International normalized ratio and activated partial thromboplastin time can be predictors of expansive intracranial hematoma among traumatic brain injured patients in a tertiary centre in Uganda

Abstract

Abstract Background Trauma-induced coagulopathy (TIC) is a common problem among traumatic brain injury (TBI) patients which may contribute to expansive intracranial hematoma (EIH). However, there is limited evidence on whether raised international normalized ratio (INR) and activated partial thromboplastin time (aPTT) which may contribute to this problem. The study assessed the effects of changes in INR and aPTT on EIH among TBI patients at the Mulago National Referral Hospital (MNRH), Kampala, Uganda. Methods A cross sectional study was conducted among TBI patients with intracranial hematoma undergoing surgical evacuation during a period of 16th June 2021 to 17th December 2022. Plasma INR and aPTT levels were analysed at Mulago hospital clinical hematological laboratory unit on admission to the Accident and emergency. Demographic and hematological data were captured using the Research Electronic Data Capture (Redcap) system. Patients with high aPTT and INR on admission were monitored for hematoma enlargement complications until surgical evacuation decision making. The independent outcomes were the INR and an aPTT value. The dependent outcomes were hematomas enlargement of over 33% evidence by two CT scans (baseline and follow up) and demographic characteristic. Univariable and multivariable logistic regression analysis were used to identify variables associated with hematoma enlargement. Results Intracranial hematomas were observed in all 324 patients and of these 59.3% had EIH. Patients with EIH had a statistically different mean age from those without EIH (42.3 ± 17.9 vs. 30.5 ± 14.0 years, p < 0.001). About 79.7% were males in EIH group versus 81.7% in no EIH group. The main cause of EIH was road traffic crushes involving motorcycle riders (60.5%). Raised INR and a PTT were observed in 58.9% and 59.6% among patients respectively. At multivariate, for every unit increased in plasma INR value, risk of hematoma expansion increased by 3.76 times [β = 3.76, 95% CI: 0.936 to 0.981]. Similarly, every unit increased in plasma aPTT value, risk of hematoma expansion increased by 5.82 times [β = 5.82, 95% CI: 0.909 to 0.954]. Conclusion EIH, elevated INR and aPTT are common with a prevalence of 59.3%,58.9% and 59.6% among TBI patients respectively. Patients with raised INR, aPTT have 3.76- and 5.82-times higher risk of developing a EIH respectively when compared to controls. These findings imply routine plasma INR and aPTT levels monitoring and could form the basis for establishing a hematological control protocol for such patients in remote settings.