gms | German Medical Science

Objective: Trauma induced coagulopathy (TIC) is a therapeutic challenge in patients with isolated blunt traumatic brain injury (iTBI). TIC is a separate entity from other causes of coagulopathy such as preinjury anticoagulation. We undertook this observational prospective study 1) to assess the impact of TIC on neurological outcome, 2) to elucidate predictive factors for hemorrhagic progression (HP). We compared TIC with two other cohorts: patients with a preinjury anticoagulation (referred to as medication induced coagulopathy MIC) and patients with an intact coagulation (referred to as non-coagulopathic NC).

Methods: 314 adult patients with an iTBI were included in the study between 2008-2015. Three cohorts were built: TIC (n92), MIC (n112) and NC (n110). Coagulation test included INR, aPTT, fibrinogen, Factor XIII, D-Dimers and platelet count. TIC was defined as any deviation from the norm. Patient demographics, GCS, pupillary status, CT scans, coagulation tests, substitution of procoagulant factors and platelets, patient outcome at discharge and at 6 months were analyzed. Multiple logistic regression, log rank test, Cox regression were performed to identify the predictors for a poor outcome, survival and HP. The analysis was also conducted after adjustment for age (<60 yrs; ≥60 yrs; data not shown in the abstract).

Results: We saw a significant association between severity of iTBI and TIC (p=0.001). 51.4% of deaths attributed to iTBI was associated with TIC (p=0.006). Patients with MIC were older than the other cohorts (median age 75 vs 50 in TIC and 56 in NC, p<0.001). Overall, patients with MIC had shorter cumulative survival than the other cohorts, but there was no significant difference between TIC and MIC. Besides, Cox regression revealed that MIC and NC had significant higher odds of survival when compared to TIC. The higher age of MIC might have biased the results. 51.1% of patients with a poor outcome at 6 months was in the TIC (p=0.005). Age >60 yrs, GCS3-12, HP and brain contusions were independent predictors of a poor outcome at 6 months. Contrary to our expectations, we did not observe a significant difference in the frequency of HP in the cohorts; TIC, MIC and NC had comparable distributions (57.6% vs 56.2% vs 43.6%). The urgency to substitute procoagulant factors, age > 60 yrs, brain contusions were significant independent predictors for HP. A separate analysis excluding MIC showed that a sustained TIC was an independent predictor of death and poor outcome; only normalization of TIC was an independent predictor of a favorable outcome (OR 16.95).

Conclusion: In this first prospective observational study comparing TIC and MIC, our results underline the importance of detecting TIC and its urgent therapy. Although prospective, the study was observational and did not stick to a treatment regime. Further prospective research will shed more light on pathopyhsiology and treatment algorithms.