Early Onset of Rapid Lesion Growth in an Acute Subdural Hematoma Model in Rats.

OBJECTIVE: Acute subdural hematoma (ASDH) leads to the highest mortality rates of all head injuries with secondary brain damage playing a pivotal role in terms of morbidity and mortality. In patients with ASDH, a delay in surgery leads to disproportional mortality. The benefit of (very) early therapy is therefore, a target of ongoing research. As the process of delayed brain damage in ASDH has not yet been described, this study therefore aimed to examine secondary lesion growth in an experimental rat model of ASDH to define the ideal timing for testing potential neuroprotective therapies. METHODS: Cerebral blood flow was monitored during ASDH induction with 300 µl of autologous blood. Lesion growth was characterized using Hematoxylin-Eosin- , Cresyl-Violet-, and Fluoro-Jade B-staining for early signs of neuronal degeneration. Histological evaluations were performed between 15 minutes and 24 hours after ASDH. RESULTS: There was a significant reduction of cerebral blood flow after ASDH. Fluoro-Jade B-positive cells were visible 15 minutes after ASDH in the lesioned hemisphere. Nonlinear growth of lesion volume from 3.7 ± 0.4 mm3 to 17.5 ± 0.6 mm3 was observed at 24 hours in Hematoxylin-Eosin-staining. CONCLUSIONS: The most damage develops between 15 minutes and 1 hour and again between 2 and 6 hours after ASDH. The time course of lesion growth supports the approach of early surgery for patients. It furthermore constitutes a basis for further ASDH research with more clearly defined time windows for therapy in animal models.

Acute subdural haematoma exacerbates cerebral blood flow disorder and promotes the development of intraoperative brain bulge in patients with severe traumatic brain injury.

BACKGROUND: Decompressive craniectomy (DC) is a routine procedure used for the treatment of severe traumatic brain injury (TBI) with concomitant acute subdural haematoma (SDH). However, certain patients are prone to developing malignant brain bulge during DC, which prolongs the operative time and worsens patient outcomes. Previous studies have shown that malignant intraoperative brain bulge (IOBB) may be associated with excessive arterial hyperaemia caused by cerebrovascular system disorders. Through a clinical retrospective analysis and prospective observations, we found that the cerebral blood flow of patients who possessed risk factors manifested high resistance and low flow velocity, which severely affected brain tissue perfusion and resulted in the occurrence of malignant IOBB. In the current literature, rat models of severe brain injury-associated brain bulge have rarely been reported. METHODS: To gain an in-depth understanding of cerebrovascular changes and the cascade of responses related to brain bulge, we introduced acute SDH into the Marmarou model for the preparation of a rat model of high intracranial pressure (ICP) to simulate the pathological conditions experienced by patients with severe brain injury. RESULTS: With the introduction of a 400-µL haematoma, significant dynamic changes occurred in ICP, mean arterial pressure, and relative blood perfusion rate of the cerebral cortical vessels. ICP increased to 56.9 ± 2.3 mmHg, mean arterial pressure showed reactive decrease, and the blood flow of cerebral cortical arteries and veins on the non-SDH-affected side decreased to < 10%. These changes could not fully recover even after DC. This resulted in generalised damage to the neurovascular unit and a lag effect to the venous blood reflux, which triggered malignant IOBB formation during DC. CONCLUSION: An excessive increase in ICP causes cerebrovascular dysfunction and brings about a cascade of damage to brain tissue, which forms the basis for the development of diffuse brain swelling. The subsequent heterogeneous responses of the cerebral arteries and veins during craniotomy may be the main cause of primary IOBB. Clinicians should pay particular attention to the redistribution of CBF to various vessels when performing DC in patients with severe TBI.

Effect of Pre-Management Antithrombotic Agent Use on Outcome after Traumatic Acute Subdural Hematoma in the Elderly: A Systematic Review.

Traumatic acute subdural hematomas (ASDH) are common in elderly patients (age ≥65 years) and are associated with a poorer prognosis compared with younger populations. Antithrombotic agent (ATA) use is also common in the elderly; however, the influence that pre-morbid ATA has on outcome in ASDH is poorly understood. We hypothesized that pre-morbid ATA use significantly worsens outcomes in elderly patients presenting with traumatic ASDH. English language medical literature was searched for articles relating to ATA use in the elderly with ASDH. Data were collated and appraised where possible. Analyses of study bias were performed. Twelve articles encompassing 2038 patients were included; controls were poorly described in the included studies. Pre-morbid ATA use was seen in 1042 (51.1%) patients and 18 different ATA combination therapies were identified, with coumarins being the most common single agent used. The newer direct oral anticoagulants were evaluated in only two studies. ATA use was associated with a lower presenting Glasgow Coma Scale (GCS) score but not hematoma volume on computed tomography (CT) or post-operative hematoma re-accumulation. No studies connected ATA use with patient outcomes without the presence of confounders and bias. Reversal strategies, bridging therapy, recommencement of ATA, and comparison groups were poorly described; accordingly, our hypothesis was rejected. ATA reversal methods, identification of surgical candidates, optimal surgery methods, and when or whether ATA should be recommenced following ASDH resolution remain topics of debate. This study defines our current understanding on this topic, revealing clear deficiencies in the literature with recommendations for future research.

Surgery for acute subdural hematoma: the value of pre-emptive decompressive craniectomy by propensity score analysis.

BACKGROUND: Acute subdural hematomas (ASDH) are found frequently following traumatic brain injury (TBI) and they are considered the most lethal type of mass lesions. The decision to perform a procedure to evacuate ASDH and the approach, either via craniotomy or decompressive craniectomy (DC), remains controversial. METHODS: We reviewed a prospectively collected series of 343 moderate to severe TBI patients in whom ASDH was the main lesion (ASDH volumes ≥10 cc). Patients with early comfort measures (early mortality prediction >50% and not ICP monitored), bilateral ASDH or the presence of another intracranial hematoma with volumes exceeding two times the volume of the ASDH were excluded. Among them, 112 were managed conservatively, 65 underwent ASDH evacuation by craniotomy and 166 by DC (103 pre-emptive DC, 63 obligatory DC). We calculated the average treatment effect by propensity score (PS) analysis using the following covariates: age, year, hypoxia, shock, pupils, major extracranial injury, motor score, midline shift, ASDH volume, swelling, intraventricular and subarachnoid hemorrhage presence. Then, multivariable binary regression and ordinal logistic regression analysis were performed to estimate associations between predictors and mortality and 12 months-GOS respectively. The patients' inverse probability weights were included as an independent variable in both regression models. RESULTS: The main variables associated with outcome were year, age, falls from patient´s own height, hypoxia, early deterioration, pupillary abnormalities, basal cistern effacement, compliance to ICP monitoring guidelines and type of surgical approach (craniotomy and pre-emptive DC). CONCLUSIONS: According to sliding dichotomy analysis, we found that patients in the intermediate or worst bands of unfavorable outcome prognosis seemed to achieve better than expected outcome if they underwent pre-emptive DC rather than craniotomy.

The Impact of Preinjury Antiplatelet and Anticoagulant Use on Elderly Patients with Moderate or Severe Traumatic Brain Injury Following Traumatic Acute Subdural Hematoma.

BACKGROUND: Although it is often assumed that preinjury anticoagulant (AC) or antiplatelet (AP) use is associated with poorer outcomes among those with acute subdural hematoma (aSDH), previous studies have had varied results. This study examines the impact of preinjury AC and AP therapy on aSDH thickness, 30-day mortality, and extended Glasgow Outcome Scale at 6 months in elderly patients (aged ≥65). METHODS: A level 1 trauma center registry was interrogated to identify consecutive elderly patients who presented with moderate or severe traumatic brain injury (TBI) and associated traumatic aSDH between the first of January 2013 and the first of January 2018. Relevant demographic, clinical, and radiological data were retrieved from institutional medical records. The 3 primary outcome measures were aSDH thickness on initial computed tomography scan, 30-day mortality, and unfavorable outcome at 6 months (extended Glasgow Outcome Scale). RESULTS: One hundred thirty-two elderly patients were admitted with moderate or severe TBI and traumatic aSDH. The mean (±SD) age was 78.39 (±7.87) years, and a majority of patients (59.8%, n = 79) were male. There was a statistically significant difference in mean aSDH thickness, but there were no significant differences in 30-day mortality (P = 0.732) and unfavorable outcome between the AP, AC, combined AP and AC, and no antithrombotic exposure groups (P = 0.342). CONCLUSIONS: Further studies with larger sample sizes are necessary to confirm these observations, but our findings do not support the preconceived notion in clinical practice that antithrombotic use is associated with poor outcomes in elderly patients with moderate or severe TBI.

Primary central nervous system angiosarcoma with recurrent acute subdural hematoma.

Angiosarcoma is an infrequent tumor among sarcomas, especially presenting as a primary tumor within the central nervous system, which can lead to a rapid neurological deterioration and death in few months. We present a 41-year old man with a right frontal enhancing hemorrhagic lesion. Surgery was performed with histopathological findings suggesting a primary central nervous system angiosarcoma. He was discharged uneventfully and received adjuvant chemotherapy and radiotherapy. At 5 months, the follow-up MRI showed two lesions with an acute subdural hematoma, suggesting a relapse. Surgery was again conducted finding tumoral membranes attached to the internal layer of the duramater around the right hemisphere. The patient died a few days later due to the recurrence of the subdural hematoma. This case report illustrates a rare and lethal complication of an unusual tumor. The literature reviewed shows that gross-total resection with adjuvant radiotherapy seems to be the best treatment of choice.

Hypothermia for Patients Requiring Evacuation of Subdural Hematoma: A Multicenter Randomized Clinical Trial.

BACKGROUND: Hypothermia is neuroprotective in some ischemia-reperfusion injuries. Ischemia-reperfusion injury may occur with traumatic subdural hematoma (SDH). This study aimed to determine whether early induction and maintenance of hypothermia in patients with acute SDH would lead to decreased ischemia-reperfusion injury and improve global neurologic outcome. METHODS: This international, multicenter randomized controlled trial enrolled adult patients with SDH requiring evacuation of hematoma within 6 h of injury. The intervention was controlled temperature management of hypothermia to 35 °C prior to dura opening followed by 33 °C for 48 h compared with normothermia (37 °C). Investigators randomly assigned patients at a 1:1 ratio between hypothermia and normothermia. Blinded evaluators assessed outcome using a 6-month Glasgow Outcome Scale Extended score. Investigators measured circulating glial fibrillary acidic protein and ubiquitin C-terminal hydrolase L1 levels. RESULTS: Independent statisticians performed an interim analysis of 31 patients to assess the predictive probability of success and the Data and Safety Monitoring Board recommended the early termination of the study because of futility. Thirty-two patients, 16 per arm, were analyzed. Favorable 6-month Glasgow Outcome Scale Extended outcomes were not statistically significantly different between hypothermia vs. normothermia groups (6 of 16, 38% vs. 4 of 16, 25%; odds ratio 1.8 [95% confidence interval 0.39 to ∞], p = .35). Plasma levels of glial fibrillary acidic protein (p = .036), but not ubiquitin C-terminal hydrolase L1 (p = .26), were lower in the patients with favorable outcome compared with those with unfavorable outcome, but differences were not identified by temperature group. Adverse events were similar between groups. CONCLUSIONS: This trial of hypothermia after acute SDH evacuation was terminated because of a low predictive probability of meeting the study objectives. There was no statistically significant difference in functional outcome identified between temperature groups.

Venous thromboembolic pharmacological prophylaxis in severe traumatic acute subdural hematomas: Early prophylaxis is effective and safe.

BACKGROUND: The purpose of this study was to evaluate the optimal timing and type of pharmacological venous thromboembolism prophylaxis (VTEp) in patients with severe blunt head trauma with acute subdural hematomas (ASDH). METHODS: Matched cohort study using ACS-TQIP database (2013-2016) including patients with isolated ASDH. Outcomes of matched patients receiving early prophylaxis (EP, ≤48 h) and late prophylaxis (LP, >48 h) were compared with univariable and multivariable regression analysis. RESULTS: In 1,660 matched cases VTE complications (3.1% vs 0.5%, p < 0.001) were more common in the LP compared to the EP group. Multivariable regression analysis identified EP as an independent protective factor for VTE complications (OR 0.169, p < 0.001) but not mortality (p = 0.260). The adjusted risk for delayed craniectomy was not associated with EP compared to LP (p = 0.095). LMWH was independently associated with a lower mortality (OR 0.480, p = 0.008) compared to UH. CONCLUSIONS: Early VTEp (≤48 h) does not increase the risk for craniectomies and is independently associated with fewer VTE complications in patients with isolated ASDH. LMWH was independently associated with a lower mortality compared to UH.

Factors Favoring the Development of Chronic Subdural Hematoma After Traumatic Acute Subdural Hematoma in the Elderly.

INTRODUCTION: Traumatic acute subdural hematoma (TASDH) is by far the most common traumatic brain injury in elderly patients presented to the emergency department, and a number of those treated conservatively will develop chronic subdural hematoma (CSDH). The factors contributing to chronicity were not well studied in the elderly; therefore, we retrospectively analyzed our elderly patients with acute subdural hematomas to identify the risk factors which might contribute to the development of subsequent CSDH. METHODS: A retrospective analysis of 254 patients with TASDH admitted between 2012 and 2016 to our level 2 trauma department in a community hospital was collected. Data include age, sex, comorbid conditions, CT findings, anticoagulant therapy, surgical interventions, disposition after discharge, and mortality. Data on those readmitted within the first 2 months with the diagnosis of CSDH were also studied (group A), and compared to those not readmitted (group B). Multiple logistic regression was used to determine the risk factors associated with readmission at P ≤ .05. Institutional review board approval was obtained for this study. RESULTS: There were 254 patients who were admitted with TASDH, 144 male (56.7%) and 110 female (43.3%), with the mean age of 71.4 (SD ± 19.38) years. Only 37 patients (14.6%) went for surgery in their initial admission. A total of 14 patients (5.6%) were readmitted subsequently with the diagnosis of CSDH within two months of initial discharge (group A). Only four patients (28.5%) were on anticoagulant therapy and these patients went for emergency craniotomy for evacuation of hematoma. All 14 patients had a history of coronary artery disease and hypertension and only 5 (35.7%) were diabetic. Review of head CT on initial admission of those patients revealed 4 patients (28.5%) had multiple lesions and 4 (28.5%) had tentorial/falax bleeding and 4 (28.5%) had a shift. The initial size and thickness of the bleeding was 1.4-5 mm. The adjusted model identified diabetes, race, and initial disposition as significant risk factors (P < .05). CONCLUSION: Risk associated with the transformation of TASDH to CSDH is difficult to assess in those group of elderly patients because of the small number; however, diabetes, race, and initial disposition to home pointed toward a risk for future development of CSDH and those patients should be followed clinically and radiographically over the next few months after discharge, particularly those on anticoagulant therapy.

Preexisting Ventricular Shunts Are Associated with Failed Evacuation of Acute Subdural Hematomas: Single-Institution Case Series of Complications and Management Strategies.

BACKGROUND: The effect of ventricular shunts on radiographic outcomes after evacuation of acute subdural hematomas (aSDHs) has not yet been established. We studied a series of patients who had undergone craniotomy for aSDH, exploring a possible relationship between the occurrence of a postoperative extra-axial collection (EAC) and the presence of a ventricular shunt. METHODS: We reviewed all craniotomies for convexity aSDH performed between July 2015 and June 2020. The medical record review included perioperative coagulation studies, platelet counts, and antiplatelet and anticoagulation agent use. Univariate and multivariate analyses were conducted to identify the factors associated with postoperative EACs and reevacuation. RESULTS: A total of 58 patients had undergone craniotomy for aSDHs, including 9 with ventricular shunts. The median age was 67 years (interquartile range, 54-78 years), and 40% of the patients were women. Of the 58 patients, 16 were taking antiplatelet agents, and 6 were taking anticoagulation agents. Ten patients had developed perioperative thrombocytopenia (platelet count, <100,000/µL). Twelve patients had perioperative coagulopathy (international normalized ratio, ≥1.5). A postoperative EAC >10 mm occurred in 17 patients (29.3%). Eight patients (13.8%) had undergone reevacuation. The presence of a shunt and an increasing preoperative aSDH size were independently associated with an EAC >10 mm (P = 0.013 and P = 0.003, respectively). Only the presence of a shunt predicted for the need for reevacuation (P = 0.001). The shunts were explanted (n = 3) or valves were adjusted (n = 3) in all but 3 cases. CONCLUSIONS: We found that a lack of brain reexpansion after aSDH evacuation worsens radiographic outcomes and was more common in patients with shunts. Increasing shunt valve resistance might help prevent the formation of large EACs after aSDH evacuation.

Timing of Restarting Anticoagulation and Antiplatelet Therapies After Traumatic Subdural Hematoma-A Single Institution Experience.

BACKGROUND: There is a paucity of information regarding the optimal timing of restarting antiplatelet therapy (APT) and anticoagulation therapy (ACT) after traumatic subdural hematoma (tSDH). Therefore, we sought to report our experience at a single level 1 trauma center with regard to restarting APT and/or ACT after tSDH. METHODS: A total of 456 consecutive records were reviewed for unplanned hematoma evacuation within 90 days of discharge and thrombotic/thromboembolic events before restarting APT and/or ACT. RESULTS: There was no difference in unplanned hematoma evacuation rate in patients not receiving APT or ACT (control) compared with those necessitating APT and/or ACT (6.4% control, 6.9% APT alone, 5.8% ACT alone, 5.4% APT and ACT). There was an increase in post-tSDH thrombosis/thromboembolism in patients needing to restart ACT (1.9% APT alone, P = 0.53 vs. control; 5.8% ACT alone, P = 0.04 vs. control; 16% APT and ACT; P < 0.001 vs. control). Subgroup analysis revealed that patients with coronary artery disease necessitating APT and patients with atrial fibrillation necessitating ACT had higher thrombosis/thromboembolism rates compared with controls (1.0% control vs. 6.1% coronary artery disease, P = 0.02; 1.0% control vs. 10.1% atrial fibrillation, P < 0.001). The median restart time of ACT was approximately 1 month after trauma; APT was restarted 2-4 weeks after trauma depending on clinical indication. CONCLUSIONS: Patients requiring reinitiation of APT and/or ACT after tSDH were at elevated risk of thrombotic/thromboembolic events but not unplanned hematoma evacuation. Therefore, patients should be followed closely until APT and/or ACT are restarted, and consideration for earlier reinitiation of blood thinners should be given on a case-by-case basis.

Effects of Acute Subdural Hematoma-Induced Brain Injury On Energy Metabolism in Peripheral Blood Mononuclear Cells.

ABSTRACT: In activated immune cells, differentiation and function are determined by cell type-specific modifications of metabolic patterns. After traumatic brain injury both immune cell activation and suppression were reported. Therefore, we sought to explore immune cell energy metabolism in a long-term, resuscitated porcine model of acute subdural hematoma (ASDH)-induced acute brain injury devoid of impaired systemic hemodynamics and oxygen transport.Before and up to 50 h after induction of ASDH, peripheral blood mononuclear cells (PBMCs) were separated by density gradient centrifugation, and cell metabolism was analyzed using high-resolution respirometry for mitochondrial respiration and electron spin resonance for reactive oxygen species production. After incubation with stable isotope-labeled 1,2-13C2-glucose or 13C5-glutamine, distinct labeling patterns of intermediates of glycolysis or tricarboxylic acid (TCA) cycle and 13CO2 production were measured by gas chromatography-mass spectroscopy. Principal component analysis was followed by a varimax rotation on the covariance across all measured variables and all measured time points.After ASDH induction, average PBMC metabolic activity remained unaffected, possibly because strict adherence to intensive care unit guidelines limited trauma to ASDH induction without any change in parameters of systemic hemodynamics, oxygen transport, and whole-body metabolism. Despite decreased glycolytic activity fueling the TCA cycle, the principal component analysis indicated a cell type-specific activation pattern with biosynthetic and proliferative characteristics.

Factors Associated with Poor Outcomes in Patients with Mild or Moderate Acute Subdural Hematomas.

The factors influencing the outcomes of mild/moderate acute subdural hematoma (ASDH) are still unclear. Retrospective analyses were performed to identify such factors. The medical records of all patients who were admitted to Saiseikai Shiga Hospital with mild (Glasgow Coma Scale [GCS] score of 14-15) or moderate (GCS score of 9-13) ASDH between April 2008 and March 2017 were reviewed. Comparisons between the patients who exhibited favorable and poor outcomes were performed. Then, independent factors that contributed to poor outcomes were identified via logistic regression analyses. A total of 266 patients with a mean age of 70.2 were included in this study. The most common concomitant injuries were subarachnoid hemorrhages (SAHs; 56.8%). The patients' Injury Severity Scores (ISS) ranged from 16 to 75 (median: 21). The 66 moderate ASDH patients exhibited significantly higher frequencies of surgery and mortality (24.2% and 13.6%, respectively) than the 200 mild ASDH patients (8.0% and 4.5%, respectively). The factors associated with poor outcomes were age (odds ratio [OR]: 1.06) and the ISS (OR: 1.24) in the mild ASDH patients, and older age (OR: 1.09) and the higher ISS (OR: 1.15) in the moderate group, too.

The Utility of the Modified Frailty Index in Outcome Prediction for Elderly Patients with Acute Traumatic Subdural Hematoma.

This study aimed to evaluate the utility of the 11-variable modified Frailty Index (mFI) in prognosticating elderly patients with traumatic acute subdural hematomas (aSDHs). A state-service level 1 trauma center registry was interrogated to investigate consecutive patients ≥65 years of age presenting with traumatic aSDH, with or without major extracranial injury, between January 2013 and December 2017. mFI on admission, demographics, and admission details, including Glasgow Coma Scale (GCS) and pupillary status and radiological findings, were retrospectively retrieved from institutional records. Clinical outcome data were retrieved from medical records and the Victorian State Trauma Registry (VSTR). Outcome measures were 1) 30-day mortality and 2) 6-month unfavorable outcome, defined by the Extended Glasgow Outcome Scale (GOS-E). Five hundred twenty-nine consecutive cases were identified from the registry. Demographic data included: 1) age (median; interquartile range) = 80.46; 74.17-85.89; 2) mFI (mean ± standard deviation) = 1.96 ± 1.42 of 11 variables. Four hundred sixteen cases (79%) had complete outcome data. As mFI increased from 0/11 variables to ≥5/11 variables (≥0.45), 30-day mortality risk increased from 17.72% to 39.29% (p = 0.023) and 6-month unfavorable outcome risk increased from 40.51% to 96.43% (p < 0.001). Multi-variate analysis showed that greater mFI score of ≥3/11 variables (≥0.27) suggested a significantly higher risk of 30-day mortality (p = 0.009) and unfavorable outcome (p < 0.001). We conclude that increasing frailty, as measured by the mFI, was associated with significantly higher risk of 30-day mortality and 6-month unfavorable outcome in elderly patients presenting with aSDH to a level 1 neurotrauma center. Assessment of mFI in elderly patients with aSDH may be a useful determinant of outcome for this rapidly growing population.

Acute Subdural Hematomas in Ruptured Brain Arteriovenous Malformations: Association with Distal Flow-Related Aneurysms.

PURPOSE: Non-traumatic acute subdural hematomas (SDH) are rare and have seldom been reported in ruptured brain arteriovenous malformations (BAVM). The aim of this study was to report the frequency of acute SDH in BAVM-related hemorrhage and to determine the relationship of SDHs with BAVM angioarchitectural features. METHODS: This was a retrospective monocentric study of patients admitted for BAVM rupture between 2003 and 2017. Patients with rupture complicating or closely following partial embolization procedures were excluded. Univariate followed by multivariate logistic regression analysis was used to determine factors significantly and independently associated with SDHs and distal flow-related aneurysms. RESULTS: A total of 181 patients with 188 BAVM ruptures admitted during the study period were included, eleven cases of acute SDH were identified (6%) and 2 cases of isolated SDH were found. The presence of a distal flow-related aneurysm was the only feature independently and significantly associated with SDH (odds ratio [OR] 8.1, 95% confidence interval, CI 1.9-34.5, P = 0.003). Distal flow-related aneurysms were associated with proximal flow-related aneurysms (OR 28, 95%CI 4.9-163.8, P < 0.001), were more frequent in infratentorial BAVMs (OR 3.7, 95%CI 1.3-10.2, P = 0.01) and more often found in cases of acute SDH (OR 16.9, 95%CI 3.6-79.6, P < 0.001) and subarachnoid hemorrhage (SAH) (OR 4.5, 95%CI 1.7-12.2, P = 0.003). CONCLUSION: Ruptured BAVMs can rarely present with acute SDH and SDH in ruptured BAVMs are often associated with distal flow-related aneurysms. This finding may impact acute management of ruptured BAVMs with SDH by eliciting an emergent and thorough imaging work-up to identify distal flow-related aneurysm(s), in turn leading to treatment.

Initial Results of Empirical Cryoprecipitate Transfusion in the Treatment of Isolated Severe Traumatic Brain Injury: Use of In-house-produced Cryoprecipitate.

Acute coagulopathy is common after traumatic brain injury (TBI), particularly in severe cases of acute subdural hemorrhage (ASDH). Although acute coagulopathy is associated with poor outcomes, the optimal treatment strategy remains unknown. Here, we report the initial results of an empirical cryoprecipitate transfusion strategy that we developed as an early intervention for acute coagulopathy after TBI. We performed chart reviews of adult patients (aged ≥18 years) who received early cryoprecipitate transfusion after admission to our institution with a diagnosis of severe TBI (Glasgow Coma Scale ≤8) and ASDH from March 2013 to December 2016. We compared the outcomes of these patients with those who were treated before the implementation of the cryoprecipitate transfusion strategy (January 2011-February 2013). During the study period, 33 patients received early cryoprecipitate transfusion and no acute transfusion-related adverse event was reported. The rate of coagulopathy development within 24 h after admission was lower in these patients (23%) than in the controls (49%), but the difference was not significant (P = 0.062). The in-hospital mortality rate was 36% in patients receiving early cryoprecipitate transfusion and 52% in controls. After adjusting for confounding factors, the in-hospital mortality rate was significantly lower in the intervention period [adjusted odds ratio: 0.25, 95% confidence interval (CI): 0.08-0.78, P = 0.017]. In summary, we analyzed initial results of a cryoprecipitate transfusion strategy in patients with severe isolated TBI and ASDH. No acute transfusion-related adverse event was observed, and early transfusion of the in-house-produced cryoprecipitate may have reduced rates of coagulopathy development and in-hospital mortality.

[Predictive Factors of Intracranial Pressure Elevation in Patients with Severe Acute Subdural Hematoma].

INTRODUCTION: Elevated intracranial pressure(ICP)can cause secondary brain injury after severe traumatic brain injury(TBI), and ICP is the key factor that determines the outcome. Therefore, prediction of elevation of ICP during the course of the injury would allow for more effective care of patients with severe TBI. In this study, we investigated predictive factors for elevation of ICP in patients with severe acute subdural hematoma(ASDH). METHODS: Twenty patients with severe isolated ASDH were admitted to our hospital between January 2009 and April 2016. The patients were divided into two groups with a maximum ICP of ≥20mmHg(elevated ICP group)and <20mmHg(normal ICP group). Age, mechanism of injury, Glasgow Coma Scale score on admission, initial head computed tomography findings, vital signs, serological and blood gas examinations, initial ICP, and clinical outcome were evaluated. RESULTS: The elevated ICP group had significantly higher initial ICP(5.0±3.1 vs. 30±22.4mmHg, p<0.01), arterial oxygen pressure(151.2±68.3 vs. 314.2±197.1mmHg, p<0.05), and activated partial thromboplastin time(APTT;28.17±3.1 vs. 35.96±8.0, p<0.05)at admission, and significantly lower fibrinogen level(273.3±65.1 vs. 188.1±82.4mg/dL, p<0.05)and favorable outcome rate(p<0.01). CONCLUSIONS: Our results show that high initial ICP, APTT, and arterial oxygen and low fibrinogen levels are associated with ICP elevation in patients with severe ASDH. These factors might be useful for the indication of therapeutic methods such as decompressive craniectomy.