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Updated: Sep 3, 2025
Author Spotlight: Deciphering Coagulation Disorders in Traumatic Brain Injury Patients
Published on: August 4, 2023
Association of Thromboelastography with Progression of Hemorrhagic Injury in Children with Traumatic Brain Injury
Elissa Abou Khalil1, Barbara A Gaines2, Robert G Kellogg3
1Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
Insights
Progression of hemorrhagic injury in children with traumatic brain injury is linked to longer Activated Clotting Time (ACT) measured by thromboelastography (TEG). Elevated TEG-ACT independently predicted PHI, suggesting it may be a therapeutic target.
Area of Science:
- Pediatric Traumatology
- Neurocritical Care
- Coagulation Medicine
Background:
- Progression of hemorrhagic injury (PHI) in pediatric traumatic brain injury (TBI) is associated with poor outcomes.
- The relationship between coagulation assays, including thromboelastography (TEG), and PHI in children is not well understood.
Purpose of the Study:
- To investigate the association between TEG parameters and PHI in pediatric TBI patients.
- To determine if specific TEG values are independent predictors of PHI.
Main Methods:
- Retrospective cohort study of children with PHI from 2015-2020.
- Analysis included rapid TEG (Activated Clotting Time [ACT], alpha angle, maximum amplitude, lysis at 30 min) and conventional coagulation tests.
- Multivariable logistic regression was used to identify independent predictors of PHI.
Main Results:
- PHI occurred in 25% of analyzed patients.
- Children with PHI had higher Injury Severity Scores and lower Glasgow Coma Scales.
- Elevated admission TEG-ACT was an independent predictor of PHI (OR 2.25, p=0.03), while other TEG values and INR were not.
Conclusions:
- Admission TEG-ACT is independently associated with PHI in pediatric TBI.
- Further research is needed to explore TEG-ACT as a potential therapeutic target for managing PHI.
Introduction:
Progression of hemorrhagic injury (PHI) in children with traumatic brain injury portends poor outcomes. The association between thromboelastography (TEG), functional coagulation assays, and PHI is not well characterized in children.
Methods:
This was a retrospective cohort study of children presenting with PHI at a pediatric level I academic trauma center from 2015 to 2020. Inclusion criteria were as follows: age less than 18 years, intracranial hemorrhage on admission head computed tomography scan, and admission rapid TEG assay and conventional coagulation tests. PHI was defined by the following radiographic criteria: any expansion of or new intracranial hemorrhage on subsequent head computed tomography scan. Rapid TEG values included Activated Clotting Time (ACT), alpha angle, maximum amplitude, and lysis at 30 min. Wilcoxon rank-sum test was used to assess baseline differences between groups with PHI and without PHI, including laboratory assays. Univariate analysis was performed to examine the association between variables of interest and PHI. Patients were dichotomized on the basis of this cut point to generate a "low ACT" group and a "high ACT" group. These variables were included in a multivariable logistic regression model to determine independent association with traumatic brain injury progression.
Results:
In total, 219 patients met criteria for analysis. In this cohort, the median (interquartile range [IQR]) age = 6 (2-12) years, median (IQR) Injury Severity Score = 21 (11-27), 68% were boys, and 69% sustained blunt injury. The rate of PHI was 25% (54). Median (IQR) time to PHI was 1 (0-4) days. Children with PHI had a higher Injury Severity Score (p < 0.001), lower Glasgow Coma Scale (p < 0.001), greater incidence of shock (p = 0.04), and lower admission hemoglobin (p = 0.02) compared with those without PHI. Children with PHI had a higher International Normalized Ratio (INR) and longer TEG-ACT; other TEG values (alpha angle, maximum amplitude, and lysis at 30 min) were not associated with PHI. In the logistic regression model accounting for other covariates associated with PHI, elevated ACT remained an independent predictor of progression (odds ratio = 2.25, 95% confidence interval 1.09-4.66; p = 0.03; area under the receiver operating characteristic curve = 0.76). After adjusting for confounders, INR fell out of the model and was not an independent predictor of progression (odds ratio = 1.32, 95% confidence interval 0.60-2.93; p = 0.49).
Conclusions:
Although INR was elevated in children with PHI and has been associated with poor clinical outcomes, only admission TEG-ACT was independently associated with PHI. Further study is warranted to determine whether TEG-ACT reflects an actionable therapeutic target.
