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The incidence and outcomes of hyperacute cardiovascular dysfunction following isolated traumatic brain injury: an
Flora Bird1, Mark Wilson2, Shadman Aziz3
1London's Air Ambulance, The Royal London Hospital, Barts NHS Trust, London, United Kingdom.
Insights
One in five patients with severe isolated traumatic brain injury (iTBI) experience early cardiovascular dysfunction (CVD), leading to higher mortality and coagulopathy. Outcomes vary significantly across iTBI severity, necessitating further research.
Area of Science:
- Neuroscience
- Cardiology
- Trauma Surgery
Background:
- The impact of early cardiovascular dysfunction (CVD) on outcomes in isolated traumatic brain injury (iTBI) remains incompletely understood.
- Severe iTBI patients often present with complex physiological derangements requiring comprehensive assessment.
Purpose of the Study:
- To determine the prevalence and characteristics of CVD in the hyper-acute phase of severe iTBI.
- To compare treatment strategies and patient outcomes between iTBI patients with and without early CVD.
Main Methods:
- Observational cohort study of severe iTBI patients (Head AIS 3+) from a level 1 trauma center and air ambulance service.
- CVD defined by tachycardia or bradycardia with hypotension; data collected on physiology, labs, transfusions, and CT scans.
- Primary outcomes included 28-day mortality and Glasgow Outcome Score (GOS).
Main Results:
- 20% of 168 severe iTBI patients exhibited early CVD, characterized by greater shock (lactate) and coagulopathy.
- CVD patients required more transfusions and had higher rates of hypoxic ischemic encephalopathy (HIE).
- Overall mortality was significantly higher in the CVD group (61% vs. 31%), though not in the most severe head injury subgroup (AIS 5).
Conclusions:
- Early CVD is prevalent in severe iTBI, associated with increased mortality, coagulopathy, and HIE.
- Outcomes for iTBI patients with CVD are highly variable across the spectrum of injury severity.
- Further research is crucial to elucidate the pathophysiology and optimize treatment for iTBI patients with CVD.
Background:
The relationship between early cardiovascular dysfunction (CVD) in isolated traumatic brain injury (iTBI) and outcome has not been fully described. We aimed to (1) determine the prevalence and phenotype of CVD after iTBI in the hyper-acute phase and (2) compare treatment and outcomes in those with CVD vs non-CVD.
Methods:
An observational cohort database study of severe iTBI patients (Head AIS 3+) at a level 1 trauma centre (2008-2019) and physician-led air ambulance service (2019-2020). CV dysfunction was defined as tachycardia or bradycardia, with hypotension. Physiology, laboratory results, 24-hour transfusion, and computer-topography (CT) findings were recorded. Outcomes were 28-day mortality and Glasgow Outcome Score (GOS).
Results:
A total of 168 patients met inclusion criteria, average age 46 years (IQR 30-61), 77% male, median ISS 25 (IQR 17-29) with 51% Head AIS 5. Time from injury to pre-hospital assessment was 31 minutes (IQR 20-42) with 20% demonstrating CVD on initial observations. The CVD group were more shocked (lactate 6.1 (1.7-10.9) vs. 2.4 (1.4-3.3), P < 0.001) and coagulopathic (43% vs. 15%, P = 0.001). There was no difference in Head AIS or CT findings between groups, except frequency of hypoxic ischemic encephalopathy (HIE) (CVD: 21% vs. non-CVD: 1%, P < 0.001). 24-hour transfusion was higher in CVD patients: 3 (0-8) vs. 0 (0-0) units, P < 0.001. Mortality was greater in CVD vs non-CVD iTBI (61% vs. 31%, P = 0.002), but in patients with AIS 5 there was no difference ( P = 0.262). One-third of CVD survivors (13/33) were discharged home, and 4/18 patients with recorded GOS had good neurological outcome.
Conclusion:
One in five patients with severe iTBI develop early CVD, associated with increased mortality, coagulopathy, and HIE. However, mortality and neurological outcome is highly variable in those with CVD across the iTBI severity spectrum. Further research is needed to define the pathophysiology and optimal treatment to improve outcomes for this subgroup of iTBI.
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