Impact of premorbid oral anticoagulant use on survival in patients with traumatic intracranial hemorrhage.

OBJECTIVE: Although oral anticoagulant use has been implicated in worse outcomes for patients with a traumatic brain injury (TBI), prior studies have mostly examined the use of vitamin K antagonists (VKAs). In an era of increasing use of direct oral anticoagulants (DOACs) in lieu of VKAs, the authors compared the survival outcomes of TBI patients on different types of premorbid anticoagulation medications with those of patients not on anticoagulation. METHODS: The authors retrospectively reviewed the records of 1186 adult patients who presented at a level I trauma center with an intracranial hemorrhage after blunt trauma between 2016 and 2022. Patient demographics; comorbidities; and pre-, peri-, and postinjury characteristics were compared based on premorbid anticoagulation use. Multivariable Cox proportional hazards regression modeling of mortality was performed to adjust for risk factors that met a significance threshold of p < 0.1 on bivariate analysis. RESULTS: Of 1186 patients with a traumatic intracranial hemorrhage, 49 (4.1%) were taking DOACs and 53 (4.5%) used VKAs at the time of injury. Patients using oral anticoagulants were more likely to be older (p < 0.001), to have a higher Charlson Comorbidity Index (p < 0.001), and to present with a higher Glasgow Coma Scale (GCS) score (p < 0.001) and lower Injury Severity Score (ISS; p < 0.001) than those on no anticoagulation. Patients using VKAs were more likely to undergo reversal than patients using DOACs (53% vs 31%, p < 0.001). Cox proportional hazards regression demonstrated significantly increased hazard ratios (HRs) for VKA use (HR 2.204, p = 0.003) and DOAC use (HR 1.973, p = 0.007). Increasing age (HR 1.040, p < 0.001), ISS (HR 1.017, p = 0.01), and Marshall score (HR 1.186, p < 0.001) were associated with an increased risk of death. A higher GCS score on admission was associated with a decreased risk of death (HR 0.912, p < 0.001). CONCLUSIONS: Patients with a traumatic intracranial injury who were on oral anticoagulant therapy before injury demonstrated higher mortality rates than patients who were not on oral anticoagulation after adjusting for age, comorbid conditions, and injury presentation.

Analysis of Clinical and Laboratory Risk Factors of Post-Traumatic Intracranial Hemorrhage in Patients on Direct Oral Anticoagulants with Mild Traumatic Brain Injury: An Observational Multicenter Cohort.

BACKGROUND: Assessing the risk of intracranial hemorrhage (ICH) in patients with a mild traumatic brain injury (MTBI) who are taking direct oral anticoagulants (DOACs) is challenging. Currently, extensive use of computed tomography (CT) is routine in the emergency department (ED). OBJECTIVE: This study aims to investigate whether the clinical and laboratory characteristics presented at the ED evaluation can also estimate the risk of post-traumatic ICH in DOAC-treated patients with MTBI. METHODS: A retrospective observational study was conducted in three EDs in Italy from January 1, 2016 to March 15, 2020. All patients treated with DOACs who were evaluated for an MTBI in the ED were enrolled. The primary outcome of the study was the presence of post-traumatic ICH in the head CT performed in the ED. RESULTS: Of 930 patients on DOACs with MTBI who were enrolled, 6.8% (63 of 930) had a post-traumatic ICH and 1.5% (14 of 930) were treated with surgery or died as a result of the ICH. None of the laboratory factors were associated with an increased risk of ICH. On multivariate analysis, previous neurosurgical intervention, major trauma dynamic, post-traumatic loss of consciousness, post-traumatic amnesia, Glasgow Coma Scale score of 14, and evidence of trauma above the clavicles were associated with a higher risk of post-traumatic ICH. The net clinical benefit provided by risk factor assessment appears superior to the strategy of performing CT on all DOAC-treated patients. CONCLUSIONS: Assessment of the clinical characteristics presented at ED admission can help identify DOAC-treated patients with MTBI who are at risk of ICH.

Does pre-injury clopidogrel use increase the risk of intracranial haemorrhage post head injury in adult patients? A systematic review and meta-analysis.

BACKGROUND: Several current guidelines do not include antiplatelet use as an explicit indication for CT scan of the head following head injury. The impact of individual antiplatelet agent use on rates of intracranial haemorrhage is unclear. The primary objective of this systematic review was to assess if clopidogrel monotherapy was associated with traumatic intracranial haemorrhage (tICH) on CT of the head within 24 hours of presentation following head trauma compared with no antithrombotic controls. METHODS: Eligible studies were non-randomised studies with participants aged ≥18 years old with head injury. Studies had to have conducted CT of the head within 24 hours of presentation and contain a no antithrombotic control group and a clopidogrel monotherapy group.Eight databases were searched from inception to December 2020. Assessment of identified studies against inclusion criteria and data extraction were carried out independently and in duplicate by two authors.Quality assessment and risk of bias (ROB) were assessed using the Newcastle-Ottawa Quality Assessment tool and Risk Of Bias In Non-randomised Studies of Interventions (ROBINS-I) tool. Meta-analysis was conducted using a random-effects model and reported as an OR and 95% CI. RESULTS: Seven studies were eligible for inclusion with a total of 21 898 participants that were incorporated into the meta-analysis. Five studies were retrospective. Clopidogrel monotherapy was not significantly associated with an increase in risk of tICH compared with no antithrombotic controls (OR 0.97, 95% CI 0.54 to 1.75). Heterogeneity was high with an I2 of 75%. Sensitivity analysis produced an I2 of 21% and did not show a significant association between clopidogrel monotherapy and risk of tICH (OR 1.16, 95% CI 0.87 to 1.55). All studies scored for moderate to serious ROB on categories in the ROBINS-I tool. CONCLUSION: Included studies were vulnerable to confounding and several were small-scale studies. The results should be interpreted with caution given the ROB identified. This study does not provide statistically significant evidence that clopidogrel monotherapy patients are at increased risk of tICH after head injury compared with no antithrombotic controls. PROSPERO REGISTRATION NUMBER: CRD42020223541.

Development of cerebral vasospasm following traumatic intracranial hemorrhage: incidence, risk factors, and clinical outcomes.

OBJECTIVE: Limited evidence exists characterizing the incidence, risk factors, and clinical associations of cerebral vasospasm following traumatic intracranial hemorrhage (tICH) on a large scale. Therefore, the authors sought to use data from a national inpatient registry to investigate these aspects of posttraumatic vasospasm (PTV) to further elucidate potential causes of neurological morbidity and mortality subsequent to the initial insult. METHODS: Weighted discharge data from the National (Nationwide) Inpatient Sample from 2015 to 2018 were queried to identify patients with tICH who underwent diagnostic angiography in the same admission and, subsequently, those who developed angiographically confirmed cerebral vasospasm. Multivariable logistic regression analysis was performed to identify significant associations between clinical covariates and the development of vasospasm, and a tICH vasospasm predictive model (tICH-VPM) was generated based on the effect sizes of these parameters. RESULTS: Among 5880 identified patients with tICH, 375 developed PTV corresponding to an incidence of 6.4%. Multivariable adjusted modeling determined that the following clinical covariates were independently associated with the development of PTV, among others: age (adjusted odds ratio [aOR] 0.98, 95% CI 0.97-0.99; p < 0.001), admission Glasgow Coma Scale score < 9 (aOR 1.80, 95% CI 1.12-2.90; p = 0.015), intraventricular hemorrhage (aOR 6.27, 95% CI 3.49-11.26; p < 0.001), tobacco smoking (aOR 1.36, 95% CI 1.02-1.80; p = 0.035), cocaine use (aOR 3.62, 95% CI 1.97-6.63; p < 0.001), fever (aOR 2.09, 95% CI 1.34-3.27; p = 0.001), and hypokalemia (aOR 1.62, 95% CI 1.26-2.08; p < 0.001). The tICH-VPM achieved moderately high discrimination, with an area under the curve of 0.75 (sensitivity = 0.61 and specificity = 0.81). Development of vasospasm was independently associated with a lower likelihood of routine discharge (aOR 0.60, 95% CI 0.45-0.78; p < 0.001) and an extended hospital length of stay (aOR 3.53, 95% CI 2.78-4.48; p < 0.001), but not with mortality. CONCLUSIONS: This population-based analysis of vasospasm in tICH has identified common clinical risk factors for its development, and has established an independent association between the development of vasospasm and poorer neurological outcomes.

Routine platelet transfusion in patients with traumatic intracranial hemorrhage taking antiplatelet medication: Is it warranted?

BACKGROUND: After a traumatic intracranial hemorrhage (tICH), patients often receive a platelet transfusion to reverse the effects of antiplatelet medication and to reduce neurologic complications. As platelet transfusions have their own risks, this study evaluated their effects on tICH progression, need for operations and mortality. METHODS: In this retrospective study, we identified patients admitted to a level 1 trauma centre with a tICH from 2011 to 2015 who were taking acetylsalicylic acid (ASA) or clopidogrel, or both. We categorized patients into 2 groups: platelet transfusion recipients and nonrecipients. We collected data on demographic characteristics, changes in brain computed tomography findings, neurosurgical interventions, in-hospital death and intensive care unit (ICU) length of stay (LOS). We used multivariable logistic regression to compare outcomes between the 2 groups. RESULTS: We identified 224 patients with tICH, 156 (69.6%) in the platelet transfusion group and 68 (30.4%) in the no transfusion group. There were no between-group differences in progression of bleeds or rates of neurosurgical interventions. In the transfusion recipients, there was a trend toward increased ICU LOS (adjusted odds ratio [OR] 1.59, 95% confidence interval [CI] 0.74-3.40) and in-hospital death (adjusted OR 3.23, 95% CI 0.48-21.74). CONCLUSION: There were no differences in outcomes between patients who received platelet transfusions and those who did not; however, the results suggest a worse clinical course, as indicated by greater ICU LOS and mortality, in the transfusion recipients. Routine platelet transfusion may not be warranted in patients taking ASA or clopidogrel who experience a tICH, as it may increase ICU LOS and mortality risk.

Coagulopathy and its effect on treatment and mortality in patients with traumatic intracranial hemorrhage.

BACKGROUND: The role of coagulopathy in patients with traumatic brain injury has remained elusive. In the present study, we aim to assess the prevalence of coagulopathy in patients with traumatic intracranial hemorrhage, their clinical features, and the effect of coagulopathy on treatment and mortality. METHODS: An observational, retrospective single-center cohort of consecutive patients with traumatic intracranial hemorrhage treated at Helsinki University Hospital between 01 January and 31 December 2010. We compared clinical and radiological parameters in patients with and without coagulopathy defined as drug- or disease-induced, i.e., antiplatelet or anticoagulant medication at a therapeutic dose, thrombocytopenia (platelet count < 100 E9/L), international normalized ratio > 1.2, or thromboplastin time < 60%. Primary outcome was 30-day all-cause mortality. Logistic regression analysis allowed to assess for factors associated with coagulopathy and mortality. RESULTS: Of our 505 patients (median age 61 years, 65.5% male), 206 (40.8%) had coagulopathy. Compared to non-coagulopathy patients, coagulopathy patients had larger hemorrhage volumes (mean 140.0 mL vs. 98.4 mL, p < 0.001) and higher 30-day mortality (18.9% vs. 9.7%, p = 0.003). In multivariable analysis, older age, lower admission Glasgow Coma Scale score, larger hemorrhage volume, and conservative treatment were independently associated with mortality. Surgical treatment was associated with lower mortality in both patients with and without coagulopathy. CONCLUSIONS: Coagulopathy was more frequent in patients with traumatic intracranial hemorrhage presenting larger hemorrhage volumes compared to non-coagulopathy patients but was not independently associated with higher 30-day mortality. Hematoma evacuation, in turn, was associated with lower mortality irrespective of coagulopathy.

Pneumonia due to Pandoraea Apista after evacuation of traumatic intracranial hematomas:a case report and literature review.

BACKGROUND: Pandoraea species is a newly described genus, which is multidrug resistant and difficult to identify. Clinical isolates are mostly cultured from cystic fibrosis (CF) patients. CF is a rare disease in China, which makes Pandoraea a total stranger to Chinese physicians. Pandoraea genus is reported as an emerging pathogen in CF patients in most cases. However, there are few pieces of evidence that confirm Pandoraea can be more virulent in non-CF patients. The pathogenicity of Pandoraea genus is poorly understood, as well as its treatment. The incidence of Pandoraea induced infection in non-CF patients may be underestimated and it's important to identify and understand these organisms. CASE PRESENTATION: We report a 44-years-old man who suffered from pneumonia and died eventually. Before his condition deteriorated, a Gram-negative bacilli was cultured from his sputum and identified as Pandoraea Apista by matrix-assisted laser desorption ionization-time-of-flight mass spectrometry (MALDI-TOF MS). CONCLUSION: Pandoraea spp. is an emerging opportunistic pathogen. The incidences of Pandoraea related infection in non-CF patients may be underestimated due to the difficulty of identification. All strains of Pandoraea show multi-drug resistance and highly variable susceptibility. To better treatment, species-level identification and antibiotic susceptibility test are necessary.

Traumatic Retroclival Epidural Hematoma.

Retroclival epidural hematomas are particularly rare conditions that are frequently the result of high-energy, hyperflexion-hyperextension injuries in pediatric patients. We present the case of a 7-year-old previously healthy girl with traumatic retroclival epidural hematoma after a fall from a swing. She presented with a Glasgow Coma Scale score of 15 with severe neck pain and limitation of cervical movements in all directions. Radiological examination revealed retroclival epidural hematoma, and the patient was managed conservatively with good recovery. Although conservative management leads to good recovery in most cases, retroclival epidural hematomas should always be kept in mind regardless of the severity of trauma.

Dissociation of identity following left parietal haematoma - a single case report.

OBJECTIVES: Dissociative identity disorder in relation to brain injury has only rarely been reported in literature. This case report, which illustrates a de novo onset of dissociative identity for the first time in an elderly man who had a left parietal haematoma, adds to this scant literature base and supports an integrative view of bridging the dichotomy between organic and functional to explain complex psychiatric phenomena. METHODS: It is a single case report collected through serial semi-structured interviews of the patient and his family over a 12-week period. RESULTS: The patient was an elderly man transiently dissociated into various identities, some of whom seemed to be based upon individuals who had traumatized him in the past. This occurred three weeks after recovery from hemiparesis and delirium following a left parietal haematoma. The dissociations ended after six weeks, which coincided not only with the resolution of the haematoma but also with a faith-healing ritual. A speculative psychobiological formulation was drawn of possible brain origins of dissociation of identity. CONCLUSIONS: This report is a compelling account of temporal correlation between dissociation of identity and left parietal haematoma.

Cerebral Arterial Compliance in Traumatic Brain Injury.

OBJECTIVE: The main role of the cerebral arterial compliance (cAC) is to maintain the stiffness of vessels and protect downstream vessels when changing cerebral perfusion pressure. The aim was to examine the flexibility of the cerebral arterial bed based on the assessment of the cAC in patients with traumatic brain injury (TBI) in groups with and without intracranial hematomas (IHs). MATERIALS AND METHODS: We examined 80 patients with TBI (mean age, 35.7 ± 12.8 years; 42 men, 38 women). Group 1 included 41 patients without IH and group 2 included 39 polytraumatized patients with brain compression by IH. Dynamic electrocardiography (ECG)-gated computed tomography angiography (DHCTA) was performed 1-14 days after trauma in group 1 and 2-8 days after surgical evacuation of the hematoma in group 2. Amplitude of arterial blood pressure (ABP), as well as systole and diastole duration were measured noninvasively. Transcranial Doppler was measured simultaneously with DHCTA. The cAC was calculated by the formula proposed by Avezaat. RESULTS: The cAC was significantly decreased (p < 0.001) in both groups 1 and 2 compared with normal data. The cAC in group 2 was significantly decreased compared with group 1, both on the side of the former hematoma (р = 0.017). CONCLUSION: The cAC in TBI gets significantly lower compared with the conditional norm (p < 0.001). After removal of the intracranial hematomas, compliance in the perifocal zone remains much lower (р = 0.017) compared with compliance of the other brain hemisphere.

The Cerebrovascular Resistance in Combined Traumatic Brain Injury with Intracranial Hematomas.

OBJECTIVE: The aim was to evaluate changes in cerebrovascular resistance (CVR) in combined traumatic brain injury (CTBI) in groups with and without intracranial hematomas (IH). MATERIALS AND METHODS: Treatment outcomes in 70 patients with CTBI (42 males and 28 females) were studied. Mean age was 35.5 ± 14.8 years (range, 15-73). The patients were divided into two groups: group 1 included 34 CTBI patients without hematomas; group 2 comprised 36 patients with CTBI and IH. The severity according to the Glasgow Coma Scale averaged 10.4 ± 2.6 in group 1, and 10.6 ± 2.8 in group 2. All patients underwent perfusion computed tomography (CT) and transcranial Doppler of both middle cerebral arteries. Cerebral perfusion pressure and CVR were calculated. RESULTS: The mean CVR values in each group (both with and without hematomas) appeared to be statistically significantly higher than the mean normal value. Intergroup comparison of CVR values showed statistically significant increase in the CVR level in group 2 on the side of the removed hematoma (р = 0.037). CVR in the perifocal zone of the removed hematoma remained significantly higher compared with the symmetrical zone in the contralateral hemisphere (p = 0.0009). CONCLUSION: CVR in patients with CTBI is significantly increased compared to the normal value and remains elevated after evacuation of hematoma in the perifocal zone compared to the symmetrical zone in the contralateral hemisphere. This is indicative of certain correlation between the mechanisms of cerebral blood flow autoregulation and maintaining CVR.

Safety of deferred CT imaging of intoxicated patients presenting with possible traumatic brain injury.

BACKGROUND: Patients presenting to the emergency department (ED) with altered mental status and alcohol intoxication can clinically resemble patients with an intracranial hemorrhage. Although intracranial hemorrhage is quickly excluded with a head computed tomographic (CT) scan, it is common practice to defer imaging and allow the patient to metabolize to spare ED resources and minimize radiation exposure to the patient. Although this reduces unnecessary scans, it may delay treatment in patients with occult intracranial hemorrhage, which some fear may increase morbidity and mortality. We sought to evaluate the safety of deferred CT imaging in these patients by evaluating whether time to scan significantly affects the rate of neurosurgical intervention. METHODS: In this retrospective medical record review, all clinically alcohol-intoxicated patients presenting to 2 university EDs were included. Time to order CT imaging, findings on imaging, and outcomes of these patients were determined. Patients were assessed in 3 groups: CT ordered within 1 hour of triage, CT ordered 1-3 hours from triage, and CT ordered 3 or more hours from triage. RESULTS: During the study period, 5943 patients were included in the study. Of these, 0 patients scanned in less than 3 hours had intracranial findings on imaging requiring neurosurgery, whereas 1 patient with a deferred CT scan required a neurosurgical intervention; however, it was not emergently performed. CONCLUSION: Routine CT scanning of alcohol-intoxicated patients with altered mental status is of low clinical value. Deferring CT imaging while monitoring improving clinical status appears to be a safe practice.

Eosinopenia in Children following Traumatic Intracranial Hemorrhage Is Associated with Poor Prognosis and Prolonged Hospital Admission.

BACKGROUND: Neutrophilia is associated with brain injury and is frequently accompanied by eosinopenia. Although eosinopenia is a poor prognostic indicator for various diseases, its significance in intracranial events has not been investigated. METHODS: We retrospectively included 22 pediatric patients (≤18 years old) who experienced traumatic intracranial hemorrhage between 2002 and 2015. Patients were divided into two groups based on the presence or absence of eosinopenia on admission, i.e. the proportion of eosinophils to total white blood cells <1.0%. RESULTS: The mean Glasgow Coma Scale score was marginally lower in the eosinopenia group (14.1 vs. 12.0, p = 0.06). The mean Glasgow Outcome Scale-Extended (GOSE) score was significantly lower in the eosinopenia group (7.5 vs. 5.7, p = 0.02), and the mean length of hospital stay tended to be longer in patients with eosinopenia (7.8 vs. 28.4, p = 0.10). In our multivariate logistic regression analysis, eosinopenia was the only significant risk factor for poor outcome (GOSE score 1-7, OR 29.7, p = 0.03) and prolonged hospital stay (>2 weeks, OR 7.1, p = 0.047). CONCLUSION: These results demonstrate the significance of eosinopenia as a novel prognostic factor in traumatic intracranial hemorrhage in children.

Platelet dysfunction and platelet transfusion in traumatic brain injury.

BACKGROUND: Both aspirin therapy and trauma impair platelet function. Platelet dysfunction is associated with worse outcomes in patients with traumatic intracranial hemorrhage (ICH). Platelet transfusion is often used to limit progression of ICH in patients on aspirin, but has not been shown to improve platelet function or outcomes. We hypothesized that platelet transfusion would improve aspirin-induced, but not trauma-induced, platelet dysfunction. MATERIALS AND METHODS: In this prospective trial, blood samples were collected from patients evaluated in our level 1 trauma center with traumatic ICH, at the time of arrival and at the next clinical laboratory draw after admission. Patients on aspirin therapy were transfused one apheresis unit of platelets. Platelet function was assessed using a Multiplate multiple electrode aggregometer. Platelet activation was induced by collagen (COL) and arachidonic acid (AA). Agonist responses are reported as area under the aggregation curve in units (U). Reference ranges for agonist response were provided by the manufacturer, based on studies of healthy controls. RESULTS: Seventeen patients with isolated ICH were enrolled, twelve taking aspirin and five not taking aspirin. All patients on aspirin received platelet transfusion. Median admission platelet function in patients taking aspirin was abnormal in response to both agonists. After transfusion, median platelet function in response to AA improved from 19.0 U to 26.0 U (P = 0.012), whereas there was no improvement in the COL response. In patients not on aspirin, platelet response to COL was abnormal at both time points. CONCLUSIONS: Patients with isolated ICH have trauma-induced platelet dysfunction. In addition, patients on aspirin have drug-induced abnormalities in platelet response to AA. Platelet transfusion improves aspirin-induced, but not trauma-induced, platelet dysfunction.

Examination of life-threatening injuries in 431 pediatric facial fractures at a level 1 trauma center.

PURPOSE: Pediatric facial fractures represent a challenge in management due to the unique nature of the growing facial skeleton. Oftentimes, more conservative measures are favored to avoid rigid internal fixation and disruption of blood supply to the bone and soft tissues. In addition, the great force required to fracture bones of the facial skeleton often produces concomitant injuries that present a management priority. The purpose of this study was to examine a level 1 trauma center's experience with pediatric facial trauma resulting in fractures of the underlying skeleton with regards to epidemiology and concomitant injuries. METHODS: A retrospective review of all facial fractures at a level 1 trauma center in an urban environment was performed for the years 2000 to 2012. Patients aged 18 years or younger were included. Patient demographics were collected, as well as location of fractures, concomitant injuries, and surgical management strategies. A significance value of 5% was used. RESULTS: During this period, there were 3147 facial fractures treated at our institution, 353 of which were pediatric patients. Upon further review, 68 patients were excluded because of insufficient data for analysis, leaving 285 patients for review. The mean age of patients was 14.2 years with a male predominance (77.9%). The mechanism of injury was assault in 108 (37.9%), motor vehicle accident in 68 (23.9%), pedestrian struck in 41 (14.4%), fall in 26 (9.1%), sporting accident in 20 (7.0%), and gunshot injury in 16 (5.6%). The mean Glasgow Coma Scale (GCS) on arrival to the emergency department was 13.7. The most common fractures were those of the mandible (29.0%), orbit (26.5%), nasal bone (14.4%), zygoma (7.7%), and frontal bone/frontal sinus (7.5%). Intracranial hemorrhage was present in 70 patients (24.6%). A skull fracture was present in 50 patients (17.5%). A long bone fracture was present in 36 patients (12.6%). A pelvic or thoracic fracture was present in 30 patients (10.5%). A cervical spine fracture was present in 10 patients (3.5%), and a lumbar spine fracture was present in 11 patients (3.9%). Fractures of the zygoma, orbit, nasal bone, and frontal sinus/bone were significantly associated with intracranial hemorrhage (P < 0.05). Fractures of the zygoma and orbit were significantly associated with cervical spine injury (P < 0.05). The mean GCS for patients with and without intracranial hemorrhages was 11.0 and 14.6, respectively (P < 0.05). The mean GCS for patients with and without cervical spine fractures was 11.2 and 13.8, respectively (P < 0.05). CONCLUSIONS: Pediatric facial fractures in our center are often caused by interpersonal violence and are frequently accompanied by other more life-threatening injuries. The distribution of fractures parallels previous literature. Midface fractures and a depressed GCS showed a strong correlation with intracranial hemorrhage and cervical spine fracture. A misdiagnosed cervical spine injury or intracranial hemorrhage has disastrous consequences. On the basis of this study, it is the authors' recommendation that any patient sustaining a midface fracture with an abnormal GCS be evaluated for the aforementioned diagnoses.

Surgical treatment of traumatic multiple intracranial hematomas.

OBJECTIVE: To summarize our experience with the surgical treatment of traumatic multiple intracranial hematomas (TMIHs) and discuss the surgical indications. METHODS: We analyzed the clinical data of 118 patients with TMIHs who were treated at the West China Hospital in Sichuan University, Chengdu, China between October 2008 and October 2011, including age, gender, cause of injury, diagnosis, treatment, and outcomes. RESULTS: Among the 118 patients, there were 12 patients with different types of hematomas at the same site, 69 with one hematoma type in different compartments, and 37 with different types of hematomas in different compartments. In total, 106 patients had obliteration of basal cisterns, and 34 had a simultaneous midline shift >/=5 mm. Eighty-nine patients underwent single-site surgery, 19 had 2-site surgeries, and 10 patients did not undergo surgery. Based on the Glasgow Outcome Scale 6 months post-injury, 41 patients had favorable outcomes, and 77 had unfavorable outcomes. Basal cisterns obliteration was a strong indicator for surgical treatment. Single- or 2-site surgery was not related to outcome (p=0.234). CONCLUSION: Obliteration of the basal cisterns is a strong indication for surgical treatment of TMIHs. After evacuation of the major hematomas, the remaining hematomas can be treated conservatively. Most patients only require single-site surgical treatment.

Evaluating CAPO®: A biocompatibility, transparency, and fitment assessment for use with CEREBO® in traumatic intracranial injury detection.

Healthcare-associated infections (HAIs) are a global concern affecting millions of patients, requiring robust infection prevention and control measures. In particular, patients with traumatic brain injury (TBI) are highly susceptible to nosocomial infections, emphasizing the importance of infection control. Non-invasive near infrared spectroscopy (NIRS) device, CEREBO® integrated with a disposable component CAPO® has emerged as a valuable tool for TBI patient triage and this study evaluated the safety and efficacy of this combination. Biocompatibility tests confirmed safety and transparency assessments demonstrated excellent light transmission. Clinical evaluation with 598 enrollments demonstrated high accuracy of CEREBO® in detecting traumatic intracranial hemorrhage. During these evaluations, the cap fitted well and moved smoothly with the probes demonstrating appropriate flexibility. These findings support the efficacy of the CAPO® and CEREBO® combination, potentially improving infection control and enhancing intracranial hemorrhage detection for TBI patient triage. Ultimately, this can lead to better healthcare outcomes and reduced global HAIs.

Risk of unfavorable long-term outcome in older adults with traumatic intracranial hemorrhage and anticoagulant or antiplatelet use.

STUDY OBJECTIVE: The objective was to compare neurological outcomes at 6 months in older patients with preinjury warfarin or clopidogrel use and mild traumatic intracranial hemorrhage with those without prior use of these medications. METHODS: This was a retrospective study conducted at a Level 1 trauma center from April 2009 to July 2010. Patients older than 55 years with isolated mild head injury (Glasgow Coma Scale score 13-15 and Abbreviated Injury Score < 3 in nonhead body region) were included. Demographic, clinical, and outcome data were abstracted from an existing traumatic brain injury database. The primary end point of unfavorable extended Glasgow Outcome Score at 6 months was compared between patients with and without preinjury warfarin or clopidogrel use. RESULTS: Seventy-seven eligible patients were identified: 27 (35%) with preinjury warfarin or clopidogrel use and 50 (65%) without. Baseline characteristics (sex, Glasgow Coma Scale score, Injury Severity Score, computed tomography score, and in-hospital mortality) were similar between cohorts, although the preinjury warfarin or clopidogrel cohort was older than the control group (P < .05). Patients in the preinjury warfarin or clopidogrel cohort were more likely to have an unfavorable outcome (16/27; 59.3%; 95% confidence interval, 40.7%-77.8%) as compared with those without (18/50; 36.0%; 95% confidence interval, 22.7%-49.3%) (P = .05). CONCLUSION: Older adults with preinjury warfarin or clopidogrel use and mild traumatic intracranial hemorrhage may be at an increased risk for unfavorable long-term neurological outcomes compared with similar patients without preinjury use of these medications.

Safety of a DVT chemoprophylaxis protocol following traumatic brain injury: a single center quality improvement initiative.

BACKGROUND: Venous thromboembolism (VTE) is a complication that affects approximately 30 % of moderate and severe traumatic brain injury (TBI) patients when pharmacologic prophylaxis is not used. Following TBI, specifically in the case of contusions, the safety and efficacy of pharmacologic thromboembolism prophylaxis (PTP) has been studied only in small sample sizes. In this study, we attempt to assess the safety and efficacy of a PTP protocol for TBI patients, as a quality improvement (QI) initiative, in the neuroscience intensive care unit (NSICU). METHODS: Between January 1st and December 31st, 2009, consecutive patients discharged from the University of Wisconsin NSICU after >a 48 h minimum stay were evaluated as part of a QI project. A protocol for the initiation of PTP was designed and implemented for NSICU patients. The protocol did not vary based on type of intracranial injury. The rate of VTE was reported as was heparin-induced thrombocytopenia and PTP-related expansion of intracranial hemorrhage (IH) requiring reoperation. The number of patients receiving PTP and the timing of therapy were tracked. Patients were excluded for persistent coagulopathy, other organ system bleeding (such as the gastrointestinal tract), or pregnancy. Faculty could opt out of the protocol without reason. Using the same criteria, patients discharged during the preceding 6 months, from July 1st to December 31st, 2008, were evaluated as controls as the PTP protocol was not in effect during this time. RESULTS: During the control period, there were 48 head trauma admissions who met the inclusion criteria. In 22 patients (45.8 %), PTP was initiated at an average of 4.9 ± 5.4 days after admission. During the protocol period, there were 87 head trauma admissions taken from 1,143 total NSICU stays who met criteria. In 63 patients (72.4 %), the care team in the NSICU successfully initiated PTP, at an average of 3.4 ± 2.8 days after admission. All 87 trauma patients were analyzed, and the rate of clinically significant deep venous thrombosis (DVT) was 6.9 % (6 of 87). Three protocol patients (3.45 %) went to the operating room for surgery after the initiation of PTP; none of these patients had a measurable change in hemorrhage size on head CT. The change in percentage of patients receiving PTP was significantly increased by the protocol (p < 0.0001); while the average days to first PTP dose trended down with institution of the protocol, this change was not statistically significant. CONCLUSION: A PTP protocol in the NSICU is useful in controlling the number of complications from DVT and pulmonary embolism while avoiding additional IH. This protocol, based on a published body of literature, allowed for VTE rates similar to published rates, while having no PTP-related hemorrhage expansion. The protocol significantly changed physician behavior, increasing the percentage of patients receiving PTP during their hospitalization; whether long-term patient outcomes are affected is a potential goal for future study.

[Clinical picture, modern approaches in diagnostics of traumatic intracranial hematomas].

An analysis of 93 patients with traumatic intracranial hematomas of different degree of severity of craniocerebral trauma was made. The patients consist of 59 (63,4%) boys and 36 (36,6%) girls. In most cases, the cause of craniocerebral injury was a fall from variable-heights 56 (60,2%) patients. Cerebral symptoms dominate in examined children more than nidal symptoms. The evidence of meningeal symptoms was in direct proportion to the severity of brain contusion and disappeared by 7-8 days after trauma in majority of cases. In almost all cases, the traumatic intracranial hematomas were diagnosed on the basis of computerized tomographic system data. The choice of treatment strategy was determined according to neurological symptomatology and CT findings.