Download PDF
CC BY-NC-ND 4.0 · Indian Journal of Neurosurgery 2022; 11(03): 253-259
DOI: 10.1055/s-0041-1728989
Original Article

Prospective Analysis of Coagulopathy Associated with Isolated Traumatic Brain Injury and Clinical Outcome

Gopal Krishna
1   Department of Neurosurgery, Pt. B.D. Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India
,
Varun Aggarwal
1   Department of Neurosurgery, Pt. B.D. Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India
,
Ishwar Singh
1   Department of Neurosurgery, Pt. B.D. Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India
› Author Affiliations
› Further Information
   Permissions and Reprints

Abstract

Introduction Traumatic brain injury (TBI) affects the coagulation pathway in a distinct way than does extracranial trauma. The extent of coagulation abnormalities varies from bleeding diathesis to disseminated thrombosis.

Design Prospective study.

Methods The study included 50 patients of isolated TBI with cohorts of moderate (MHI) and severe head injury (SHI). Coagulopathy was graded according to the values of parameters in single laboratory. The incidence of coagulopathy according to the severity of TBI and correlation with disseminated intravascular coagulation (DIC) score, platelets, prothrombin time (PT), activated partial thromboplastin time (APTT), D-dimer, and fibrinogen was observed. The comparison was also made between expired and discharged patients within each group. It also compared coagulation derailments with clinical presentation (Glasgow Coma Scale [GCS]) and outcome (Glasgow Outcome Scale [GOS]).

Results Road traffic accident was the primary (72%) mode of injury. Fifty-two percent had MHI and rest had SHI. Eighty-four percent of cases were managed conservatively. The mean GCS was 12.23 and 5.75 in MHI and SHI, respectively. Sixty-two percent of MHI and 96% of the patients with SHI had coagulation abnormalities. On statistical analysis, DIC score (p < 0.001) strongly correlated with the severity of head injury and GOS. PT and APTT were also significantly associated with the severity of TBI. In patients with moderate TBI, D-dimer and platelet counts showed association with clinical outcome. Fibrinogen levels did not show any statistical significance. The mean platelet counts remained normal in both the groups of TBI. The mean GOS was 1.54 and 4.62 in SHI and MHI, respectively.

Conclusion Coagulopathy is common in isolated TBI. The basic laboratory parameters are reliable predictors of coagulation abnormalities in TBI. Coagulopathy is directly associated with the severity of TBI, GCS, and poor outcome.

Keywords

coagulopathy - TBI - DIC score - head injury


Publication History

Article published online:
29 April 2021

© 2021. Neurological Surgeons’ Society of India. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).

Thieme Medical and Scientific Publishers Pvt. Ltd.
A-12, 2nd Floor, Sector 2, Noida-201301 UP, India

 

  • References

  • 1 Laroche M, Kutcher ME, Huang MC, Cohen MJ, Manley GT. Coagulopathy after traumatic brain injury. Neurosurgery 2012; 70 (06) 1334-1345
    CrossrefPubMedGoogle Scholar
  • 2 van Gent JAN, van Essen TA, Bos MHA, Cannegieter SC, van Dijck JTM, Peul WC. Coagulopathy after hemorrhagic traumatic brain injury, an observational study of the incidence and prognosis. Acta Neurochir (Wien) 2020; 162 (02) 329-336
    CrossrefPubMedGoogle Scholar
  • 3 Stein SC, Smith DH. Coagulopathy in traumatic brain injury. Neurocrit Care 2004; 1 (04) 479-488
    CrossrefPubMedGoogle Scholar
  • 4 van der Sande JJ, Emeis JJ, Lindeman J. Intravascular coagulation: a common phenomenon in minor experimental head injury. J Neurosurg 1981; 54 (01) 21-25
    CrossrefPubMedGoogle Scholar
  • 5 Scherer RU, Spangenberg P. Procoagulant activity in patients with isolated severe head trauma. Crit Care Med 1998; 26 (01) 149-156
    CrossrefPubMedGoogle Scholar
  • 6 Hulka F, Mullins RJ, Frank EH. Blunt brain injury activates the coagulation process. Arch Surg 1996; 131 (09) 923-927 , discussion 927−928
    CrossrefPubMedGoogle Scholar
  • 7 Brohi K, Cohen MJ, Davenport RA. Acute coagulopathy of trauma: mechanism, identification and effect. Curr Opin Crit Care 2007; 13 (06) 680-685
    CrossrefPubMedGoogle Scholar
  • 8 Cohen MJ, Brohi K, Ganter MT, Manley GT, Mackersie RC, Pittet JF. Early coagulopathy after traumatic brain injury: the role of hypoperfusion and the protein C pathway. J Trauma 2007; 63 (06) 1254-1261 , discussion 1261−1262
    PubMedGoogle Scholar
  • 9 Kuo JR, Chou TJ, Chio CC. Coagulopathy as a parameter to predict the outcome in head injury patients–analysis of 61 cases. J Clin Neurosci 2004; 11 (07) 710-714
    CrossrefPubMedGoogle Scholar
  • 10 Harhangi BS, Kompanje EJ, Leebeek FW, Maas AI. Coagulation disorders after traumatic brain injury. Acta Neurochir (Wien) 2008; 150 (02) 165-175 , discussion 175
    CrossrefPubMedGoogle Scholar
  • 11 Carrick MM, Tyroch AH, Youens CA, Handley T. Subsequent development of thrombocytopenia and coagulopathy in moderate and severe head injury: support for serial laboratory examination. J Trauma 2005; 58 (04) 725-729 , discussion 729−730
    CrossrefPubMedGoogle Scholar
  • 12 Van Beek JG, Mushkudiani NA, Steyerberg EW. et al. Prognostic value of admission laboratory parameters in traumatic brain injury: results from the IMPACT study. J Neurotrauma 2007; 24 (02) 315-328
    CrossrefPubMedGoogle Scholar
  • 13 Affonseca CA, Carvalho LF, Guerra SD, Ferreira AR, Goulart EM. Coagulation disorder in children and adolescents with moderate to severe traumatic brain injury. J Pediatr (Rio J) 2007; 83 (03) 274-282
    CrossrefPubMedGoogle Scholar
  • 14 Kuo JR, Lin KC, Lu CL, Lin HJ, Wang CC, Chang CH. Correlation of a high D-dimer level with poor outcome in traumatic intracranial hemorrhage. Eur J Neurol 2007; 14 (10) 1073-1078
    CrossrefPubMedGoogle Scholar
  • 15 Nekludov M, Antovic J, Bredbacka S, Blombäck M. Coagulation abnormalities associated with severe isolated traumatic brain injury: cerebral arterio-venous differences in coagulation and inflammatory markers. J Neurotrauma 2007; 24 (01) 174-180
    CrossrefPubMedGoogle Scholar
  • 16 Fuller G, Pattani H, Chalmers A. et al. Coagulopathy predicts poor outcome in traumatic brain injury. Crit Care 2008; 12: 126
    CrossrefPubMedGoogle Scholar
  • 17 Pereira EA, Green AL, Chandran H, Joshi SM, Shlugman D, Cudlip SA. Disseminated intravascular coagulation after isolated mild head injury. Acta Neurochir (Wien) 2009; 151 (11) 1521-1524
    CrossrefPubMedGoogle Scholar
  • 18 Shahrokh Yousefzadeh C, Anosh Dehnadi M, Shahrokh E, Mohhammad S, Haniyeh Mohammadi M. A review of intraparenchymal hemorrhage and contusion progression in traumatic brain injury. Neurosurg Q 2010; 20 (02) 65-67
    CrossrefPubMedGoogle Scholar
  • 19 Pahatouridis D, Alexiou GA, Zigouris A, Mihos E, Drosos D, Voulgaris S. Coagulopathy in moderate head injury. The role of early administration of low molecular weight heparin. Brain Inj 2010; 24 (10) 1189-1192
    CrossrefPubMedGoogle Scholar
  • 20 Greuters S, van den Berg A, Franschman G. et al. ALARM-BLEEDING investigators. Acute and delayed mild coagulopathy are related to outcome in patients with isolated traumatic brain injury. Crit Care 2011; 15 (01) R2
    CrossrefPubMedGoogle Scholar
  • 21 Alexiou GA, Pahatouridis D, Vulgaris S. Coagulopathy in traumatic brain injury. Injury 2011; 42 (01) 113-author reply 114
    CrossrefPubMedGoogle Scholar
  • 22 Gutman SA. Traumatic brain injury. In Pedretti LW, Early MB, eds. Occupational therapy: Practice skills for physical dysfunction. 5th ed. St. Louis, MO: Mosby 2001: 671-701
  • 23 Gan BK, Lim JH, Ng IH. Outcome of moderate and severe traumatic brain injury amongst the elderly in Singapore. Ann Acad Med Singapore 2004; 33 (01) 63-67
    CrossrefPubMedGoogle Scholar
  • 24 Nguyen R, Fiest KM, McChesney J. et al. The international incidence of traumatic brain injury: a systematic review and meta-analysis. Can J Neurol Sci 2016; 43 (06) 774-785
    CrossrefPubMedGoogle Scholar
  • 25 Frost RB, Farrer TJ, Primosch M, Hedges DW. Prevalence of traumatic brain injury in the general adult population: a meta-analysis. Neuroepidemiology 2013; 40 (03) 154-159
    CrossrefPubMedGoogle Scholar
  • 26 Khan A, Prince M, Brayne C, Prina AM. Lifetime prevalence and factors associated with head injury among older people in low and middle income countries: a 10/66 study. PLoS One 2015; 10 (07) e0132229
    CrossrefPubMedGoogle Scholar
  • 27 Gardner AJ, Zafonte R. Neuroepidemiology of traumatic brain injury. Handb Clin Neurol 2016; 138: 207-223
    CrossrefPubMedGoogle Scholar
  • 28 Feigin VL, Theadom A, Barker-Collo S. et al. BIONIC Study Group. Incidence of traumatic brain injury in New Zealand: a population-based study. Lancet Neurol 2013; 12 (01) 53-64
    CrossrefPubMedGoogle Scholar
  • 29 Eshete A, Taye F. Magnitude of severe head injury and its associated factors among head injury patients in Gedeo Zone, Southern Ethiopia: a two-year retrospective study. Ethiop J Health Sci 2018; 28 (03) 323-330
    CrossrefPubMedGoogle Scholar
  • 30 Wafaisade A, Wutzler S, Lefering R. et al. Trauma Registry of DGU. Drivers of acute coagulopathy after severe trauma: a multivariate analysis of 1987 patients. Emerg Med J 2010; 27 (12) 934-939
    CrossrefPubMedGoogle Scholar
  • 31 Zhang J, Zhang F, Dong JF. Coagulopathy induced by traumatic brain injury: systemic manifestation of a localized injury. Blood 2018; 131 (18) 2001-2006
    CrossrefPubMedGoogle Scholar
  • 32 Bakhtiari K, Meijers JC, de Jonge E, Levi M. Prospective validation of the International Society of Thrombosis and Haemostasis scoring system for disseminated intravascular coagulation. Crit Care Med 2004; 32 (12) 2416-2421
    CrossrefPubMedGoogle Scholar
  • 33 Yuan Q, Yu J, Wu X. et al. Prognostic value of coagulation tests for in-hospital mortality in patients with traumatic brain injury. Scand J Trauma Resusc Emerg Med 2018; 26 (01) 3
    CrossrefPubMedGoogle Scholar
  • 34 Dharap SB, Kamath S, Kumar V. Does prehospital time affect survival of major trauma patients where there is no prehospital care?. J Postgrad Med 2017; 63 (03) 169-175
    CrossrefPubMedGoogle Scholar
  • 35 Lustenberger T, Talving P, Kobayashi L. et al. Time course of coagulopathy in isolated severe traumatic brain injury. Injury 2010; 41 (09) 924-928
    CrossrefPubMedGoogle Scholar
  • 36 Davis PK, Musunuru H, Walsh M. et al. Platelet dysfunction is an early marker for traumatic brain injury-induced coagulopathy. Neurocrit Care 2013; 18 (02) 201-208
    CrossrefPubMedGoogle Scholar
  • 37 Ploplis VA, Donahue DL, Sandoval-Cooper MJ. et al. Systemic platelet dysfunction is the result of local dysregulated coagulation and platelet activation in the brain in a rat model of isolated traumatic brain injury. J Neurotrauma 2014; 31 (19) 1672-1675
    CrossrefPubMedGoogle Scholar
  • 38 Wohlauer MV, Moore EE, Thomas S. et al. Early platelet dysfunction: an unrecognized role in the acute coagulopathy of trauma. J Am Coll Surg 2012; 214 (05) 739-746
    CrossrefPubMedGoogle Scholar
  • 39 Kweon JG, Hwang SK, Park YM, Kim SL. Coagulopathy in head injury.. J Korean Neurosurg Soc 1991; 20: 406-413
    PubMedGoogle Scholar
  • 40 Engström M, Romner B, Schalén W, Reinstrup P. Thrombocytopenia predicts progressive hemorrhage after head trauma. J Neurotrauma 2005; 22 (02) 291-296
    CrossrefPubMedGoogle Scholar
  • 41 Saggar V, Mittal RS, Vyas MC. Hemostatic abnormalities in patients with closed head injuries and their role in predicting early mortality. J Neurotrauma 2009; 26 (10) 1665-1668
    CrossrefPubMedGoogle Scholar
  • 42 MacLeod JB, Lynn M, McKenney MG, Cohn SM, Murtha M. Early coagulopathy predicts mortality in trauma. J Trauma 2003; 55 (01) 39-44
    CrossrefPubMedGoogle Scholar
  • 43 Allard CB, Scarpelini S, Rhind SG. et al. Abnormal coagulation tests are associated with progression of traumatic intracranial hemorrhage. J Trauma 2009; 67 (05) 959-967
    PubMedGoogle Scholar
  • 44 Epstein DS, Mitra B, O’Reilly G, Rosenfeld JV, Cameron PA. Acute traumatic coagulopathy in the setting of isolated traumatic brain injury: a systematic review and meta-analysis. Injury 2014; 45 (05) 819-824
    CrossrefPubMedGoogle Scholar
  • 45 Selladurai BM, Vickneswaran M, Duraisamy S, Atan M. Coagulopathy in acute head injury–a study of its role as a prognostic indicator. Br J Neurosurg 1997; 11 (05) 398-404
    CrossrefPubMedGoogle Scholar
  • 46 May AK, Young JS, Butler K, Bassam D, Brady W. Coagulopathy in severe closed head injury: is empiric therapy warranted?. Am Surg 1997; 63 (03) 233-236 , discussion 236−237
    PubMedGoogle Scholar
  • 47 Talving P, Benfield R, Hadjizacharia P, Inaba K, Chan LS, Demetriades D. Coagulopathy in severe traumatic brain injury: a prospective study. J Trauma 2009; 66 (01) 55-61 , discussion 61−62
    PubMedGoogle Scholar