Initial Results of Empirical Cryoprecipitate Transfusion in the Treatment of Isolated Severe Traumatic Brain Injury: Use of In-house-produced Cryoprecipitate

Abstract

Acute coagulopathy is common after traumatic brain injury (TBI), particularly in severe cases of acute subdural hemorrhage (ASDH). Although acute coagulopathy is associated with poor outcomes, the optimal treatment strategy remains unknown. Here, we report the initial results of an empirical cryoprecipitate transfusion strategy that we developed as an early intervention for acute coagulopathy after TBI. We performed chart reviews of adult patients (aged ≥18 years) who received early cryoprecipitate transfusion after admission to our institution with a diagnosis of severe TBI (Glasgow Coma Scale ≤8) and ASDH from March 2013 to December 2016. We compared the outcomes of these patients with those who were treated before the implementation of the cryoprecipitate transfusion strategy (January 2011–February 2013). During the study period, 33 patients received early cryoprecipitate transfusion and no acute transfusion-related adverse event was reported. The rate of coagulopathy development within 24 h after admission was lower in these patients (23%) than in the controls (49%), but the difference was not significant (P = 0.062). The in-hospital mortality rate was 36% in patients receiving early cryoprecipitate transfusion and 52% in controls. After adjusting for confounding factors, the in-hospital mortality rate was significantly lower in the intervention period [adjusted odds ratio: 0.25, 95% confidence interval (CI): 0.08–0.78, P = 0.017]. In summary, we analyzed initial results of a cryoprecipitate transfusion strategy in patients with severe isolated TBI and ASDH. No acute transfusion-related adverse event was observed, and early transfusion of the in-house-produced cryoprecipitate may have reduced rates of coagulopathy development and in-hospital mortality.

Coagulopathy and Traumatic Brain Injury: Overview of New Diagnostic and Therapeutic Strategies

“…There are only a few small observational studies on the administration of cryoprecipitate 59 , 60 ) or fibrinogen concentrate 61 ) in TBI patients, and the effects are not clear. In Japan, the correction of acquired hypofibrinogenemia by fibrinogen concentrates and cryoprecipitates has not been approved.…”

Controversies and evidence gaps in the early management of severe traumatic brain injury: back to the ABCs

“… 80 Cryoprecipitate is another promising blood product that has shown favorable results, both in isolated and polytrauma TBI, in two small studies based out of Japan. 81 82 There is a growing initiative, initially inspired by the military medicine philosophy of ‘walking blood banks’, to use fresh WB. It is believed to achieve hemostatic resuscitation with less requirement for blood transfusion while avoiding the anticoagulant additives of balanced blood component therapy.…”

Fibrinolysis in Traumatic Brain Injury: Diagnosis, Management, and Clinical Considerations

“…98 It has been proposed that this effect is a result of the antifibrinolytic effect of factor XIII exerted through plasmin inhibitor interaction, as well as restoration of fibrinogen, the first clotting factor exhausted in posttraumatic coagulopathy. 99 Administration of cryoprecipitate <90 minutes postinjury has been shown to reduce 24-hour mortality in trauma patients with severe TBI. 100 Similarly, in a small retrospective study, early empiric transfusion of cryoprecipitate in patients with severe TBI was associated with reduced in-hospital mortality.…”

“…100 Similarly, in a small retrospective study, early empiric transfusion of cryoprecipitate in patients with severe TBI was associated with reduced in-hospital mortality. 99 Lower administration volume and concentrated protein components represent potential advantages over FFP, particularly for achieving targeted fibrinogen restoration in the context of hyperfibrinolysis after TBI. However, excess fibrinogen may trigger a proinflammatory response, leading to vascular remodeling and impaired healing after TBI.…”