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

• Published in: Acta neurologica Belgica Vol. 123; no. 1; pp. 161 - 171
• Main Authors: Tsuneoka, Haruka, Tosaka, Masahiko, Nakata, Satoshi, Ishii, Nobukazu, Osawa, Sho, Shimauchi-Ohtaki, Hiroya, Honda, Fumiaki, Yoshimoto, Yuhei
• Format: Journal Article
• Language: English
• Published: Cham Springer International Publishing 01.02.2023
• Subjects: Anemia - complications; Biomedical and Life Sciences; Biomedicine; Brain Edema; Brain Injuries, Traumatic - complications; Brain Injuries, Traumatic - diagnostic imaging; Brain Injuries, Traumatic - surgery; Craniotomy - adverse effects; Hematoma - etiology; Humans; Intracranial Hemorrhage, Traumatic - complications; Intracranial Hemorrhage, Traumatic - diagnostic imaging; Intracranial Hemorrhage, Traumatic - surgery; Medicine/Public Health; Neurology; Neuroradiology; Neurosciences; Original Article; Persistent Vegetative State - complications; Retrospective Studies; Thrombocytopenia - complications; Thrombocytopenia; Craniotomy; Traumatic brain injury; Outcome; Coagulopathy
• ISSN: 0300-9009; 2240-2993
• DOI: 10.1007/s13760-021-01786-z

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 × 10 9 /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.