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Emergent surgical evacuation of traumatic intracranial hematoma in patients with preoperative thrombocytopenia: surgical risk and early outcome

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Abstract

Background

Surgical evacuation of intracranial hematoma, including epidural, subdural, intracerebral, and intraventricular hematoma, is recommended in patients with traumatic brain injury (TBI) for prevention of cerebral herniation and possible saving of life. However, preoperative coagulopathy is a major concern for emergent surgery on patients with severe TBI.

Methods

We reviewed 65 consecutive patients with severe TBI who underwent emergency craniotomy for intracranial hematomas.

Results

Univariate analysis showed preoperative pupil abnormality, absence of pupil light reflex, respiratory failure, preoperative thrombocytopenia (< 100 × 109/L), increased activated partial thromboplastin time (> 36 s), low fibrinogen (< 150 mg/dL), platelet transfusion, red cell concentrate transfusion, and presence of brain contusion and traumatic subarachnoid hemorrhage (SAH) on computed tomography were correlated with poor outcome (death or vegetative state). Multivariate analysis revealed that pupil abnormality (p = 0.001; odds ratio [OR] 0.064, 95% confidence interval [CI] 0.012–0.344), preoperative thrombocytopenia (p = 0.016; OR 0.101, 95% CI 0.016–0.656), and traumatic SAH (p = 0.021; OR 0.211, 95% CI 0.057–0.791) were significant factors. Investigation of the 14 patients with preoperative thrombocytopenia found the emergency surgery was successful, with no postoperative bleeding during hospitalization. However, half of the patients died, and almost a quarter remained in the vegetative state mainly associated with severe cerebral edema.

Conclusions

Emergent craniotomy for patients with severe TBI who have preoperative thrombocytopenia is often successful, but the prognosis is often poor. Emergency medical care teams and neurosurgeons should be aware of this discrepancy between successful surgery and poor prognosis in these patients. Further study may be needed on the cerebral edema regulator function of platelets.

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References

  1. Bullock MR, Chesnut R, Ghajar J, Gordon D, Hartl R, Newell DW et al (2006) Surgical management of traumatic brain injury author group, surgical management of acute epidural hematomas. Neurosurgery 58:S7–S15

    PubMed  Google Scholar 

  2. Bullock MR, Chesnut R, Ghajar J, Gordon D, Hartl R, Newell DW et al (2006) Surgical management of traumatic brain injury author group: surgical management of acute subdural hematomas. Neurosurgery 58:S16–S24

    PubMed  Google Scholar 

  3. Bullock MR, Chesnut R, Ghajar J, Gordon D, Hartl R, Newell DW et al (2006) Surgical management of traumatic brain injury author group: surgical management of traumatic parenchymal lesions. Neurosurgery 58:S25–S46

    PubMed  Google Scholar 

  4. Hutchinson PJ, Kolias AG, Tajsic T, Adeleye A, Aklilu AT, Apriawan T et al (2019) Consensus statement from the International consensus meeting on the role of decompressive craniectomy in the management of traumatic brain injury: consensus statement. Acta Neurochir (Wien) 161:1261–1274

    Article  PubMed  Google Scholar 

  5. Harhangi BS, Kompanje EJ, Leebeek FW, Maas AI (2008) Coagulation disorders after traumatic brain injury. Acta Neurochir (Wien) 150:165–175

    Article  CAS  PubMed  Google Scholar 

  6. Talving P, Benfield R, Hadjizacharia P, Inaba K, Chan LS, Demetriades D (2009) Coagulopathy in severe traumatic brain injury: a prospective study. J Trauma 66:55–61

    PubMed  Google Scholar 

  7. Zhang J, Jiang R, Liu L, Watkins T, Zhang F, Dong JF (2012) Traumatic brain injury-associated coagulopathy. J Neurotrauma 29:2597–2605

    Article  PubMed  PubMed Central  Google Scholar 

  8. Zhang J, Zhang F, Dong JF (2018) Coagulopathy induced by traumatic brain injury: systemic manifestation of a localized injury. Blood 131:2001–2006

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  9. Armand R, Hess JR (2003) Treating coagulopathy in trauma patients. Transfus Med Rev 17:223–231

    Article  PubMed  Google Scholar 

  10. de Oliveira Manoel AL, Neto AC, Veigas PV, Rizoli S (2015) Traumatic brain injury associated coagulopathy. Neurocrit Care 22:34–44

    Article  PubMed  Google Scholar 

  11. Yuan Q, Yu J, Wu X, Sun YR, Li ZQ, Du ZY et al (2018) Prognostic value of coagulation tests for in-hospital mortality in patients with traumatic brain injury. Scand J Trauma Resusc Emerg Med 26:3

    Article  PubMed  PubMed Central  Google Scholar 

  12. Chan KH, Mann KS, Chan TK (1989) The significance of thrombocytopenia in the development of postoperative intracranial hematoma. J Neurosurg 71:38–41

    Article  CAS  PubMed  Google Scholar 

  13. Maegele M, Schöchi H, Menovsky T, Maréchal H, Marklund N, Buki A et al (2017) Coagulopathy and haemorrhagic progression in traumatic brain injury: advances in mechanisms, diagnosis, and management. Lancet Neurol 16:630–647

    Article  PubMed  Google Scholar 

  14. Lorente L, Martín MM, González-Rivero AF, Pérez-Cejas A, Abreu-González P, Ramos L et al (2020) Association between DNA and RNA oxidative damage and mortality of patients with traumatic brain injury. Neurocrit Care 32:790–795

    Article  CAS  PubMed  Google Scholar 

  15. Choi SP, Park HK, Park KN, Kim YM, Ahn KJ, Choi KH et al (2008) The density ratio of grey to white matter on computed tomography as an early predictor of vegetative state or death after cardiac arrest. Emerg Med J 25:666–669

    Article  CAS  PubMed  Google Scholar 

  16. Gura M, Elmaci I, Sari R, Coskun N (2011) Correlation of pulsatility index with intracranial pressure in traumatic brain injury. Turk Neurosurg 21:210–215

    PubMed  Google Scholar 

  17. Kaloostian P, Robertson C, Gopinath SP, Stippler M, King CC, Qualls C et al (2012) Outcome prediction within twelve hours after severe traumatic brain injury by quantitative cerebral blood flow. J Neurotrauma 29:727–734

    Article  PubMed  PubMed Central  Google Scholar 

  18. Nakagawa K, Hoshide RR, Asai SM, Johnson KG, Beniga JG, Albano MC et al (2013) Favorable outcomes for Native Hawaiians and other Pacific Islanders with severe traumatic brain injury. Hawaii J Med Public Health 72:129–135

    PubMed  PubMed Central  Google Scholar 

  19. Shibahashi K, Sugiyama K, Hoda H, Hamabe Y (2017) Skeletal muscle as a factor contributing to better stratification of older patients with traumatic brain injury: a retrospective cohort study. World Neurosurg 106:589–594

    Article  PubMed  Google Scholar 

  20. Hawryluk GWJ, Rubiano AM, Totten AM, O’Reilly C, Ullman JS, Bratton SL et al (2020) Guidelines for the management of severe traumatic brain injury: 2020 update of the decompressive craniectomy recommendations. Neurosurgery 87:427–434

    Article  PubMed  PubMed Central  Google Scholar 

  21. Trauma B, Foundation; American Association of Neurological Surgeons (AANS); Congress of Neurological Surgeons (CNS); AANS, CNA Joint Section on Neurotrauma and Critical Care (2007) Guidelines for the management of severe traumatic brain injury. J Neurotrauma 24(Suppl 1):S1–S106

    Google Scholar 

  22. Cooper SW, Bethea KB, Skrobut TJ, Gerardo R, Herzing K, Torres-Reveron J et al (2019) Management of traumatic subarachnoid hemorrhage by the trauma service: is repeat CT scanning and routine neurosurgical consultation necessary? Trauma Surg Acute Care Open 4: e000313

  23. Kerezoudis P, Goyal A, Puffer RC, Parney IF, Meyer FB, Bydon M (2020) Morbidity and mortality in elderly patients undergoing evacuation of acute traumatic subdural hematoma. Neurosurg Focus 49:E22

    Article  PubMed  Google Scholar 

  24. Prasad GL, Anmol N, Menon GR (2018) Outcome of traumatic brain injury in the elderly population: a tertiary center experience in a developing country. World Neurosurg 111:e228–e234

    Article  PubMed  Google Scholar 

  25. Nakae R, Takayama Y, Kuwamoto K, Naoe Y, Sato H, Yokota H (2016) Time course of Coagulation and fibrinolytic parameters in patients with traumatic brain injury. J Neurotrauma 33:688–695

    Article  PubMed  Google Scholar 

  26. Kumar MA (2013) Coagulopathy associated with traumatic brain injury. Curr Neurol Neurosci Rep 13:391

    Article  PubMed  Google Scholar 

  27. Schnüriger B, Inaba K, Abdelsayed GA, Lustenberger T, Eberle BM, Barmparas G et al (2010) The impact of platelets on the progression of traumatic intracranial hemorrhage. J Trauma 68:881–885

    PubMed  Google Scholar 

  28. Carrick MM, Tyroch AH, Youens CA, Handley T (2005) Subsequent development of thrombocytopenia and coagulopathy in moderate and severe head injury: support for serial laboratory examination. J Trauma 58:725–729

    Article  PubMed  Google Scholar 

  29. Lustenberger T, Talving P, Kobayashi L, Inaba K, Lam L, Plurad D et al (2010) Time course of coagulopathy in isolated severe traumatic brain injury. Injury 41:924–928

    Article  PubMed  Google Scholar 

  30. Folkerson LE, Sloan D, Cotton BA, Holcomb JB, Tomasek JS, Wade CE (2015) Predicting progressive hemorrhagic injury from isolated traumatic brain injury and coagulation. Surgery 158:655–661

    Article  PubMed  Google Scholar 

  31. Liu J, Tian HL (2016) Relationship between trauma-induced coagulopathy and progressive hemorrhagic injury in patients with traumatic brain injury. Chin J Traumatol 19:172–175

    Article  PubMed  PubMed Central  Google Scholar 

  32. Suzuki-Inoue K, Fuller GL, García A, Eble JA, Pöhlmann S, Inoue O et al (2006) A novel Syk-dependent mechanism of platelet activation by the C-type lectin receptor CLEC-2. Blood 107:542–549

    Article  CAS  PubMed  Google Scholar 

  33. Herzog BH, Fu J, Wilson SJ, Hess PR, Sen A, McDaniel JM et al (2013) Podoplanin maintains high endothelial venule integrity by interacting with platelet CLEC-2. Nature 502:105–109

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  34. Boulaftali Y, Hess PR, Getz TM, Cholka A, Stolla M, Mackman N et al (2013) Platelet ITAM signaling is critical for vascular integrity in inflammation. J Clin Invest 123:908–916

    CAS  PubMed  PubMed Central  Google Scholar 

  35. Gao C, Wang H, Wang T, Luo C, Wang Z, Zhang M et al (2020) Platelet regulates neuroinflammation and restores blood-brain barrier integrity in a mouse model of traumatic brain injury. J Neurochem 154:190–204

    Article  CAS  PubMed  Google Scholar 

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Funding

No funding or support was supplied for this work.

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Authors and Affiliations

  1. Department of Neurosurgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan

    Haruka Tsuneoka, Masahiko Tosaka, Satoshi Nakata, Nobukazu Ishii, Sho Osawa, Hiroya Shimauchi-Ohtaki, Fumiaki Honda & Yuhei Yoshimoto

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  1. Haruka Tsuneoka
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  2. Masahiko Tosaka
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  3. Satoshi Nakata
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  4. Nobukazu Ishii
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  5. Sho Osawa
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  6. Hiroya Shimauchi-Ohtaki
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  7. Fumiaki Honda
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  8. Yuhei Yoshimoto
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Contributions

Conception and design: TM; Acquisition of data: TH, NS, IN, HF; Analysis and interpretation of data: TH, NS, IN, OS, S-OH; Drafting the article: TM, TH; Critically revising the article: HF, YY; Approved the final version of the manuscript on behalf of all authors: TH, TM, YY; Statistical analysis: TH, OS, S-OH; Study supervision: YY.

Corresponding author

Correspondence to Masahiko Tosaka.

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The authors declare they have no conflict of interest.

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This study was conducted under the institutional review board approval (HS2020-264).

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Written informed consent was not obtained due to the retrospective manner of the study. Alternatively, this study was carried out by the opt-out method of our department website.

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Tsuneoka, H., Tosaka, M., Nakata, S. et al. Emergent surgical evacuation of traumatic intracranial hematoma in patients with preoperative thrombocytopenia: surgical risk and early outcome. Acta Neurol Belg 123, 161–171 (2023). https://doi.org/10.1007/s13760-021-01786-z

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  • DOI: https://doi.org/10.1007/s13760-021-01786-z

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