Desmopressin for antiplatelet-associated traumatic intracranial hemorrhage: A systematic review.

Prevalence and presenting symptoms of intracranial hemorrhage in older adults presenting with subacute head injuries in a level-2 trauma center: A retrospective cohort study.

Traumatic intracranial hemorrhage with blood-fluid level

BackgroundTraumatic brain injury (TBI) is a major public health concern in Thailand, contributing to substantial morbidity and mortality. This study aimed to identify prognostic factors associated with poor Glasgow Outcome Scale (GOS) scores 1 month after TBI with intracranial hemorrhage (ICH). This is particularly relevant in the emergency department (ED), where early decisions regarding triage, monitoring, and disposition must be made rapidly.MethodsWe conducted a retrospective cohort study at Ramathibodi Hospital, Bangkok, Thailand, including trauma patients aged ≥ 15 years with TBI and ICH who presented to the ED between 2020 and 2022. Outcomes were categorized into three groups based on the 1‐month GOS: unfavorable (GOS 1–2), intermediate (GOS 3–4), and favorable (GOS 5). Clinical factors and CT findings were analyzed using multivariable ordinal logistic regression to identify factors associated with poor GOS scores across these groups.ResultsA total of 227 patients were included in the study. Among them, 31 patients (13.6%) were in the unfavorable group, 81 patients (35.7%) in the intermediate group, and 115 patients (50.7%) in the favorable group. Factors associated with poorer outcomes included elderly patients (age ≥ 65 years) (multivariable odds ratio [mOR] 5.25, 95% confidence interval [CI] 2.33–11.85), low initial systolic blood pressure (SBP < 100 mmHg) (mOR 4.38, 95% CI 1.02–18.86), and initial glasgow coma scale (GCS) scores: severe vs. mild (mOR 49.88, 95% CI 14.26–174.44) and moderate vs. mild (mOR 12.26, 95% CI 3.86–38.98). Other factors included slight pupillary reaction (mOR 8.36, 95% CI 1.76–39.67), although this finding should be interpreted cautiously due to the small number of abnormal observations and wide CIs, as well as subdural hematoma (SDH) (mOR 3.10, 95% CI 1.53–6.25) and midline shift or brain herniation (mOR 4.41, 95% CI 1.84–10.57).ConclusionsThese factors were associated with poorer 1‐month GOS scores and may support early risk stratification in adult TBI patients with traumatic ICH.

To determine whether routinely available radiology reports, together with basic clinical data, can identify patients with traumatic intracranial hemorrhage (TICH) who are at low risk of adverse events. This retrospective cohort study of adults with TICH in Region Jönköping, Sweden (2019-2021). Clinical data, findings from radiology reports and outcomes were extracted from medical records. Hemorrhage size was classified as small (≤ 4mm or described as minimal/very small/discrete) or larger. Adverse events were defined as neurosurgical intervention or death directly attributable to the TICH. Risk difference (RD), relative risk (RR), and Firth's penalized logistic regression were used to assess associations with adverse events. Among 527 included patients, 195 (37%) had small TICHs. None of these patients experienced adverse events, compared with 13.6% neurosurgical interventions and 13.0% trauma-related deaths in the group with larger TICHs (RD 24.5% points, 95% CI 18.4-29.6; RR 97.1, 95% CI 6.1-1557.1; p < 0.001). Small TICH size had the strongest association with absence of adverse events. Normal neurological status and GCS 14-15 were also associated with a low risk of adverse events. Anticoagulant or antiplatelet therapy showed no significant association with adverse events. Routinely available radiology reports, combined with basic clinical data, can identify a low-risk subgroup of patients with small TICHs. Hemorrhage size appears to be a useful factor for risk stratification, but the findings require internal and external prospective validation before implementation in clinical practice.

Managing patients on oral anticoagulant therapy (OAC) who present with traumatic intracranial hemorrhage (ICH) poses a critical challenge in balancing the prevention of thromboembolic events and the risk of progression or recurrent ICH. The objective of this systematic review was to determine the optimal timing for resuming OAC in patients with traumatic ICH, and to assess the risk of hemorrhagic and thromboembolic events, and mortality in patients for whom anticoagulation was resumed. With a medical librarian, 4 databases and gray literature were searched without language or date restrictions. Eligible studies included patients with traumatic ICH undergoing OAC resumption and reporting on timing, ICH progression or recurrence, thromboembolic events, and/or mortality. Of 3384 identified studies, 12 cohort studies met inclusion criteria, involving 13,528 patients with varying severities of traumatic brain injury. Most patients were treated with vitamin K antagonists; only 3 studies included patients on direct oral anticoagulants. The median time to resume OAC ranged from 8 to 67 days. In studies limited to traumatic ICH, OAC resumption was not associated with increased recurrent ICH risk with reported RR 0.70 (95% CI, 0.52-0.95) and HR 0.45 (95% CI, 0.26-0.76). All but one study reported reduced thromboembolic events with OAC resumption. The studies also suggested that complete resolution of the initial ICH allowed for safe resumption of OAC. This systematic review suggests that resumption of OAC after traumatic ICH may be considered in selected patients, without a clear evidence of increase in the risk of recurrent ICH and with a potential reduction in thromboembolic events. However, we were unable to define a safe timeframe, and further studies are needed to establish recommendations to guide clinical practice. Level III, Systematic Review and Meta-Analysis.

The impact of pre-hospital transport process optimization on rescue efficiency and complications in patients with traumatic intracranial hemorrhage.

In this review, traumatic brain injury (TBI) is found to be a frequent cause of contact in primary and secondary healthcare services. Intracranial haemorrhage associated with TBI occurs when direct or indirect forces to the head damage intracranial vessels. Patients with mild TBI, defined as a GCS of 14-15, seldom require CT imaging unless they were unconscious or had a seizure at the time of injury, are receiving anticoagulant therapy, have coagulopathies, present with focal neurological deficits, have shunt-treated hydrocephalus, or show clinical signs of a skull fracture.

Traumatic intracranial hemorrhage (ICH) is a major driver of traumatic brain injury-related mortality. Although plasma transfusion has been associated with improved survival in these patients, the timing of transfusion influences outcomes is unclear. We sought to determine how plasma transfusion timing affects survival in patients with tICH, hypothesizing that earlier transfusion improves outcomes and that there is a threshold after which survival benefits diminish. We conducted a retrospective analysis of adult trauma patients (≥18y) with tICH who received plasma-based resuscitation within 4 hours of ED arrival between 2020 and 2021 from the ACS-TQIP database. Patients with prehospital cardiac arrest, anticoagulant therapy, nonsurvivable head injuries, and interfacility transfers were excluded. The multivariable Royston-Parmar flexible parametric regression model assessed the primary outcome of 30-day mortality. A total of 6,183 patients were included. Median age was 41 years, 73% were male. Median injury severity score was 34, the median head AIS score was 4, and 88% were blunt mechanisms. The overall in-hospital 30-day mortality was 45%. Survival analysis showed that patients who received plasma transfusion compared with those who had not yet received plasma at similar time points had a 45% lower hazard of death at 30 days (aHR, 0.55; 95% CI: 0.33-0.92; p =0.02). Predicted survival declined sharply in the first 30 minutes, with a 5% absolute decrease per 10-minute delay. Beyond 30 minutes, survival benefit plateaued, and the risk of neurosurgical interventions increased. Early plasma transfusion within the first 4 hours of ED arrival is associated with improved survival in patients with tICH, with the most pronounced benefit seen when plasma is given within the first 30 minutes. These findings highlight urgent plasma administration as a key element of early resuscitation in TBI and support prospective validation to inform trauma protocols. ( J Trauma Acute Care Surg . 2026;101: 89-96. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). Therapeutic/Care Management; Level III.

Background: The clinical outcomes of patients with intracranial haemorrhage (ICH) whilst using direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) are uncertain. This study aimed to assess outcomes and management in patients receiving DOACs compared with those receiving VKAs. Methods: In this retrospective study, patients hospitalised during the period from 1 January 2017 to 31 December 2023 for traumatic and non-traumatic ICH and using oral anticoagulants (OACs) were included. The primary outcomes were mortality and functional outcomes, as measured by the modified Rankin Scale (mRS) during admission and 90-day follow-up. ICH management and complications were studied and compared between the two OAC groups. Results: A total of 171 eligible patients were included, comprising 24 patients on DOACs and 147 patients on VKAs. Patients receiving DOACs were older (79.1 vs. 66.8, p < 0.001) and had a higher proportion of traumatic ICH (75.0% vs. 46.3%, p = 0.009) than those receiving VKAs. In-hospital and 90-day outcomes were not statistically different between the two groups, with an adjusted odds ratio (aOR) of 1.30 (0.39-4.36) for in-hospital mortality, p = 0.67, and an aOR of 0.89 (0.33-2.41) for mRS 0-2 at 90 days, p = 0.83. In total, 81.3% of patients received at least one reversal agent; fresh frozen plasma was commonly used in the VKA group (78.9% vs. 33.3%, p < 0.001), whereas prothrombin complex concentrate was significantly prescribed in patients with DOAC-associated ICH (29.2% vs. 3.4%, p < 0.001). Conclusions: Patients with DOAC-associated ICH had comparable in-hospital and long-term clinical outcomes to those with VKA use.

A lack of widely adopted guidelines assisting trauma systems in triaging mild traumatic brain injury (TBI) patients results in potentially avoidable transfers (PATs) associated with significant economic burden. As both transfers and costs associated with TBI increase, improved patient selection for transfer is needed to deliver quality care and contain costs. This study aims to quantify the rate and patient cost of PATs for mild TBI, as well as characterize demographics, risk factors, and clinical outcomes. Retrospective review of 905 patients transferred to University of Wisconsin Hospital with primary intracranial hemorrhage (ICH) diagnoses from 2014 through 2022. PATs were defined as Glasgow Coma Scale (GCS) > 13, not requiring a neurosurgical procedure within 2 weeks (including angiography), and not requiring intensive care unit admission; comparisons were made to all other transfers, which were considered justifiable. Of 905 adult patients with primary ICH diagnoses, 362 (40%) were designated potentially avoidable. Of these, 9% were by air and 88% by ground. PATs are associated with female sex, traumatic subarachnoid hemorrhage, higher admission GCS, lack of anticoagulation use, shorter length of stay (total and non-intensive care unit), rapid discharge (<24 and <48 hours), lower in-hospital and 30/90-day mortality rates, lower 30-day post discharge mortality, higher rate of home discharge, and lower rate of neurosurgery follow-up. Potential surprise out-of-network charges associated with PATs was $101,601 by ground and $523,790 by air. A subset of adult mild traumatic ICH patients underwent PATs with significant financial liability related to transfer in the form of surprise out-of-network charges. Overall, PAT traumatic ICH patients had better clinical outcomes, were more likely to be rapidly discharged and less likely to require neurosurgical follow-up. In an era of increasing costs and TBI emergency department visits, trauma systems must do more to deliver quality-focused care and contain costs for TBI patients.

Nationwide expert survey on transfusion and coagulation management strategies for bleeding critically ill patients in China.

Best platelet transfusion practices are unclear across intracranial hemorrhage (ICH) types, given the mortality risk. Reasons for this risk are unknown, but ABO-incompatible platelet transfusions may confer risk in certain populations. We assessed contemporary ICH platelet transfusion practices and whether ABO-incompatible platelet transfusions increase ICH mortality risk. Adult patients with spontaneous intracerebral hemorrhage (sICH), traumatic ICH, and aneurysmal subarachnoid hemorrhage hospitalizations between 2019 and 2024 were assessed from a multicenter transfusion network. Relationships of platelet transfusions with 30-day mortality were assessed using logistic regression models adjusting for demographics, ICH type/severity, comorbidities, and other hemorrhage control therapies/transfusions. Among those receiving platelet transfusions, relationships of major ABO-incompatible platelet units with mortality risk were investigated using Cox models adjusting for similar covariates. Analyses were performed across the cohort and stratified by ICH subtype. Among 13 068 patients with ICH, 60% were male individuals, mean age was 66 (±19) years, 23% were from sICH, 69% from traumatic ICH, and 8% from aneurysmal subarachnoid hemorrhage cohorts. Acute platelet transfusions were given to 12% of the patients. Thrombocytopenia (<100 000 platelets/μL) and neurosurgical procedures, seen in 6% and 18% of the patients, respectively, were largest factors for platelet transfusions. In regression analyses, platelet transfusions themselves did not associate with mortality (adjusted hazard ratio [HR]: 1.14 [0.96-1.35]). However, among patients with ICH receiving platelet transfusions, ABO-incompatible units were common (37%) and had dose-dependent relationships with mortality (adjusted HR ≥2 exposures: 1.78 [1.18-2.70]). Stratified analyses revealed that patients with sICH were particularly vulnerable to mortality from even single exposures of ABO-incompatible units (adjusted HR 1 exposure: 1.97 [1.13-3.45]; ≥2 exposures: 2.78 [0.98-7.87]) compared with other ICH subtypes. Acute platelet transfusion practice remains prevalent in ICH, and platelet transfusion-related 30-day mortality risk may be influenced by ABO-incompatible platelet units. Clinical trials are needed to assess whether transfusion practice changes in providing ABO-matched platelets can improve outcomes in certain patients with ICH.

Withdrawal of life-sustaining treatment (WLST) is common in clinical trials of patients with acute brain injuries (ABI), but current reporting practices and impact on trial-reported findings are unclear. We evaluated reporting practices of WLST in contemporary clinical trials of patients with ABI and quantified the magnitude of bias on treatment effect estimates in hypothetical trials. We conducted a literature review of contemporary ABI randomized clinical trials and a simulation-based analysis. In the literature review, we included two-arm, randomized, superiority trials of adults with ABI (traumatic brain injury, intracranial hemorrhage, subarachnoid hemorrhage, ischemic stroke, or post-cardiac arrest brain injury) published in 10 high-impact journals from January 1, 2015 to December 19, 2024. We extracted WLST characteristics including frequency, timing, reasons, and neuro-prognostication criteria. In the simulation-based analysis, we evaluated the impact of WLST misclassification-defined as WLST occurring in patients who could have survived with a good neurological outcome-on observed treatment effects. For each scenario, we estimated the observed treatment effect after misclassification and calculated bias as the difference between observed and true treatment effects. We assessed both blinded and unblinded trials and binary and ordinal neurologic outcomes. Among 69 trials included in the literature review, 17 trials (24.6%) reported WLST frequency, 9 (13.0%) timing, 10 (14.5%) reasons, and 7 (10.1%) standardized neuro-prognostication criteria. In simulations of blinded trials, WLST misclassification consistently attenuated observed treatment effects. Increasing the fraction of misclassified WLST events led to progressively greater bias, making beneficial treatments appear less effective and harmful treatments appear less harmful. In unblinded trial simulations, the direction of bias varied by the magnitude of the true treatment effect and degree of misclassification. Findings were similar for binary and ordinal neurologic outcomes. Across all simulations, WLST misclassification reversed statistical conclusions in a median of 22.1% (interquartile range 17.4-32.4%) of trials. WLST is poorly reported in contemporary ABI trials. Misclassification of WLST-related deaths leads to important bias in trial-reported treatment effects, potentially yielding underpowered studies and erroneous trial conclusions. Standardized, transparent WLST reporting is essential to strengthen ABI trial design and interpretation.

The Archeoptix NIRD device is a handheld near infrared scanner for intracranial hemorrhage of at least 3 mL in volume located up to 3.5cm from the scalp. It generates an image that approximates hemorrhage location on a schematic head. We report a prospectively collected cohort of scans from patients with traumatic brain injury and CT-confirmed intracranial hemorrhage, alongside healthy control subjects, to evaluate the utility and accuracy of this technology. Patients with hemorrhage were recruited from the neurosurgical service within 24h of trauma for a single scan, and also controls with no history of head trauma or neurological symptoms. Blinded reviewers judged each scan for presence or absence of hemorrhage and whether hemorrhage position matched CT. Thirty-seven patients with hemorrhage and 40 controls were scanned. Reviewers identified hemorrhage in 37/37 patients and no hemorrhage in 40/40 controls, with correct localization in 35/37 scans. Repeat passes were sometimes required for user-induced errors from external light exposure or loss of detector contact, occurring more often in hemorrhage cases and modestly increasing time to complete subsequent paths. The Archeoptix NIRD device shows promise as a point-of-care or remote diagnostic tool, and further work can fully establish sensitivity, specificity, and user experience.

Objective : Acute kidney injury (AKI) is a common and serious complication in traumatic intracranial hemorrhage (tICH), leading to worse outcomes. Blood pressure variability (BPV), beyond mean blood pressure levels, may impair end-organ perfusion and predispose to AKI. However, the relationship between BPV and AKI in tICH patients remains poorly defined. We investigated the association between BPV and AKI in patients with tICH.Methods : We conducted a retrospective cohort study of tICH patients from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. Inclusion required ≥24 systolic and diastolic blood pressure measurements within the first 24 hours of intensive care unit admission. BPV indices, average real variability (ARV), standard deviation (SD), and coefficient of variation (CV), were calculated for both systolic (SBP) and diastolic pressures. Univariate and multivariate logistic regression models were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for AKI. Two adjustment schemes were applied : group 1 (age, congestive heart failure, diabetes) and group 2 (group 1 covariates + vasoactive agents, mannitol, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, hypertonic saline). Analyses were performed in the hypertensive subgroup (mean SBP ≥140 mmHg), using the same covariate adjustment schemes.Results : Among 551 patients, AKI developed in 385 (69.9%). In multivariate analysis with adjusted for all confounders, higher SBP_ARV (OR, 1.046; 95% CI, 1.004–1.095; p=0.048) and SBP_SD (OR, 1.052; 95% CI, 1.010–1.099; p=0.018) were independent predictors of AKI. In hypertensive subgroups, after adjustment for all confounders, associations were even stronger : SBP_ARV (OR, 1.285; 95% CI, 1.064–1.553; p=0.009), SBP_SD (OR, 1.203; 95% CI, 1.022–1.417; p=0.027) and SBP_CV (OR, 1.273; 95% CI, 1.012–1.601; p=0.039).Conclusion : Elevated systolic BPV independently predicts AKI in tICH patients. Incorporating BPV monitoring into neurocritical care protocols may help identify high-risk patients and guide interventions to stabilize blood pressure fluctuations, potentially minimizing AKI risk.

Introduction: Despite a lack of clinical data, platelet transfusions and desmopressin (DDAVP) are widely used to reverse the effect of antiplatelet medications for patients with traumatic intracranial hemorrhage (tICH). The objective of this study was to elicit the opinions of academic neurosurgeons on their confidence in the effectiveness of available therapies and clinical practice guidelines for antiplatelet effects in tICH. Methods: We conducted an in-person and electronic survey of academic faculty neurosurgeons in 10 geographically diverse academic medical centers in the U.S. Questions were developed by a group of 4 clinical and methodology researchers. Survey responses are presented using descriptive statistics in aggregate. Results: We analyzed responses from 62 neurosurgeons (66% response rate). Of those, 34% never administer platelets to those on aspirin, and 18% never administer platelets to those on P2Y12 inhibitors (with the remainder always, usually, or sometimes administering platelet transfusions). Among those who administer platelets, 81% use platelet function tests sometimes or always. There was wide variation in confidence that platelet transfusion reduces hematoma expansion (mean 53 mm, SD 25 mm on 100-mm visual-analog scale [VAS]) and on agreement with national platelet transfusion guideline recommendations for antiplatelet-associated tICH (mean 52 mm, SD 27 mm on 100-mm VAS). Most respondents (59%) administer DDAVP at least sometimes to those on P2Y12 inhibitors, but the confidence in the effectiveness of DDAVP was lower than for platelets (mean 46 mm, SD 23 mm on 100-mm VAS). The majority (89%) acknowledged that they would be willing to enroll patients in a clinical trial of platelet transfusion with a no-platelet control arm in non-operative tICH patients. Conclusions: Academic neurosurgeons expressed significant uncertainty on the utility of platelet transfusion and DDAVP for tICH, they describe significant practice variation, and many disagree with national clinical practice guideline recommendations. These data support the importance of a future clinical trial to determine definitively the utility of platelet transfusion in these patients.

Introduction: Recent literature has questioned whether patients with traumatic intracranial hemorrhage (ICH) on an oral anticoagulant (OAC) require anticoagulation (AC) reversal in populations that are predominantly neurologically intact. A parafalcine subdural hematoma (SDH) is associated with a low incidence of hematoma progression and favorable neurologic outcomes relative to other select ICH locations. This study aims to assess the impact of AC reversal vs no treatment on hemostasis in patients with a parafalcine SDH. Methods: This IRB-exempt retrospective cohort study at two Trauma Centers included patients presenting between 03/01/2016 to 10/31/2024 with a parafalcine SDH while receiving an OAC. Patients were excluded if they had an additional ICH location. Cohorts were based on receipt of treatment for AC reversal. The primary outcome was hemostasis on first repeat computed tomography of the head, defined as absence of any bleeding progression, tested for superiority with the Fisher’s exact test. Secondary endpoints include neurosurgical intervention, hematoma expansion > 35%, rescue treatment for AC reversal, in-hospital mortality or hospice, and thrombotic events within 7 days. Results: 53 patients (median (IQR) age, 78.0 (68.0-87.0); mean (SD) Glasgow Coma Scale (GCS), 14.9 (0.3); apixaban, 26 (49.1%); mean (SD) SDH thickness, 4.1 (2.7) mm) were included, 18 (control) vs 35 (reversal). Baseline characteristics were similar except the reversal cohort had a higher median (IQR) Injury Severity Score 10.0 (9.0-10.0) vs 14.0 (10.0-20.0) (p = 0.0008), higher mean (SD) head Abbreviated Injury Scale 3.0 (0.0) vs 3.4 (0.6) (p = 0.0002), and higher proportion of ICU admissions 7 (38.9%) vs 24 (68.6%) (p = 0.0378). The primary outcome occurred in 16 (88.9%) (control) vs 32 (91.4%) (reversal) patients (p = 1.0000). No patients required neurosurgical intervention. Hematoma expansion > 35% (1 (5.6%) vs 0 (p = 0.3462)) and the need for rescue treatment (0 vs 1 (2.9%) (p = 1.00)) was infrequent. 1 (2.9%) patient in the reversal group was discharged to hospice (p = 1.00). No thrombotic events occurred. Conclusions: Receipt of AC reversal in the setting of a parafalcine SDH did not appear to impact hemostasis in a population with a baseline GCS of 14-15 and with a baseline hematoma thickness predominantly < 1.0 cm.

Introduction: Elevated intracranial pressure (ICP) remains a challenge and immediate danger in patients with acute brain injury. Current literature supports the use of a single hyperosmolar agent, primarily hypertonic saline or mannitol, to reduce the ICP. However, the efficacy and safety of alternating hyperosmolar agents has not been evaluated. The objectives of this study are to analyze the ICP lowering effects and evaluate the safety profile of alternating hyperosmolar therapy. Methods: This was a single-center, retrospective study of adults (≥ 18 years old) with acute brain injury admitted to the Neurosciences Intensive Care Unit between May 7, 2018, and September 6, 2024. Patients with intracranial hypertension refractory to a single hyperosmolar agent who received alternating doses of mannitol and hypertonic sodium approximately every 3 hours with an ICP monitor were included in the study. We evaluated the impact of alternating hyperosmolar therapy on ICP. Safety was assessed by measuring the frequency of acute kidney injury, electrolyte disturbances, and changes in volume status. Results: A total of 46 patients were included in this study with 29 (63%) males and a median (IQR) age of 46.5 (35.9, 62.4) years. Traumatic brain injury and intracranial hemorrhage were the most frequently reported brain injuries accounting for 17 (37%) and 12 (26%) patients, respectively. The median (IQR) dose of mannitol was 40.1 (34.6, 50.0) grams while the median (IQR) dose of hypertonic sodium was 120 (90, 125) milliequivalents. The median (IQR) duration of alternating hyperosmolar therapy was 14.0 (7.8, 37.3) hours. Eighty-six percent of patients experienced a decrease in ICP after initiation of alternating hyperosmolar therapy with a median (IQR) baseline ICP of 12 (6, 21) mmHg and a median (IQR) trough ICP of 2 (0, 8) mmHg. Seven acute kidney injuries occurred, and 7 patients experienced pulmonary edema. Median (IQR) peak sodium, chloride, and osmolar gap values were 149 (144, 155) mEq/L, 115 (111, 119) mEq/L, and 5.7 (0.7, 9.0) mOsm/kg, respectively, while receiving alternating hyperosmolar therapy. Conclusions: Alternating hyperosmolar therapy may provide a transient ICP reduction without a substantial increase in adverse effects in patients with refractory ICP to a single hyperosmolar agent.

Whole Blood-Based Resuscitation and Mortality in Patients with Traumatic Intracranial Hemorrhage.