Prognostic significance of abnormal hematological parameters in severe traumatic brain injury requiring decompressive craniectomy

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OBJECTIVE

Hematological abnormalities after severe traumatic brain injury (TBI) are common, and are associated with a poor outcome. Whether these abnormalities offer additional prognostic significance over and beyond validated TBI prognostic models is uncertain.

METHODS

This retrospective cohort study compared the ability of admission hematological abnormalities to that of the IMPACT (International Mission for Prognosis and Analysis of Clinical Trials) prognostic model to predict 18-month neurological outcome of 388 patients who required a decompressive craniectomy after severe TBI, between 2004 and 2016, in Western Australia. Area under the receiver operating characteristic (AUROC) curve was used to assess predictors’ ability to discriminate between patients with and without an unfavorable outcome of death, vegetative state, or severe disability.

RESULTS

Of the 388 patients included in the study, 151 (38.9%) had an unfavorable outcome at 18 months after decompressive craniectomy for severe TBI. Abnormalities in admission hemoglobin (AUROC 0.594, p = 0.002), plasma glucose (AUROC 0.592, p = 0.002), fibrinogen (AUROC 0.563, p = 0.036), international normalized ratio (INR; AUROC 0.645, p = 0.001), activated partial thromboplastin time (AUROC 0.564, p = 0.033), and disseminated intravascular coagulation score (AUROC 0.623, p = 0.001) were all associated with a higher risk of unfavorable outcome at 18 months after severe TBI. As a marker of inflammation, neutrophil to lymphocyte ratio was not significantly associated with the risk of unfavorable outcome (AUROC 0.500, p = 0.998). However, none of these parameters, in addition to the platelet count, were significantly associated with an unfavorable outcome after adjusting for the IMPACT predicted risk (odds ratio [OR] per 10% increment in risk 2.473, 95% confidence interval [CI] 2.061–2.967; p = 0.001). After excluding 8 patients (2.1%) who were treated with warfarin prior to the injury, there was a suggestion that INR was associated with some additional prognostic significance (OR 3.183, 95% CI 0.856–11.833; p = 0.084) after adjusting for the IMPACT predicted risk.

CONCLUSIONS

In isolation, INR was the best hematological prognostic parameter in severe TBI requiring decompressive craniectomy, especially when patients treated with warfarin were excluded. However, the prognostic significance of admission hematological abnormalities was mostly captured by the IMPACT prognostic model, such that they did not offer any additional prognostic information beyond the IMPACT predicted risk. These results suggest that new prognostic factors for TBI should be evaluated in conjunction with predicted risks of a comprehensive prognostic model that has been validated, such as the IMPACT prognostic model.

ABBREVIATIONS aPTT = activated partial thromboplastin time; AUROC = area under the receiver operating characteristic; CI = confidence interval; CRASH = Corticosteroid Randomization After Significant Head Injury; DIC = disseminated intravascular coagulation; GCS = Glasgow Coma Scale; GOS = Glasgow Outcome Scale; IMPACT = International Mission for Prognosis and Analysis of Clinical Trials; INR = international normalized ratio; NLR = neutrophil to lymphocyte ratio; OR = odds ratio; SAH = subarachnoid hemorrhage; TBI = traumatic brain injury.
Article Information

Contributor Notes

Correspondence Kwok M. Ho: Royal Perth Hospital, Perth, WA, Australia. kwok.ho@health.wa.gov.au.INCLUDE WHEN CITING Published online February 8, 2019; DOI: 10.3171/2018.10.JNS182293.Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
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References
  • 1

    Anglin COSpence JSWarner MAPaliotta CHarper CMoore C: Effects of platelet and plasma transfusion on outcome in traumatic brain injury patients with moderate bleeding diatheses. J Neurosurg 118:6766862013

    • Search Google Scholar
    • Export Citation
  • 2

    Baharoglu MICordonnier CAl-Shahi Salman Rde Gans KKoopman MMBrand A: Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH): a randomised, open-label, phase 3 trial. Lancet 387:260526132016

    • Search Google Scholar
    • Export Citation
  • 3

    Bauer DFMcGwin G JrMelton SMGeorge RLMarkert JM: The relationship between INR and development of hemorrhage with placement of ventriculostomy. J Trauma 70:111211172011

    • Search Google Scholar
    • Export Citation
  • 4

    Chang RFolkerson LESloan DTomasek JSKitagawa RSChoi HA: Early plasma transfusion is associated with improved survival after isolated traumatic brain injury in patients with multifocal intracranial hemorrhage. Surgery 161:5385452017

    • Search Google Scholar
    • Export Citation
  • 5

    Chen WYang JLi BPeng GLi TLi L: Neutrophil to lymphocyte ratio as a novel predictor of outcome in patients with severe traumatic brain injury. J Head Trauma Rehabil 33:E53E592018

    • Search Google Scholar
    • Export Citation
  • 6

    Dekker SEDuvekot Ade Vries HMGeeraedts LM JrPeerdeman SMde Waard MC: Relationship between tissue perfusion and coagulopathy in traumatic brain injury. J Surg Res 205:1471542016

    • Search Google Scholar
    • Export Citation
  • 7

    Greuters Svan den Berg AFranschman GViersen VABeishuizen APeerdeman SM: Acute and delayed mild coagulopathy are related to outcome in patients with isolated traumatic brain injury. Crit Care 15:R22011

    • Search Google Scholar
    • Export Citation
  • 8

    Han JKing NKNeilson SJGandhi MPNg I: External validation of the CRASH and IMPACT prognostic models in severe traumatic brain injury. J Neurotrauma 31:114611522014

    • Search Google Scholar
    • Export Citation
  • 9

    Hanley JAMcNeil BJ: A method of comparing the areas under receiver operating characteristic curves derived from the same cases. Radiology 148:8398431983

    • Search Google Scholar
    • Export Citation
  • 10

    Herbert JPGuillotte ARHammer RDLitofsky NS: Coagulopathy in the setting of mild traumatic brain injury: truths and consequences. Brain Sci 7:E922017

    • Search Google Scholar
    • Export Citation
  • 11

    Honeybul SHo KM: Predicting long-term neurological outcomes after severe traumatic brain injury requiring decompressive craniectomy: a comparison of the CRASH and IMPACT prognostic models. Injury 47:188618922016

    • Search Google Scholar
    • Export Citation
  • 12

    Honeybul SHo KMLind CRGillett GR: Validation of the CRASH model in the prediction of 18-month mortality and unfavorable outcome in severe traumatic brain injury requiring decompressive craniectomy. J Neurosurg 120:113111372014

    • Search Google Scholar
    • Export Citation
  • 13

    Maegele MSchöchl HMenovsky TMaréchal HMarklund NBuki A: Coagulopathy and haemorrhagic progression in traumatic brain injury: advances in mechanisms, diagnosis, and management. Lancet Neurol 16:6306472017

    • Search Google Scholar
    • Export Citation
  • 14

    Perel PArango MClayton TEdwards PKomolafe EPoccock S: Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients. BMJ 336:4254292008

    • Search Google Scholar
    • Export Citation
  • 15

    Rowell SEBarbosa RRLennox TCFair KARao AJUnderwood SJ: Moderate elevations in international normalized ratio should not lead to delays in neurosurgical intervention in patients with traumatic brain injury. J Trauma Acute Care Surg 77:8468512014

    • Search Google Scholar
    • Export Citation
  • 16

    Steyerberg EWMushkudiani NPerel PButcher ILu JMcHugh GS: Predicting outcome after traumatic brain injury: development and international validation of prognostic scores based on admission characteristics. PLoS Med 5:e1652008

    • Search Google Scholar
    • Export Citation
  • 17

    Tao CWang JHu XMa JLi HYou C: Clinical value of neutrophil to lymphocyte and platelet to lymphocyte ratio after aneurysmal subarachnoid hemorrhage. Neurocrit Care 26:3934012017

    • Search Google Scholar
    • Export Citation
  • 18

    Toh CHHoots WK: The scoring system of the Scientific and Standardisation Committee on Disseminated Intravascular Coagulation of the International Society on Thrombosis and Haemostasis: a 5-year overview. J Thromb Haemost 5:6046062007

    • Search Google Scholar
    • Export Citation
  • 19

    Wang FXu FQuan YWang LXia JJJiang TT: Early increase of neutrophil-to-lymphocyte ratio predicts 30-day mortality in patients with spontaneous intracerebral hemorrhage. CNS Neurosci Ther [epub ahead of print] 2018

    • Search Google Scholar
    • Export Citation
  • 20

    Yuan QSun YRWu XYu JLi ZQDu ZY: Coagulopathy in traumatic brain injury and its correlation with progressive hemorrhagic injury: a systematic review and meta-analysis. J Neurotrauma 33:127912912016

    • Search Google Scholar
    • Export Citation
  • 21

    Yuan QYu JWu XSun YRLi ZQDu ZY: Prognostic value of coagulation tests for in-hospital mortality in patients with traumatic brain injury. Scand J Trauma Resusc Emerg Med 26:32018

    • Search Google Scholar
    • Export Citation
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