Department of Neurosurgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA; Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.
Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.
World Neurosurg. 2022 Mar;159:221-236.e4. doi: 10.1016/j.wneu.2021.10.180. Epub 2021 Nov 27.
Coagulopathy in traumatic brain injury (TBI) occurs frequently and is associated with poor outcomes. Conventional coagulation assays (CCA) traditionally used to diagnose coagulopathy are often not time sensitive and do not assess complete hemostatic function. Viscoelastic hemostatic assays (VHAs) including thromboelastography and rotational thromboelastography provide a useful rapid and comprehensive point-of-care alternative for identifying coagulopathy, which is of significant consequence in patients with TBI with intracranial hemorrhage.
A systematic review was performed in accordance with PRISMA guidelines to identify studies comparing VHA with CCA in adult patients with TBI. The following differences in outcomes were assessed based on ability to diagnose coagulopathy: mortality, need for neurosurgical intervention, and progression of traumatic intracranial hemorrhage (tICH).
Abnormal reaction time (R time), maximum amplitude, and K value were associated with increased mortality in certain studies but not all studies. This association was reflected across studies using different statistical parameters with different outcome definitions. An abnormal R time was the only VHA parameter found to be associated with the need for neurosurgical intervention in 1 study. An abnormal R time was also the only VHA parameter associated with progression of tICH. Overall, many studies also reported abnormal CCAs, mainly activated partial thromboplastin time, to be associated with poor outcomes.
Given the heterogenous nature of the available evidence including methodology and study outcomes, the comparative difference between VHA and CCA in predicting rates of neurosurgical intervention, tICH progression, or mortality in patients with TBI remains inconclusive.
创伤性脑损伤（TBI）常伴有凝血功能障碍，且与预后不良相关。传统的用于诊断凝血功能障碍的常规凝血检测（CCA）通常不敏感，也不能评估完整的止血功能。包括血栓弹力图和旋转血栓弹力图在内的黏弹性止血检测（VHA）为识别凝血功能障碍提供了一种有用的快速、全面的即时护理替代方法，对于伴有颅内出血的 TBI 患者具有重要意义。
按照 PRISMA 指南进行系统评价，以确定比较 VHA 与 CCA 在 TBI 成年患者中的研究。根据诊断凝血功能障碍的能力评估以下结局的差异：死亡率、需要神经外科干预和创伤性颅内出血（tICH）进展。
某些研究中异常的反应时间（R 时间）、最大振幅和 K 值与死亡率增加相关，但并非所有研究均如此。这种关联在使用不同的统计参数和不同的结局定义的研究中均有体现。在 1 项研究中，异常的 R 时间是唯一与需要神经外科干预相关的 VHA 参数。异常的 R 时间也是唯一与 tICH 进展相关的 VHA 参数。总体而言，许多研究还报告了异常的 CCA，主要是活化部分凝血活酶时间，与不良结局相关。
鉴于现有证据的异质性，包括方法学和研究结局，VHA 与 CCA 在预测 TBI 患者神经外科干预、tICH 进展或死亡率的发生率方面的差异仍不确定。
