of PHI.

Association of APOE ε4 with progressive hemorrhagic injury in patients with traumatic intracerebral hemorrhage.

The intracranial hematoma volume in patients with traumatic brain injury is a key parameter for the determination of the management approach and outcome. Apolipoprotein E (APOE) ε4 is reported to be a risk factor for larger hematoma volume, which might contribute to a poor outcome. However, whether APOE ε4 is related to progressive hemorrhagic injury (PHI), a common occurrence in the clinical setting, remains unclear. In this study, the authors aimed to investigate the association between the APOE genotype and occurrence of PHI. This prospective study included a cohort of 123 patients with traumatic intracerebral hemorrhage who initially underwent conservative treatment. These patients were assigned to the PHI or non-PHI group according to the follow-up CT scan. A polymerase chain reaction and sequencing method were carried out to determine the APOE genotype. Multivariate logistic regression analysis was applied to identify predictors of PHI. The overall frequency of the alleles was as follows: E2/2, 0%; E2/3, 14.6%; E3/3, 57.8%; E2/4, 2.4%; E3/4, 22.8%; and E4/4, 2.4%. Thirty-four patients carried at least one allele of ε4. In this study 60 patients (48.8%) experienced PHI, and the distribution of the alleles was as follows: E2/2, 0%; E2/3, 5.7%; E3/3, 22.8%; E2/4, 2.4%; E3/4, 16.3%; and E4/4, 1.6%, which was significantly different from that in the non-PHI group (p = 0.008). Additionally, the late operation rate in the PHI group was significantly higher than that in the non-PHI group (24.4% vs 11.4%, p = 0.002). Multivariate logistic regression identified APOE ε4 (OR 5.14, 95% CI 2.40-11.62), an elevated international normalized ratio (OR 3.57, 95% CI 1.61-8.26), and higher glucose level (≥ 10 mmol/L) (OR 3.88, 95% CI 1.54-10.77) as independent risk factors for PHI. Moreover, APOE ε4 was not a risk factor for the coagulopathy and outcome of the patients with traumatic intracerebral hemorrhage. The presence of APOE ε4, an elevated international normalized ratio, and a higher glucose level (≥ 10 mmol/L) are predictors of PHI. Additionally, APOE ε4 is not associated with traumatic coagulopathy and patient outcome.

Usefulness of serum interleukin-33 as a prognostic marker of severe traumatic brain injury

BackgroundInterleukin-33 is recently identified as a brain injury biomarker. We determined whether serum interlerukin-33 concentrations are associated with inflammation, severity and prognosis after traumatic brain injury (TBI). MethodsWe detected serum interlerukin-33 concentrations of 102 healthy controls and 102 severe TBI patients, as well as serum concentrations of 3 inflammatory biomarkers (interleukin-6, tumor necrosis factor-alpha and C-reactive protein) and 7 cell-specific proteins (myelin basic protein, glial fibrillary astrocyte protein, S100B, neuron-specific enolase, phosphorylated axonal neurofilament subunit H, Tau and ubiquitin carboxyl-terminal hydrolase L1) in 102 severe TBI patients. The recorded poor prognosis variables included acute lung injury, acute traumatic coagulopathy, progressive hemorrhagic injury, posttraumatic cerebral infarction and six-month mortality and poor outcome (Glasgow score of 1–3). ResultsMedian interlerukin-33 concentration of patients (692 pg/mL) was substantially raised, as compared to controls. Interlerukin-33 concentrations were significantly correlated with Glasgow coma scale (GCS) score and the preceding biomarkers concentrations. Interlerukin-33 concentration > 692 pg/mL emerged as an independent prognostic predictor and its discriminatory capability exceeded those of the above-mentioned inflammatory biomarkers concentrations and was in the range of GCS scores and the aforementioned cell-specific proteins concentrations. ConclusionAscending serum interlerukin-33 concentrations could reflect inflammation, severity and worse prognosis following TBI.

Expressions of plasma cystatin C, D-dimer and hypersensitive C-reactive protein in patients with intracranial progressive hemorrhagic injury after craniocerebral injury, and their clinical significance.

To investigate the expressions of plasma cystatin C (Cys-C), D-dimer (D-D) and hypersensitive C-reactive protein (hs-CRP) in patients with intracranial progressive hemorrhagic injury (IPHI) after craniocerebral injury, and their clinical significance. Forty-two IPHI patients and 20 healthy participants (control) were enrolled. The severity and outcome of IPHI were determined according to the Glasgow Coma Scale and Glasgow Outcome Scale, and the plasma Cys-C, hs-CRP and D-D levels were measured. The plasma Cys-C, D-D and hs-CRP levels in the IPHI group were significantly higher than those in the control group (p < 0.01). There were significant differences of plasma Cys-C, D-D and hs-CRP levels among different IPHI patients according to the Glasgow Coma Scale and according to the Glasgow Outcome Scale (all p < 0.05). In the IPHI patients, the plasma Cys-C, D-D and hs-CRP levels were positively correlated with each other (p < 0.001). The increase of plasma Cys-C, D-D and hs-CRP levels may be involved in IPHI after craniocerebral injury. The early detection of these indexes may help to understand the severity and outcome of IPHI.

Postoperative complications influencing the long-term outcome of head-injured patients after decompressive craniectomy.

ObjectivePostoperative complications are common in patients who underwent decompressive craniectomy (DC) after traumatic brain injury (TBI). However, little is known about the degree of association between the postoperative complications and the long‐term outcome of adult TBI patients after DC. The aim of this study was to evaluate the risk of postoperative complications that influenced the long‐term outcome of DC in TBI patients.MethodA total of 121 patients were studied up to 6 months after DC in TBI. The collected data included demographic, clinical and radiological information, postoperative complications, and Glasgow Outcome Scale‐Extended (GOSE) scores at follow‐up 6 months after DC. Based on their GOSE scores, they were divided into two functional groups: favorable (GOSE = 5–8) or unfavorable outcome (GOSE = 2–4) group. The characteristics of the two groups were compared using statistical analysis. Finally, a regression model was established and a receiver operating characteristic (ROC) curve was applied to analyze its performance power.ResultsOf 121 admitted patients, 31 (25.62%) sustained an unfavorable outcome. A logistic regression analysis showed that the presence of Glasgow Coma Scale (GCS) scores on admission (odds ratio [OR] 0.285, p = 0.001), posttraumatic hydrocephalus (PTH) (OR 8.688, p = 0.003), craniectomy site (OR 8.068, p = 0.033), and postoperative progressive hemorrhagic injury (PHI) (OR 6.196, p = 0.026) were independent risk factors that correlated with an unfavorable outcome. Analysis using ROC curves demonstrated that these factors had different accuracies in predicting an unfavorable outcome (AUC = 0.852 for GCS scores on admission; AUC = 0.826 for PTH, AUC = 0.617 for craniectomy site; AUC = 0.616 for postoperative PHI). The performance power of the GCS scores on admission and PTH influenced the patient's outcomes to a similar degree (p = 0.623), and either predicted the outcome better than the craniectomy site or the postoperative PHI (p < 0.05, respectively).ConclusionThese findings suggest that the occurrence of PTH and postoperative PHI were independently associated with an unfavorable long‐term outcome after DC in patients with TBI. Early prevention and treatment of PTH and postoperative PHI may be beneficial to improve the long‐term outcome, especially in patients with lower admission GCS scores or bilateral DC.

Prognostic significance of serum translocator protein in patients with traumatic brain injury

BackgroundTranslocator protein (TP) is related to inflammation and is involved in brain injury. The objective of this study was to ascertain whether serum TP concentrations are associated with the severity and prognosis of traumatic brain injury (TBI). MethodsWe quantified the serum concentrations of TP in 106 healthy controls and 106 patients with severe TBI. Recorded prognostic variables included acute lung injury, acute traumatic coagulopathy, progressive hemorrhagic injury, posttraumatic cerebral infarction, 6-month mortality and 6-month poor outcome (Glasgow Outcome Scale score of 1–3). Trauma severity was assessed by Glasgow coma scale (GCS) score. Extent of inflammatory response was indicated by serum interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-a) and C-reactive protein (CRP) concentrations. ResultsPatients had significantly higher serum TP concentrations than controls. Among patients, serum TP concentrations strongly and independently correlated with GCS score and serum IL-6, TNF-a and CRP concentrations. Serum TP was identified as an independent predictor for the preceding prognostic variables, its prognostic predictive ability was similar to that of GCS score and it also significantly improved prognostic predictive ability of GCS score. ConclusionSerum TP may be intimately linked with in inflammation, disease progression and poor prognosis in TBI patients.

Serum ST2 as a potential prognostic biomarker for traumatic brain injury

BackgroundST2, a receptor of interleukin-33, is involved in inflammation. We discerned the relationship between serum soluble ST2 (sST2) concentrations, inflammation, severity and prognosis following traumatic brain injury (TBI). MethodsWe measured serum sST2, interleukin-6, tumor necrosis factor-alpha, C-reactive protein, myelin basic protein, glial fibrillary astrocyte protein, S100B, neuron-specific enolase, phosphorylated axonal neurofilament subunit H, Tau and ubiquitin carboxyl-terminal hydrolase L1 concentrations in 106 healthy controls and 106 severe TBI patients. We recorded long-term prognosis (i.e., 6-month mortality and functional outcome) and in-hospital major adverse events, including in-hospital mortality, acute lung injury, acute traumatic coagulopathy, progressive hemorrhagic injury and posttraumatic cerebral infarction. ResultssST2 concentrations were significantly higher in patients than in controls and were significantly correlated with Glasgow coma scale (GCS) score and the preceding biomarkers concentrations. Serum sST2 was an independent prognostic predictor and its predictive ability significantly exceeded those of serum interleukin-6, tumor necrosis factor-alpha and C-reactive protein concentrations and was similar to those of GCS scores and serum concentrations of other remaining biomarkers. Moreover, sST2 concentrations significantly improved predictive ability of GCS score. ConclusionIncreased serum sST2 concentrations are significantly related to inflammation, severity and prognosis, substantialized ST2 as a potential prognostic biomarker for TBI.

Prognostic role of D-dimer level upon admission in patients with traumatic brain injury.

Background:The aim of this study was to evaluate the prognostic role of D-dimer level upon admission in patients with traumatic brain injury (TBI) through performing a meta-analysis.Methods:PubMed, Web of Science, Cochrane Library, and EMBASE were searched for potential eligible literature. The study characteristics and relevant data were extracted. Poor functional outcome was defined according to the Glasgow Outcome Scale (GOS ≤3). Odds ratios (ORs) with 95% confidence intervals (CIs) were pooled to estimate the predictive value of D-dimer for progressive hemorrhagic injury (PHI) and poor functional outcome at 3 months (3M GOS ≤3) in patients with TBI.Results:Eleven studies with 2761 patients were included. Eight studies examined the predictive role of higher D-dimer level for the risk of PHI, and the pooled OR was 1.72 (95% CI, 1.23–2.42). Three studies examined the predictive role of higher D-dimer level for the risk of 3M GOS ≤3, and the pooled OR was 2.00 (95% CI, 0.87–4.59). Significant between-study heterogeneities were observed, and sensitivity analyses and subgroup analyses were performed. No significant publication bias was found.Conclusions:In conclusion, in patients with TBI, higher D-dimer level upon admission was associated with higher risk of PHI, yet no significant relationship was found between D-dimer level and the risk of 3M GOS ≤3. In the future, this readily available marker could help identify patients at risk and tailor management of these patients, thus reducing PHI and improving outcome.