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Coagulopathy in Penetrating Ballistic Cranial Trauma: A 7-Year Experience
Ahmad Alhourani1, Tyler L Stephenson1, Elizabeth M Bridwell1
1Department of Neurosurgery, University of Louisville, Louisville , Kentucky , USA.
Insights
Nearly half of patients with penetrating ballistic cranial trauma (PBCT) develop coagulopathy, a condition linked to severe injuries and higher mortality. Thromboelastography may improve coagulopathy detection and guide treatment in these critical cases.
Area of Science:
- Trauma Surgery
- Emergency Medicine
- Hematology
Background:
- Penetrating ballistic cranial trauma (PBCT) is associated with higher mortality than blunt trauma.
- Coagulopathy is a significant predictor of mortality in PBCT patients.
- Understanding coagulopathy incidence and risk factors is crucial for improving outcomes.
Purpose of the Study:
- To determine the incidence and risk factors of coagulopathy in PBCT.
- To evaluate the effectiveness of tranexamic acid in PBCT patients.
- To explore the utility of thromboelastography in identifying coagulopathy.
Main Methods:
- Retrospective analysis of 270 PBCT patients from a Level 1 trauma center (2016-2023).
- Assessment of coagulopathy development and its correlation with injury patterns and laboratory values.
- Evaluation of tranexamic acid administration and use of thromboelastography.
Main Results:
- 47% of PBCT patients developed coagulopathy upon presentation.
- Coagulopathy was associated with more severe injury patterns (bihemispheric, transventricular) and larger base deficits.
- Tranexamic acid did not impact coagulopathy development; thromboelastography identified additional coagulopathic patients.
Conclusions:
- Coagulopathy is highly prevalent in PBCT and can be persistent.
- Thromboelastography offers increased sensitivity for coagulopathy detection compared to conventional tests.
- Significant base deficit on arterial blood gas is a risk factor for coagulopathy in PBCT.
Background And Objectives:
Penetrating ballistic cranial trauma (PBCT) carries significant mortality when compared with blunt trauma. The development of coagulopathy in PBCT is a strong predictor of mortality. The goal of the study was to describe the incidence and risk factors of coagulopathy in PBCT and to report the value of tranexamic acid administration in PBCT.
Methods:
We retrospectively analyzed 270 patients who presented with PBCT to a single, Level 1 trauma center between 2016 and 2023.
Results:
A total of 47% (127/270) of patients with PBCT developed coagulopathy at presentation. Fifty-seven patients received tranexamic acid at presentation, which did not affect the development of coagulopathy. Coagulopathic patients were more likely to have more serious injury patterns (bihemispheric [adjusted odds ratio, aOR: 2.6 CI: 1.4-4.9, P = .004] or transventricular trajectories [aOR: 4.9 CI: 1.9-19.6, P = .03]). In addition, they presented with a larger base deficit (aOR: 0.9 CI: 1.002-1.2 per mEq/L, P = .006) which negatively correlated with the international normalized ratio (ρ: -0.46, P < .0001, Spearman correlation). Using thromboelastography helped to identify an additional 20% of patients who presented with normal coagulation on conventional testing.
Conclusion:
Coagulopathy is prevalent in approximately 50% of patients with PBCT and is persistent despite treatment in a substantial subset of patients. The addition of thromboelastography with its increased coagulopathy sensitivity can potentially guide treatment more efficiently than traditional coagulopathy laboratory tests and fibrinogen alone. Patients with a significant base deficit on arterial blood gas are at higher risk for coagulopathy.
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