Allard Christopher B, Scarpelini Sandro, Rhind Shawn G, Baker Andrew J, Shek Pang N, Tien Homer, Fernando Michael, Tremblay Lorraine, Morrison Laurie J, Pinto Ruxandra, Rizoli Sandro B
Department of Surgery and/or Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
J Trauma. 2009 Nov;67(5):959-67. doi: 10.1097/TA.0b013e3181ad5d37.
Intracranial hemorrhage (ICH) is common in traumatic brain injury (TBI) and a major determinant of death and disability. ICH commonly increases in size and coagulopathy has been implicated in such progression. We investigated the association between coagulopathy diagnosed by routine laboratory tests and ICH progression.
Subgroup post hoc analysis from a randomized controlled trial including adult patients with blunt severe TBI (Glasgow Coma Scale score <or=8) and repeat computerized tomography scans in 48 hours. Coagulopathy was defined as international normalized ratio >or=1.3, activated partial thromboplastin time >or=35, or platelet count (PLT) <or=100 x 10/L any time in the first 24 hours. Progression was any size increase or new ICH. TBI-associated coagulopathy was investigated measuring soluble tissue factor (TF) and d-dimer.
The ICH progressed in 37 of 72 patients (51%), in 80% if any abnormal laboratory test (coagulopathic patients) versus 36% in noncoagulopathic (p = 0.0004). Abnormal international normalized ratio (odds ratio [OR] = 4.09; 95% confidence interval [CI] = 1.29-12.95; p = 0.017), PLT (OR = 12.59; 95% CI = 1.52-108.57; p = 0.019), head Abbreviated Injury Scale (AIS) (OR = 1.82; 95% CI = 1.15-2.88; p = 0.011) were significantly associated with progression (univariate analysis). In a multiple logistic regression, only head AIS (OR = 1.81; 95% CI 1.10-2.98; p = 0.0198) and PLT (OR = 11.8; 95% CI = 1.38-101.23; p = 0.024) correlated with progression. All patients with abnormal partial thromboplastin time experienced progression. ICH progression carried a 5-fold higher odds of death; 32% with progression died versus 8.6% without. Age, head AIS, Injury Severity Score, and d-dimer were also associated with mortality. Tissue factor was not associated with progression or mortality.
This study demonstrates an association between coagulopathy, diagnosed by routine laboratorial tests in the first 24 hours, with ICH progression; and ICH progression with mortality in patients with severe TBI. The causal relationship between coagulopathy and ICH progression will require further studies.
颅内出血（ICH）在创伤性脑损伤（TBI）中很常见，是死亡和残疾的主要决定因素。ICH通常会增大，凝血病被认为与这种进展有关。我们研究了通过常规实验室检查诊断的凝血病与ICH进展之间的关联。
对一项随机对照试验进行亚组事后分析，该试验纳入了成年钝性重度TBI患者（格拉斯哥昏迷量表评分≤8），并在48小时内进行重复计算机断层扫描。凝血病定义为国际标准化比值≥1.3、活化部分凝血活酶时间≥35或血小板计数（PLT）在最初24小时内的任何时间≤100×10⁹/L。进展是指任何大小增加或新的ICH。通过测量可溶性组织因子（TF）和D-二聚体来研究TBI相关凝血病。
72例患者中有37例（51%）的ICH出现进展，凝血病患者（任何一项实验室检查异常）中80%出现进展，而非凝血病患者中为36%（p = 0.0004）。国际标准化比值异常（优势比[OR]=4.09；95%置信区间[CI]=1.29 - 12.95；p = 0.017）、PLT（OR = 12.59；95% CI = 1.52 - 108.57；p = 0.019）、头部简明损伤量表（AIS）（OR = 1.82；95% CI = 1.15 - 2.88；p = 0.011）与进展显著相关（单因素分析）。在多因素逻辑回归中，只有头部AIS（OR = 1.81；95% CI 1.10 - 2.98；p = 0.0198）和PLT（OR = 11.8；95% CI = 1.38 - 101.23；p = 0.024）与进展相关。所有活化部分凝血活酶时间异常的患者均出现进展。ICH进展使死亡几率高出5倍；进展患者中有32%死亡，而未进展患者中为8.6%。年龄、头部AIS、损伤严重程度评分和D-二聚体也与死亡率相关。组织因子与进展或死亡率无关。
本研究表明，在最初24小时通过常规实验室检查诊断的凝血病与ICH进展之间存在关联；并且严重TBI患者中ICH进展与死亡率之间存在关联。凝血病与ICH进展之间的因果关系需要进一步研究。
