Prognostic impact of cardiac wall motion abnormalities after TBI: Association with pulmonary complications and cardiovascular comorbidities

Prognostic impact of cardiac wall motion abnormalities after TBI: Association with pulmonary complications and cardiovascular comorbidities | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Prognostic impact of cardiac wall motion abnormalities after TBI: Association with pulmonary complications and cardiovascular comorbidities Young Ju Lee, Jihye Song, Yong Cheol Lim This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7092075/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Cardiac injury is a well-recognized extracranial complication in patients with acute brain injury, yet limited data exist on its occurrence and clinical implications in traumatic brain injury (TBI). This study aimed to evaluate the incidence, associated risk factors, and outcomes of cardiac wall motion abnormalities (WMA) detected by echocardiography in patients with TBI. Methods: A retrospective observational study was conducted at a regional trauma center in South Korea. Patients admitted with TBI between 2019 and 2023 who underwent transthoracic echocardiography (TTE) were included. Cardiac injury was defined as newly appeared WMA on TTE. Demographics, clinical characteristics, cardiovascular comorbidities, complications, and Glasgow Outcome Scale-Extended (GOSE) scores were analyzed. Comparative analyses between WMA and non-WMA groups were performed using chi-square and t-tests, and univariate/multivariable logistic regression analyses were conducted to identify predictors of post-traumatic WMA and unfavorable outcomes. Results: Among 1,942 TBI patients, 659 underwent TTE, and after excluding preexisting WMA, 641 were analyzed. Of these, 41 patients (6.4%) demonstrated post-traumatic WMA. Patients with WMA had a significantly higher prevalence of cardiovascular comorbidities (75.6% vs. 56.0%, OR = 2.436, p = 0.014) and pulmonary complications (31.7% vs. 18.7%, OR = 2.023, p = 0.041). Severe TBI and major trauma were not significantly associated with WMA. The WMA group had lower mean GOSE scores (3.78 ± 1.90 vs. 4.19 ± 1.86), and a higher proportion of patients with poor outcomes (GOSE 1–2: 31.7% vs. 20.7%). Pulmonary complication was significantly associated with poor outcomes (OR = 2.433, p < 0.001). Conclusion: Cardiac WMA is not uncommon in TBI patients and may be associated with preexisting cardiovascular disease, increased pulmonary complications, and poor neurological outcomes. Early screening for cardiac injury in high-risk TBI patients may enable tailored treatment strategies and improve clinical outcomes. Brain Injuries Traumatic Cardiomyopathies Myocardial Stunning Echocardiography Multiple Trauma Comorbidity Glasgow Outcome Scale Critical Care Pleural Effusion Figures Figure 1 Introduction TBI is a significant global health burden, contributing to mortality and long-term quality of life ( 1 ). Aside the primary brain damage, TBI often leads to secondary dysfunction of extracranial organs, which can contribute to morbidity and adverse outcomes ( 2 ). Among these, cardiac injury is relatively well-known secondary dysfunction following primary injury of brain. Concepts such as “Catecholamine surge” or “Neurocardiac axis” have been proposed in previous studies to explain brain-heart interactions in acute brain injury ( 3 – 5 ). While such mechanisms have been extensively studied in context like subarachnoid hemorrhage, there remains a paucity of data regarding the incidence, prognostic implications, and risk factors specific to cardiac injury following TBI ( 6 , 7 ). This study aims to elucidate the prevalence and risk factors of secondary cardiac injury in TBI patients, thereby underscoring the need for early screening in patients with elevated risk and development of tailored treatment strategies to improve patient outcomes. This retrospective study adheres to ethical guidelines and has been approved by the institutional review board at Ajou university school of medicine. Patients and methods This retrospective, observational study was conducted in the Ajou university medical center, a regional trauma center located in the southern Gyeonggi province. Inclusion criteria were: (ⅰ) admission to Ajou university medical center between January 2019 and December 2023; (ⅱ) diagnosis of TBI; and (ⅲ) performance of TTE during hospitalization. Exclusion criteria were: (ⅰ) evidence of preexisting cardiac wall motion abnormalities on echocardiography performed prior to trauma; and (ⅱ) incomplete or missing essential clinical data in the medical records. Data was retrospectively collected from medical records and imaging archives. Variables reviewed included demographic factors, medical history, laboratory findings, Glasgow Coma Scale (GCS) score at admission, Injury Severity Score (ISS), complications during hospitalization, and discharge status. TTE was performed as deemed necessary by the attending physician, particularly in patients with known cardiovascular comorbidities or clinical signs of hemodynamic instability. Cardiac injury was defined as the presence of WMA on echocardiography. Among those with WMA, patients with prior echocardiographic reports presenting similar abnormalities were excluded and remaining patients were classified as presenting post-traumatic cardiac injury. Severe TBI was defined as a GCS score of 8 or less at presentation. Major trauma was defined as an ISS of 15 or higher. Troponin elevation was defined as rise in either troponin I or high-sensitivity troponin T levels in blood tests performed upon admission. The referance range for normal values were 0.000-0.046 ng/mL for troponin I and 0.000-0.013 ng/mL for high-sensitivity troponin T. Hypotension was defined as a systolic blood pressure of 90mmHg or lower at the time of presentation. Statistical analysis Statistical analysis was performed using IBM SPSS Statistics, version 29.0.2.0 (IBM Corp., Armonk, NY, USA). Categorical data were presented as frequency (%). Univariable and multivariable analysis were conducted to compare demographic and clinical variables between patients with and without WMA on echocardiography following trauma. The patients were classified into 2 groups for favorable GOSE score ( 3 – 8 ) and unfavorable GOSE score ( 1 – 2 ). Univariate and multivariable analyses were conducted to identify factors associated with unfavorable outcomes. Variables with a p -value of < 0.05 were considered statistically significant, and variables with a p -value < 0.2 in the univariable analysis or considered clinically significant were included in the multivariable logistic regression model to identify independent predictors. Results A total of 1,942 patients were hospitalized during the study period. Of these, TTE was performed in 659 (33.9%) patients. After excluding 18 patients who demonstrated similar WMA on echocardiography performed prior to admission, 641 patients were included in the final analysis. The study population selection process is illustrated in Figure 1. Table 1 summarizes the demographic and clinical characteristics, laboratory findings, trauma mechanisms, and TTE results of the 641 patients with TBI included in the study. Of these, 468 (73.1%) were male, and the mean age was 65.35 ± 16.48 years. Severe TBI, defined as a GCS score ≤ 8 at presentation, was observed in 234 patients (36.5%). Major trauma, defined as an ISS ≥ 15, was present in 540 (84.2%) patients. Forty-one patients (6.4%) demonstrated cardiac WMA. Cardiovascular comorbidities such as hypertension and coronary artery occlusive disease were present in 367 (57.3%) patients. During hospitalization, pulmonary complications including acute respiratory distress syndrome (ARDS) and pleural effusion occurred in 125 patients (19.5%). Among the included 641 patients included in the study, 304 (47.4%) underwent decompressive surgical procedure such as craniectomy or craniotomy. The distribution of GOSE scores was as follows: 149 patients (23.2%) had scores of 1-2, 199 patients (31.0%) had scores of 3-4, 219 patients (34.2%) had scores of 5-6, and 74 patients (11.5%) had scores of 7-8. Most patients were transported to the hospital via public emergency medical services (119 ambulance) (370 patients, 57.7%) or private ambulance services (138 patients, 21.5%). The most common mechanism of injury was slip-down accidents, accounting for 175 patients (27.3%). Among the the included patients, 41 identified with post-traumatic WMA. Table 2 presents the results of comparative analyses between patients with post-traumatic wall motion abnormalities and those without. Clinical variable, complication rates and the prevalence of cardiovascular comorbidities were compared using independent t-test and chi-square test. The mean age of WMA group was 67.15 ± 13.44 years, which was higher than that of the remaining 600 patients without WMA (65.23 ± 16.66 years). The mean GOSE score was lower in the WMA group (3.78 ± 1.90) compared to the non-WMA group (4.19 ± 1.86), suggesting poorer functional outcomes at discharge. The proportion of patients with troponin elevation was higher in the WMA group (32.5% vs 25.3%, OR=1.421, p =0.314). In addition, the proportion of patients with major trauma (ISS ≥ 15) was higher in WMA group (87.8% vs 84.0%, OR=1.371, p= 0.518). On the other hand, the proportion of patients with severe TBI (GCS ≤ 8) was lower in WMA group (26.8% vs 37.2%, OR=0.621, p =0.183). However, none of these variables were found to be statistically significant. Patients with post-traumatic WMA had a significantly higher prevalence of overall cardiovascular comorbidities (75.6% vs 56.0%, OR=2.436, p= 0.014) as well as a higher incidence of overall pulmonary complications such as ARDS, pleural effusion, pneumonia or pulmonary edema (31.7% vs 18.7%, OR=2.023, p =0.041), during hospitalization. Variables such as hypotension at presentation (4.9% vs 3.5%, OR=1.414, p =0.646), isolated TBI status (39.0% vs 39.3%, OR=0.987, p =0.969), the presence of chest injury within the ISS scoring system (36.6% vs 39.2%, OR=0.896, p =0.743), the use of mannitol (35.0% vs 39.3%, OR=0.832, p =0.591), hypertonic saline (17.1% vs 15.0%, OR=1.167, p =0.720) for intracranial pressure (ICP) control, and decompressive surgical procedure (53.7% vs 47.0%, OR=1.306, p =0.409) also did not show statistically significant differences between the WMA group and the non-WMA group. In the multivariate analysis, overall pulmonary complications (OR=1.863, p =0.088) during hospitalization and history of coronary artery occlusive disease (CAOD) (OR=2.912, p =0.005) remained covariates of post-traumatic WMA. For outcome-based analysis, patients were dichotomized into a favorable outcome group (GOSE 3–8) and an unfavorable outcome group (GOSE 1-2). Univariate and multivariable logistic regression analyses were performed to identify clinical, laboratory, and echocardiographic variables associated with unfavorable outcomes (Table 3). In univariate analysis, severe TBI (OR=6.485, p <0.001), major trauma (OR=6.982, p <0.001) and the occurrence of overall pulmonary complications (OR=2.808, p <0.001), ARDS (OR=4.222, p <0.001), pneumonia (OR=2.407, p <0.001), hypotension (OR=3.188, p =0.004) and chest injury (OR=1.903, p <0.001) were significantly associated with unfavorable outcome. Among these, severe TBI (OR=5.728, p <0.001), major trauma (OR=2.506, p =0.062) and overall pulmonary complications (OR=2.433, p <0.001) remained independent predictors of unfavorable outcome in the multivariable analysis. Discussions Cardiac injury associated with acute brain injury has been previously studied in conditions such as aneurysmal subarachnoid hemorrhage and ischemic stroke ( 8 – 10 ). Furthermore, much of the existing literature has focused on identifying its risk factors and clinical outcomes in such disease settings. However, limited data are available on cardiac WMA in patients with TBI ( 11 , 12 ). Risk factors for cardiac injury following acute brain injury have been primarily identified in studies focusing on stress-induced cardiomyopathy (SICMP), particularly Takotsubo cardiomyopathy, in the context of aneurysmal subarachnoid hemorrhage (aSAH) ( 5 , 13 ). These studies have suggested that female sex and aneurysms located in the anterior circulation are associated with increased risk. In our study, only 8 of the 41 patients (19.5%) with post-traumatic WMA were female, which is lower than the overall proportion of female patients (23.6%) among all TBI admissions during the study period. Previous reports on cardiomyopathy following TBI have proposed that severe TBI may be a potential risk factor for cardiac dysfunction ( 14 ). However, in our cohort, the presence of severe TBI did not show a significant association with WMA occurrence. In fact, the proportion of severe TBI cases within the WMA group was 26.8% (11/41), which was lower than that observed in the overall TBI population (31.9%). Among several proposed mechanisms for the development of cardiac WMA following TBI, the most plausible explanation is the multiple-hit phenomenon ( 3 , 15 ). This concept suggests that WMA results from a combination of pathophysiological insults rather than a single causative factor. The first component involves catecholamine surge-induced myocardial stunning, which is triggered by the systemic stress response following trauma ( 16 ). Traumatic injuries can activate the sympathetic nervous system through multiple mechanisms—including hemorrhage, pain, and systemic inflammatory stress—leading to elevated catecholamine levels and subsequent myocardial dysfunction ( 15 ). In aSAH, catecholamine surge has been attributed to direct brainstem injury caused by hemorrhage, which upregulates tyrosine hydroxylase, a key enzyme in catecholamine synthesis ( 17 , 18 ). This mechanism has been proposed to underlie the development of Takotsubo cardiomyopathy observed in aSAH patients. In contrast, trauma-induced catecholamine release is less likely to result solely from central nervous system injury and more likely to involve systemic compensatory responses. Consistent with this hypothesis, our study found that the presence of severe TBI was not significantly associated with WMA (OR = 0.621, p = 0.183), suggesting that in trauma settings, WMA may occur independently of brain injury severity. A second factor in the multiple-hit model is the exacerbation of preexisting cardiac disease during the acute phase of trauma care ( 3 ). In our cohort, the presence of cardiovascular comorbidities was significantly associated with WMA (OR = 2.436, p = 0.014), supporting this mechanism. Of the 41 patients with WMA, 17 underwent follow-up echocardiography. Among them, 13 (76.5%) showed resolution of WMA, while 4 patients exhibited persistent abnormalities. These findings are in line with previous studies describing WMA as a typically self-limiting phenomenon ( 19 , 20 ). Notably, WMA was significantly associated with the development of pulmonary complications during hospitalization (OR = 2.023, p = 0.041). This relationship raises concerns about impaired cardiopulmonary dynamics, which may compromise perfusion not only to the lungs but also to other critical organs, including the brain. Pulmonary complications were also significantly associated with worse outcomes (OR = 2.433, p < 0.001) in this study, along with variables such as severe TBI, major trauma, hypotension at presentation, and chest injury. In addition, it remained in multivariable analysis as significant covariate of unfavorable outcome (OR = 2.433, p < 0.001) highlighting the importance of identifying WMA as it is a significant risk factor for pulmonary complications. In addition, in our study, among the 41 patients with post-traumatic WMA, 13 (31.7%) had poor outcomes, defined as a GOSE score of 1 or 2. This proportion was notably higher than that observed in the overall TBI cohort admitted to our institution during the same period, where 402 out of 1,942 patients (20.7%) had GOSE scores of 1 or 2. Although WMA did not show a statistically significant association with outcomes in this study, its significant association with pulmonary complications suggest it may still have important clinical implication for effective cardiopulmonary management strategies. Echocardiographic screening in high-risk TBI patients may potentially mitigate secondary systemic deterioration to improve outcomes. Limitations This study has several limitations. First, as a retrospective observational analysis, causality cannot be definitively established, and prospective validation is warranted. Second, the decision to perform echocardiography was at the discretion of the attending physician, which may have introduced selection bias and underestimation of the true incidence of WMA. Third, the timing of echocardiography varied among patients, which may have influenced the detection of WMA. Future prospective studies with standardized protocol of echocardiographic diagnosis are warranted. Conclusion WMA following TBI is associated with unfavorable outcomes. Preexisting cardiovascular comorbidities, particularly CAOD, were significant risk factors for WMA development. Additionally, WMA correlated with an increased incidence of pulmonary complications, which were independently associated with worse functional outcomes. Our findings highlight the need to integrate cardiovascular assessment into the early evaluation and management of TBI patients, particularly in those with preexisting cardiac risk factors. Early identification of WMA in high-risk patients may facilitate tailored management strategies and improve prognosis in this vulnerable populations. Abbreviations ARDS – acute respiratory distress syndrome aSAH – aneurysmal subarachnoid hemorrhage CAOD – coronary artery occlusive disease GCS – Glasgow Coma Scale GOSE – Glasgow Outcome Scale-Extended ISS – Injury Severity Score OR – Odds ratio SICMP – stress-induced cardiomyopathy TBI – Traumatic brain injury TTE – transthoracic echocardiography WMA – wall motion abnormalities Declarations Ethics approval and consent to participate This retrospective study adheres to ethical guidelines and has been approved by the institutional review board at Ajou university school of medicine (IRB no. [AJOUIRB-DB-2025-337]). The requirement for informed consent was waived due to the retrospective nature of the study and the use of anonymized patient data. Consent for publication Not applicable. This study was a retrospective analysis of anonymized data, and the requirement for patient consent for publication was waived by the Institutional Review Board for Ajou university school of medicine. Availability of data and material The data supporting this study are not publicly available due to institutional confidentiality policy. Competing interests All authors have no conflicts of interests to declare. Funding The authors received no financial support for the research and authorship, or publication of this article. Author contributions YJL: Conceptualization, data curation, formal analysis, investigation, methodology, visualization, original draft JS: Formal analysis, validation, review & editing YCL: Conceptualization, methodology, supervision, review & editing Acknowledgements We acknowledge the use of ChatGPT (OpenAI) to support language editing during manuscript preparation. Author information Young Ju Lee 1 , Jihye Song 2 , Yong Cheol Lim 2* Department of Neurosurgery, Ajou University School of Medicine, Suwon, MD, Korea Department of Neurosurgery, Ajou University School of Medicine, Suwon, MD, PhD, Korea * Correspondence: [email protected] References Maas AIR, Menon DK, Adelson PD, Andelic N, Bell MJ, Belli A, et al. Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research. Lancet Neurol. 2017;16(12):987-1048. Robba C, Bonatti G, Pelosi P, Citerio G. Extracranial complications after traumatic brain injury: targeting the brain and the body. Curr Opin Crit Care. 2020;26(2):137-46. Coppalini G, Salvagno M, Peluso L, Bogossian EG, Quispe Cornejo A, Labbe V, et al. Cardiac injury after traumatic brain injury: clinical consequences and management. Neurocrit Care. 2024;40(2):477-85. Chen Z, Venkat P, Seyfried D, Chopp M, Yan T, Chen J. Brain–heart interaction: cardiac complications after strokes. Circ Res. 2017;121(4):451-68. Kaculini C, Sy C, Lacci JV, Jafari AA, Mirmoeeni S, Seifi A. The association of Takotsubo cardiomyopathy and aneurysmal subarachnoid hemorrhage: a US nationwide analysis. Clin Neurol Neurosurg. 2022;215:107211. Riera M, Llompart-Pou JA, Carrillo A, Blanco C. Head injury and inverted Takotsubo cardiomyopathy. J Trauma. 2010;68(1):E13-5. Prathep S, Sharma D, Hallman M, Joffe A, Krishnamoorthy V, Mackensen GB, et al. Preliminary report on cardiac dysfunction after isolated traumatic brain injury. Crit Care Med. 2014;42(1):142-7. Tung P, Kopelnik A, Banki N, Ong K, Ko N, Lawton MT, et al. Predictors of neurocardiogenic injury after subarachnoid hemorrhage. Stroke. 2004;35(2):548-51. Parekh N, Venkatesh B, Cross D, Leditschke A, Atherton J, Miles W, et al. Cardiac troponin I predicts myocardial dysfunction in aneurysmal subarachnoid hemorrhage. J Am Coll Cardiol. 2000;36(4):1328-35. Song HS, Back JH, Jin DK, Chung PW, Moon HS, Suh BC, et al. Cardiac troponin T elevation after stroke: relationships between elevated serum troponin T, stroke location, and prognosis. J Clin Neurol. 2008;4(2):75-83. Hasanin A, Kamal A, Amin S, Zakaria D, El Sayed R, Mahmoud K, et al. Incidence and outcome of cardiac injury in patients with severe head trauma. Scand J Trauma Resusc Emerg Med. 2016;24:58. Bahloul M, Chaari AN, Kallel H, Khabir A, Ayadi A, Charfeddine H, et al. Neurogenic pulmonary edema due to traumatic brain injury: evidence of cardiac dysfunction. Am J Crit Care. 2006;15(5):462-70. Ghafoor K, Ghafoor HU, Rasla S, Dimitrios A. Bilateral subarachnoid hemorrhage and bilateral intracranial hemorrhage with reversible cardiomyopathy during dobutamine stress echocardiography. Cureus. 2021;13(4):e14725. Corral L, Javierre CF, Ventura JL, Marcos P, Herrero JI, Manez R. Impact of non-neurological complications in severe traumatic brain injury outcome. Crit Care. 2012;16(2):R44. Stocchetti N, Zanier ER. Chronic impact of traumatic brain injury on outcome and quality of life: a narrative review. Crit Care. 2016;20(1):148. Zygun DA, Kortbeek JB, Fick GH, Laupland KB, Doig CJ. Non-neurologic organ dysfunction in severe traumatic brain injury. Crit Care Med. 2005;33(3):654-60. Lucifero AG, Baldoncini M, Bruno N, Tartaglia N, Ambrosi A, Marseglia GL, et al. Microsurgical neurovascular anatomy of the brain: the posterior circulation (part II). Acta Biomed. 2021;92(Suppl 4):e2021413. Weihe E, Depboylu C, Schutz B, Schafer MK, Eiden LE. Three types of tyrosine hydroxylase-positive CNS neurons distinguished by dopa decarboxylase and VMAT2 co-expression. Cell Mol Neurobiol. 2006;26(4-6):659-78. Talahma M, Alkhachroum AM, Alyahya M, Manjila S, Xiong W. Takotsubo cardiomyopathy in aneurysmal subarachnoid hemorrhage: institutional experience and literature review. Clin Neurol Neurosurg. 2016;141:65-70. Veillet-Chowdhury M, Hassan SF, Stergiopoulos K. Takotsubo cardiomyopathy: a review. Acute Card Care. 2014;16(1):15-22. Tables Table 1. Baseline characteristics, comorbidities, and clinical outcomes of the TBI patients (Total: 641) Clinical characteristics value Clinical characteristics value Male gender 468 (73.1%) Decompressive surgical procedure 304 (47.4%) Age 65.35 (±16.48) GCS Transfer methods 3-8 234 (36.5%) 119 ambulance 370 (57.7%) 9-15 407 (63.5%) Private ambulance 138 (21.5%) Isolated TBI 252 (39.3%) Another car 85 (13.3%) Major trauma (ISS score≥15) 540 (84.2%) Air ambulance 45 (7.0%) Cardiovascular comorbidity 367 (57.3%) Other 3 (0.5%) HTN 312 (48.7%) Type of injury CAOD 82 (12.8%) Slip down 175 (27.3%) CMP 2 (0.3%) Fall from height 105 (16.4%) HF 14 (2.2%) Motor cycle, bicycle 83 (13%) Arrythmia 62 (9.7%) Pedestrian TA 53 (8.3%) VHD 25 (3.9%) Driver TA 17 (2.7%) Tn elevation 159 (24.8%) Work related 9 (1.4%) Pulmonary complication 125 (19.5%) Sports 3 (0.5%) ARDS 22 (3.4%) Violence 2 (0.3%) Pleural effusion 60 (9.4%) Other 157 (24.5%) Pneumonia 85 (13.3%) Pulmonary edema 6 (0.9%) GOSE 1-2 149 (23.2%) 3-4 199 (31.1%) 5-6 219 (34.2%) 7-8 74 (11.5%) Table 2. Comparison of clinical characteristics, complications and outcomes between patients with and without post-traumatic cardiac wall motion abnormalities Univariable Multivariable Wall motion abnormality after trauma OR(95%CI) p -value OR(95%CI) p -value No, N=600 (n, %) Yes, N=41 (n, %) Age 65.23 (±16.66) 67.15 (±13.44) 0.235 GOSE 4.19 (±1.86) 3.78 (±1.904) 0.085 ISS 24.43 (±10.56) 24.68 (±10.00) 0.441 Tn elevation 146 (25.3%) 13 (32.5%) 1.421(0.715-2.827) 0.314 Severe TBI (GCS ≤ 8) 223 (37.2%) 11 (26.8%) 0.620(0.305-1.261) 0.183 Major trauma (ISS ≥ 15) 504 (84.0%) 36 (87.8%) 1.371(0.525-3.584) 0.518 Hypotension 21 (3.5%) 2 (4.9%) 1.414(0.320-6.250) 0.646 Isolated TBI 236 (39.3%) 16 (39.0%) 0.987(0.516-1.888) 0.969 Chest injury 235 (39.2%) 15 (36.6%) 0.896(0.465-1.727) 0.743 Mannitol 229 (39.3%) 14 (35.0%) 0.832(0.426-1.628) 0.591 Hypertonic saline 90 (15.0%) 7 (17.1%) 1.167(0.502-2.713) 0.720 Decompressive surgery 282 (47.0%) 22 (53.7%) 1.306(0.692-2.462) 0.409 Overall pulmonary complication 112 (18.7%) 13 (31.7%) 2.023(1.016-4.030) 0.041 1.863(0.912-3.806) 0.088 ARDS 19 (3.2%) 3 (7.3%) 2.414(0.684-8.520) 0.158 Pleural effusion 53 (8.8%) 7 (17.1%) 2.125(0.898-5.026) 0.080 Pneumonia 76 (12.7%) 9 (22.0%) 1.939(0.891-4.220) 0.090 Pulmonary edema 3 (0.5%) 3 (7.3%) 15.711(3.067-80.470) <0.001 Cardiovascular comorbidity 336 (56.0%) 31 (75.6%) 2.436(1.173-5.058) 0.014 HTN 289 (48.2%) 23 (56.1%) 1.375(0.727-2.601) 0.326 CAOD 70 (11.7%) 12 (29.3%) 3.133(1.529-6.420) 0.001 2.912(1.386-6.119) 0.005 Arrythmia 58 (9.7%) 4 (9.8%) 1.010(0.348-2.935) 0.985 VHD 22 (3.7%) 3 (7.3%) 2.074(0.594-7.241) 0.243 Table 3. Univariate and Multivariate Analyses of Factors associated with unfavorable functional outcomes following traumatic brain injury Univariate Multivariate Favorable outcome, N=492 (n, %) Unfavorable outcome (GOSE=1or2), N=149 (n, %) OR (95%CI) p -value OR (95%CI) p -value Male 355 (72.2%) 113 (75.8%) 1.211(0.793-1.851) 0.375 Wall motion abnormality after trauma 28 (5.7%) 13 (8.7%) 1.584(0.799-3.142) 0.185 Tn elevation 118 (24.9%) 41 (28.7%) 1.213(0.798-1.842) 0.365 Severe TBI 129 (26.3%) 104 (69.8%) 6.485(4.333-9.708) <0.001 5.728(3.718-8.824) <0.001 Major Trauma 396 (80.5%) 144 (96.6%) 6.982(2.785-17.503) <0.001 2.506(0.956-6.570) 0.062 Pulmonary complication 75 (15.2%) 50 (33.6%) 2.808(1.846-4.272) <0.001 2.433(1.520-3.896) <0.001 ARDS 10 (2.0%) 12 (8.1%) 4.222(1.786-9.981) <0.001 Pleural effusion 35 (7.1%) 25 (16.8%) 2.632(1.518-4.564) <0.001 Pneumonia 52 (10.6%) 33 (22.1%) 2.407(1.487-3.897) <0.001 Pulmonary edema 5 (1.0%) 1 (0.7%) 0.658(0.076-5.678) 0.702 Hypotension 12 (2.4%) 11 (7.4%) 3.188(1.377-7.384) 0.004 Chest injury 174 (35.4%) 76 (51.0%) 1.903(1.313-2.756) <0.001 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7092075","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":498712969,"identity":"01ccdebb-96e7-43a2-a128-c7e89e951b93","order_by":0,"name":"Young Ju Lee","email":"","orcid":"","institution":"Ajou University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Young","middleName":"Ju","lastName":"Lee","suffix":""},{"id":498712970,"identity":"6e43b0b4-0e04-447e-b13a-bb2fc1fb5987","order_by":1,"name":"Jihye Song","email":"","orcid":"","institution":"Ajou University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Jihye","middleName":"","lastName":"Song","suffix":""},{"id":498712971,"identity":"c60629e4-5aa3-405b-a1fb-302d25f333d3","order_by":2,"name":"Yong Cheol Lim","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAv0lEQVRIiWNgGAWjYLCCBwYMciD6wAOitSQYMBiDtSQQr4WBIbEByiAMzPnPGH5IKNiWPj/s8EOgLXZyug0EtFjOyDGWSDC4nbvxdpoBUEuysdkBAloMbvCYMYC1zE4AaTmQuI2glvNnwFrSDWenfyBSy4EcsJYEeekcYm25kVYM8ovhBumcggMJBsT45fzhjR8+/LktLz87ffOHDxV2cgS1MDBwGEBdCCYJKgcB9gdgSr6BKNWjYBSMglEwEgEAfg5IbNiJ8d0AAAAASUVORK5CYII=","orcid":"","institution":"Ajou University School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Yong","middleName":"Cheol","lastName":"Lim","suffix":""}],"badges":[],"createdAt":"2025-07-10 10:38:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7092075/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7092075/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89230524,"identity":"ec8348ea-c9df-46dc-bbf3-6073616a3be4","added_by":"auto","created_at":"2025-08-17 14:14:52","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":41532,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of patient selection with inclusion and exclusion criteria for the study cohort\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7092075/v1/db1c175192c98006651746e8.png"},{"id":103399986,"identity":"447f2978-7dd0-4dc0-ab37-2b583aae829d","added_by":"auto","created_at":"2026-02-25 09:13:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1119116,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7092075/v1/e27d9a1b-607f-4435-be4e-0bf3ee392ada.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Prognostic impact of cardiac wall motion abnormalities after TBI: Association with pulmonary complications and cardiovascular comorbidities","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTBI is a significant global health burden, contributing to mortality and long-term quality of life (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Aside the primary brain damage, TBI often leads to secondary dysfunction of extracranial organs, which can contribute to morbidity and adverse outcomes (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Among these, cardiac injury is relatively well-known secondary dysfunction following primary injury of brain. Concepts such as “Catecholamine surge” or “Neurocardiac axis” have been proposed in previous studies to explain brain-heart interactions in acute brain injury (\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e–\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). While such mechanisms have been extensively studied in context like subarachnoid hemorrhage, there remains a paucity of data regarding the incidence, prognostic implications, and risk factors specific to cardiac injury following TBI (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). This study aims to elucidate the prevalence and risk factors of secondary cardiac injury in TBI patients, thereby underscoring the need for early screening in patients with elevated risk and development of tailored treatment strategies to improve patient outcomes. This retrospective study adheres to ethical guidelines and has been approved by the institutional review board at Ajou university school of medicine.\u003c/p\u003e"},{"header":"Patients and methods","content":"\u003cp\u003e This retrospective, observational study was conducted in the Ajou university medical center, a regional trauma center located in the southern Gyeonggi province. Inclusion criteria were: (ⅰ) admission to Ajou university medical center between January 2019 and December 2023; (ⅱ) diagnosis of TBI; and (ⅲ) performance of TTE during hospitalization. Exclusion criteria were: (ⅰ) evidence of preexisting cardiac wall motion abnormalities on echocardiography performed prior to trauma; and (ⅱ) incomplete or missing essential clinical data in the medical records. Data was retrospectively collected from medical records and imaging archives. Variables reviewed included demographic factors, medical history, laboratory findings, Glasgow Coma Scale (GCS) score at admission, Injury Severity Score (ISS), complications during hospitalization, and discharge status.\u003c/p\u003e\u003cp\u003eTTE was performed as deemed necessary by the attending physician, particularly in patients with known cardiovascular comorbidities or clinical signs of hemodynamic instability. Cardiac injury was defined as the presence of WMA on echocardiography. Among those with WMA, patients with prior echocardiographic reports presenting similar abnormalities were excluded and remaining patients were classified as presenting post-traumatic cardiac injury.\u003c/p\u003e\u003cp\u003eSevere TBI was defined as a GCS score of 8 or less at presentation. Major trauma was defined as an ISS of 15 or higher. Troponin elevation was defined as rise in either troponin I or high-sensitivity troponin T levels in blood tests performed upon admission. The referance range for normal values were 0.000-0.046 ng/mL for troponin I and 0.000-0.013 ng/mL for high-sensitivity troponin T. Hypotension was defined as a systolic blood pressure of 90mmHg or lower at the time of presentation.\u003c/p\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eStatistical analysis was performed using IBM SPSS Statistics, version 29.0.2.0 (IBM Corp., Armonk, NY, USA). Categorical data were presented as frequency (%). Univariable and multivariable analysis were conducted to compare demographic and clinical variables between patients with and without WMA on echocardiography following trauma. The patients were classified into 2 groups for favorable GOSE score (\u003cspan additionalcitationids=\"CR4 CR5 CR6 CR7\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e–\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) and unfavorable GOSE score (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e–\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Univariate and multivariable analyses were conducted to identify factors associated with unfavorable outcomes. Variables with a \u003cem\u003ep\u003c/em\u003e-value of \u0026lt; 0.05 were considered statistically significant, and variables with a \u003cem\u003ep\u003c/em\u003e-value \u0026lt; 0.2 in the univariable analysis or considered clinically significant were included in the multivariable logistic regression model to identify independent predictors.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 1,942 patients were hospitalized during the study period. Of these, TTE was performed in 659 (33.9%) patients. After excluding 18 patients who demonstrated similar WMA on echocardiography performed prior to admission, 641 patients were included in the final analysis. The study population selection process is illustrated in Figure 1.\u003c/p\u003e\n\u003cp\u003eTable 1 summarizes the demographic and clinical characteristics, laboratory findings, trauma mechanisms, and TTE results of the 641 patients with TBI included in the study. Of these, 468 (73.1%) were male, and the mean age was 65.35 \u0026plusmn; 16.48 years. Severe TBI, defined as a GCS score \u0026le; 8 at presentation, was observed in 234 patients (36.5%). Major trauma, defined as an ISS \u0026ge; 15, was present in 540 (84.2%) patients. Forty-one patients (6.4%) demonstrated cardiac WMA. Cardiovascular comorbidities such as hypertension and coronary artery occlusive disease were present in 367 (57.3%) patients. During hospitalization, pulmonary complications including acute respiratory distress syndrome (ARDS) and pleural effusion occurred in 125 patients (19.5%). Among the included 641 patients included in the study, 304 (47.4%) underwent decompressive surgical procedure such as craniectomy or craniotomy. The distribution of GOSE scores was as follows: 149 patients (23.2%) had scores of 1-2, 199 patients (31.0%) had scores of 3-4, 219 patients (34.2%) had scores of 5-6, and 74 patients (11.5%) had scores of 7-8. Most patients were transported to the hospital via public emergency medical services (119 ambulance) (370 patients, 57.7%) or private ambulance services (138 patients, 21.5%). The most common mechanism of injury was slip-down accidents, accounting for 175 patients (27.3%).\u003c/p\u003e\n\u003cp\u003eAmong the the included patients, 41 identified with post-traumatic WMA. Table 2 presents the results of comparative analyses between patients with post-traumatic wall motion abnormalities and those without. Clinical variable, complication rates and the prevalence of cardiovascular comorbidities were compared using independent t-test and chi-square test. The mean age of WMA group was 67.15 \u0026plusmn; 13.44 years, which was higher than that of the remaining 600 patients without WMA (65.23\u0026nbsp;\u0026plusmn; 16.66 years). The mean GOSE score was lower in the WMA group (3.78 \u0026plusmn; 1.90) compared to the non-WMA group (4.19 \u0026plusmn; 1.86), suggesting poorer functional outcomes at discharge.\u0026nbsp;The proportion of patients with troponin elevation was higher in the WMA group (32.5% vs 25.3%, OR=1.421, \u003cem\u003ep\u003c/em\u003e=0.314). In addition, the proportion of patients with major trauma (ISS \u0026ge; 15)\u0026nbsp;was higher in WMA group (87.8% vs 84.0%, OR=1.371, \u003cem\u003ep=\u003c/em\u003e0.518). On the other hand, the proportion of patients with severe TBI (GCS \u0026le; 8)\u0026nbsp;was lower in WMA group (26.8% vs 37.2%, OR=0.621, \u003cem\u003ep\u003c/em\u003e=0.183). However, none of these variables were found to be statistically significant. Patients with post-traumatic WMA had a significantly higher prevalence of overall cardiovascular comorbidities (75.6% vs 56.0%, OR=2.436, \u003cem\u003ep=\u003c/em\u003e0.014) as well as a higher incidence of overall pulmonary complications such as ARDS, pleural effusion, pneumonia or pulmonary edema (31.7% vs 18.7%, OR=2.023, \u003cem\u003ep\u003c/em\u003e=0.041), during hospitalization. Variables such as hypotension at presentation (4.9% vs 3.5%, OR=1.414, \u003cem\u003ep\u003c/em\u003e=0.646), isolated TBI status (39.0% vs 39.3%, OR=0.987, \u003cem\u003ep\u003c/em\u003e=0.969), the presence of chest injury within the ISS scoring system (36.6% vs 39.2%, OR=0.896, \u003cem\u003ep\u003c/em\u003e=0.743), the use of mannitol (35.0% vs 39.3%, OR=0.832, \u003cem\u003ep\u003c/em\u003e=0.591), hypertonic saline (17.1% vs 15.0%, OR=1.167, \u003cem\u003ep\u003c/em\u003e=0.720) for intracranial pressure (ICP) control, and decompressive surgical procedure (53.7% vs 47.0%, OR=1.306, \u003cem\u003ep\u003c/em\u003e=0.409) also did not show statistically significant differences between the WMA group and the non-WMA group. In the multivariate analysis, overall pulmonary complications (OR=1.863, \u003cem\u003ep\u003c/em\u003e=0.088) during hospitalization and history of coronary artery occlusive disease (CAOD) (OR=2.912, \u003cem\u003ep\u003c/em\u003e=0.005) remained covariates of post-traumatic WMA.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor outcome-based analysis, patients were dichotomized into a favorable outcome group (GOSE 3\u0026ndash;8) and an unfavorable outcome group (GOSE 1-2). Univariate and multivariable logistic regression analyses were performed to identify clinical, laboratory, and echocardiographic variables associated with unfavorable outcomes (Table 3). In univariate analysis, severe TBI (OR=6.485, \u003cem\u003ep\u003c/em\u003e\u0026lt;0.001), major trauma (OR=6.982, \u003cem\u003ep\u003c/em\u003e\u0026lt;0.001) and the occurrence of overall pulmonary complications (OR=2.808, \u003cem\u003ep\u003c/em\u003e\u0026lt;0.001), ARDS (OR=4.222, \u003cem\u003ep\u003c/em\u003e\u0026lt;0.001), pneumonia (OR=2.407, \u003cem\u003ep\u003c/em\u003e\u0026lt;0.001), hypotension (OR=3.188, \u003cem\u003ep\u003c/em\u003e=0.004) and chest injury (OR=1.903, \u003cem\u003ep\u003c/em\u003e\u0026lt;0.001) were significantly associated with unfavorable outcome. Among these, severe TBI (OR=5.728, \u003cem\u003ep\u003c/em\u003e\u0026lt;0.001), major trauma (OR=2.506, \u003cem\u003ep\u003c/em\u003e=0.062) and overall pulmonary complications (OR=2.433, \u003cem\u003ep\u003c/em\u003e\u0026lt;0.001) remained independent predictors of unfavorable outcome in the multivariable analysis.\u003c/p\u003e"},{"header":"Discussions","content":"\u003cp\u003eCardiac injury associated with acute brain injury has been previously studied in conditions such as aneurysmal subarachnoid hemorrhage and ischemic stroke (\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Furthermore, much of the existing literature has focused on identifying its risk factors and clinical outcomes in such disease settings. However, limited data are available on cardiac WMA in patients with TBI (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Risk factors for cardiac injury following acute brain injury have been primarily identified in studies focusing on stress-induced cardiomyopathy (SICMP), particularly Takotsubo cardiomyopathy, in the context of aneurysmal subarachnoid hemorrhage (aSAH) (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). These studies have suggested that female sex and aneurysms located in the anterior circulation are associated with increased risk. In our study, only 8 of the 41 patients (19.5%) with post-traumatic WMA were female, which is lower than the overall proportion of female patients (23.6%) among all TBI admissions during the study period. Previous reports on cardiomyopathy following TBI have proposed that severe TBI may be a potential risk factor for cardiac dysfunction (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). However, in our cohort, the presence of severe TBI did not show a significant association with WMA occurrence. In fact, the proportion of severe TBI cases within the WMA group was 26.8% (11/41), which was lower than that observed in the overall TBI population (31.9%). Among several proposed mechanisms for the development of cardiac WMA following TBI, the most plausible explanation is the multiple-hit phenomenon (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). This concept suggests that WMA results from a combination of pathophysiological insults rather than a single causative factor. The first component involves catecholamine surge-induced myocardial stunning, which is triggered by the systemic stress response following trauma (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Traumatic injuries can activate the sympathetic nervous system through multiple mechanisms\u0026mdash;including hemorrhage, pain, and systemic inflammatory stress\u0026mdash;leading to elevated catecholamine levels and subsequent myocardial dysfunction (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). In aSAH, catecholamine surge has been attributed to direct brainstem injury caused by hemorrhage, which upregulates tyrosine hydroxylase, a key enzyme in catecholamine synthesis (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). This mechanism has been proposed to underlie the development of Takotsubo cardiomyopathy observed in aSAH patients. In contrast, trauma-induced catecholamine release is less likely to result solely from central nervous system injury and more likely to involve systemic compensatory responses. Consistent with this hypothesis, our study found that the presence of severe TBI was not significantly associated with WMA (OR\u0026thinsp;=\u0026thinsp;0.621, p\u0026thinsp;=\u0026thinsp;0.183), suggesting that in trauma settings, WMA may occur independently of brain injury severity. A second factor in the multiple-hit model is the exacerbation of preexisting cardiac disease during the acute phase of trauma care (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). In our cohort, the presence of cardiovascular comorbidities was significantly associated with WMA (OR\u0026thinsp;=\u0026thinsp;2.436, p\u0026thinsp;=\u0026thinsp;0.014), supporting this mechanism. Of the 41 patients with WMA, 17 underwent follow-up echocardiography. Among them, 13 (76.5%) showed resolution of WMA, while 4 patients exhibited persistent abnormalities. These findings are in line with previous studies describing WMA as a typically self-limiting phenomenon (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Notably, WMA was significantly associated with the development of pulmonary complications during hospitalization (OR\u0026thinsp;=\u0026thinsp;2.023, p\u0026thinsp;=\u0026thinsp;0.041). This relationship raises concerns about impaired cardiopulmonary dynamics, which may compromise perfusion not only to the lungs but also to other critical organs, including the brain. Pulmonary complications were also significantly associated with worse outcomes (OR\u0026thinsp;=\u0026thinsp;2.433, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) in this study, along with variables such as severe TBI, major trauma, hypotension at presentation, and chest injury. In addition, it remained in multivariable analysis as significant covariate of unfavorable outcome (OR\u0026thinsp;=\u0026thinsp;2.433, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) highlighting the importance of identifying WMA as it is a significant risk factor for pulmonary complications. In addition, in our study, among the 41 patients with post-traumatic WMA, 13 (31.7%) had poor outcomes, defined as a GOSE score of 1 or 2. This proportion was notably higher than that observed in the overall TBI cohort admitted to our institution during the same period, where 402 out of 1,942 patients (20.7%) had GOSE scores of 1 or 2. Although WMA did not show a statistically significant association with outcomes in this study, its significant association with pulmonary complications suggest it may still have important clinical implication for effective cardiopulmonary management strategies. Echocardiographic screening in high-risk TBI patients may potentially mitigate secondary systemic deterioration to improve outcomes.\u003c/p\u003e\u003cp\u003e\u003cem\u003eLimitations\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThis study has several limitations. First, as a retrospective observational analysis, causality cannot be definitively established, and prospective validation is warranted. Second, the decision to perform echocardiography was at the discretion of the attending physician, which may have introduced selection bias and underestimation of the true incidence of WMA. Third, the timing of echocardiography varied among patients, which may have influenced the detection of WMA. Future prospective studies with standardized protocol of echocardiographic diagnosis are warranted.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWMA following TBI is associated with unfavorable outcomes. Preexisting cardiovascular comorbidities, particularly CAOD, were significant risk factors for WMA development. Additionally, WMA correlated with an increased incidence of pulmonary complications, which were independently associated with worse functional outcomes. Our findings highlight the need to integrate cardiovascular assessment into the early evaluation and management of TBI patients, particularly in those with preexisting cardiac risk factors. Early identification of WMA in high-risk patients may facilitate tailored management strategies and improve prognosis in this vulnerable populations.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eARDS \u0026ndash; acute respiratory distress syndrome\u003c/p\u003e\n\u003cp\u003eaSAH \u0026ndash; aneurysmal subarachnoid hemorrhage\u003c/p\u003e\n\u003cp\u003eCAOD \u0026ndash; coronary artery occlusive disease\u003c/p\u003e\n\u003cp\u003eGCS \u0026ndash; Glasgow Coma Scale\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGOSE \u0026ndash; Glasgow Outcome Scale-Extended\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eISS \u0026ndash; Injury Severity Score\u003c/p\u003e\n\u003cp\u003eOR \u0026ndash; Odds ratio\u003c/p\u003e\n\u003cp\u003eSICMP \u0026ndash; stress-induced cardiomyopathy\u003c/p\u003e\n\u003cp\u003eTBI \u0026ndash; Traumatic brain injury\u003c/p\u003e\n\u003cp\u003eTTE \u0026ndash; transthoracic echocardiography\u003c/p\u003e\n\u003cp\u003eWMA \u0026ndash; wall motion abnormalities\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective study adheres to ethical guidelines and has been approved by the institutional review board at Ajou university school of medicine (IRB no. [AJOUIRB-DB-2025-337]). The requirement for informed consent was waived due to the retrospective nature of the study and the use of anonymized patient data.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. This study was a retrospective analysis of anonymized data, and the requirement for patient consent for publication was waived by the Institutional Review Board for Ajou university school of medicine. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data supporting this study are not publicly available due to institutional confidentiality policy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors have no conflicts of interests to declare.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no financial support for the research and authorship, or publication of this article.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYJL: Conceptualization, data curation, formal analysis, investigation, methodology, visualization, original draft\u003c/p\u003e\n\u003cp\u003eJS: Formal analysis, validation, review \u0026amp; editing\u003c/p\u003e\n\u003cp\u003eYCL: Conceptualization, methodology, supervision, review \u0026amp; editing\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe acknowledge the use of ChatGPT (OpenAI) to support language editing during manuscript preparation. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYoung Ju Lee\u003csup\u003e1\u003c/sup\u003e, Jihye Song\u003csup\u003e2\u003c/sup\u003e, Yong Cheol Lim\u003csup\u003e2*\u003c/sup\u003e\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eDepartment of Neurosurgery, Ajou University School of Medicine, Suwon, MD, Korea\u003c/li\u003e\n \u003cli\u003eDepartment of Neurosurgery, Ajou University School of Medicine, Suwon, MD, PhD, Korea\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003csup\u003e*\u003c/sup\u003eCorrespondence: [email protected]\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMaas AIR, Menon DK, Adelson PD, Andelic N, Bell MJ, Belli A, et al. Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research. Lancet Neurol. 2017;16(12):987-1048.\u003c/li\u003e\n\u003cli\u003eRobba C, Bonatti G, Pelosi P, Citerio G. Extracranial complications after traumatic brain injury: targeting the brain and the body. Curr Opin Crit Care. 2020;26(2):137-46.\u003c/li\u003e\n\u003cli\u003eCoppalini G, Salvagno M, Peluso L, Bogossian EG, Quispe Cornejo A, Labbe V, et al. Cardiac injury after traumatic brain injury: clinical consequences and management. Neurocrit Care. 2024;40(2):477-85.\u003c/li\u003e\n\u003cli\u003eChen Z, Venkat P, Seyfried D, Chopp M, Yan T, Chen J. Brain\u0026ndash;heart interaction: cardiac complications after strokes. Circ Res. 2017;121(4):451-68.\u003c/li\u003e\n\u003cli\u003eKaculini C, Sy C, Lacci JV, Jafari AA, Mirmoeeni S, Seifi A. The association of Takotsubo cardiomyopathy and aneurysmal subarachnoid hemorrhage: a US nationwide analysis. Clin Neurol Neurosurg. 2022;215:107211.\u003c/li\u003e\n\u003cli\u003eRiera M, Llompart-Pou JA, Carrillo A, Blanco C. Head injury and inverted Takotsubo cardiomyopathy. J Trauma. 2010;68(1):E13-5.\u003c/li\u003e\n\u003cli\u003ePrathep S, Sharma D, Hallman M, Joffe A, Krishnamoorthy V, Mackensen GB, et al. Preliminary report on cardiac dysfunction after isolated traumatic brain injury. Crit Care Med. 2014;42(1):142-7.\u003c/li\u003e\n\u003cli\u003eTung P, Kopelnik A, Banki N, Ong K, Ko N, Lawton MT, et al. Predictors of neurocardiogenic injury after subarachnoid hemorrhage. Stroke. 2004;35(2):548-51.\u003c/li\u003e\n\u003cli\u003eParekh N, Venkatesh B, Cross D, Leditschke A, Atherton J, Miles W, et al. Cardiac troponin I predicts myocardial dysfunction in aneurysmal subarachnoid hemorrhage. J Am Coll Cardiol. 2000;36(4):1328-35.\u003c/li\u003e\n\u003cli\u003eSong HS, Back JH, Jin DK, Chung PW, Moon HS, Suh BC, et al. Cardiac troponin T elevation after stroke: relationships between elevated serum troponin T, stroke location, and prognosis. J Clin Neurol. 2008;4(2):75-83.\u003c/li\u003e\n\u003cli\u003eHasanin A, Kamal A, Amin S, Zakaria D, El Sayed R, Mahmoud K, et al. Incidence and outcome of cardiac injury in patients with severe head trauma. Scand J Trauma Resusc Emerg Med. 2016;24:58.\u003c/li\u003e\n\u003cli\u003eBahloul M, Chaari AN, Kallel H, Khabir A, Ayadi A, Charfeddine H, et al. Neurogenic pulmonary edema due to traumatic brain injury: evidence of cardiac dysfunction. Am J Crit Care. 2006;15(5):462-70.\u003c/li\u003e\n\u003cli\u003eGhafoor K, Ghafoor HU, Rasla S, Dimitrios A. Bilateral subarachnoid hemorrhage and bilateral intracranial hemorrhage with reversible cardiomyopathy during dobutamine stress echocardiography. Cureus. 2021;13(4):e14725.\u003c/li\u003e\n\u003cli\u003eCorral L, Javierre CF, Ventura JL, Marcos P, Herrero JI, Manez R. Impact of non-neurological complications in severe traumatic brain injury outcome. Crit Care. 2012;16(2):R44.\u003c/li\u003e\n\u003cli\u003eStocchetti N, Zanier ER. Chronic impact of traumatic brain injury on outcome and quality of life: a narrative review. Crit Care. 2016;20(1):148.\u003c/li\u003e\n\u003cli\u003eZygun DA, Kortbeek JB, Fick GH, Laupland KB, Doig CJ. Non-neurologic organ dysfunction in severe traumatic brain injury. Crit Care Med. 2005;33(3):654-60.\u003c/li\u003e\n\u003cli\u003eLucifero AG, Baldoncini M, Bruno N, Tartaglia N, Ambrosi A, Marseglia GL, et al. Microsurgical neurovascular anatomy of the brain: the posterior circulation (part II). Acta Biomed. 2021;92(Suppl 4):e2021413.\u003c/li\u003e\n\u003cli\u003eWeihe E, Depboylu C, Schutz B, Schafer MK, Eiden LE. Three types of tyrosine hydroxylase-positive CNS neurons distinguished by dopa decarboxylase and VMAT2 co-expression. Cell Mol Neurobiol. 2006;26(4-6):659-78.\u003c/li\u003e\n\u003cli\u003eTalahma M, Alkhachroum AM, Alyahya M, Manjila S, Xiong W. Takotsubo cardiomyopathy in aneurysmal subarachnoid hemorrhage: institutional experience and literature review. Clin Neurol Neurosurg. 2016;141:65-70.\u003c/li\u003e\n\u003cli\u003eVeillet-Chowdhury M, Hassan SF, Stergiopoulos K. Takotsubo cardiomyopathy: a review. Acute Card Care. 2014;16(1):15-22.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1. Baseline characteristics, comorbidities, and clinical outcomes of the TBI patients (Total: 641)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClinical characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e\u003cstrong\u003evalue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClinical characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e\u003cstrong\u003evalue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMale gender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e468 (73.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eDecompressive surgical procedure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e304 (47.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e65.35 (\u0026plusmn;16.48)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGCS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTransfer methods\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e3-8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e234 (36.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e119 ambulance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e370 (57.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e9-15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e407 (63.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003ePrivate ambulance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e138 (21.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIsolated TBI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e252 (39.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eAnother car\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e85 (13.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMajor trauma (ISS score\u0026ge;15)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e540 (84.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eAir ambulance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e45 (7.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCardiovascular comorbidity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e367 (57.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e3 (0.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eHTN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e312 (48.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of injury\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eCAOD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e82 (12.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eSlip down\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e175 (27.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eCMP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e2 (0.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eFall from height\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e105 (16.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eHF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e14 (2.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eMotor cycle, bicycle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e83 (13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eArrythmia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e62 (9.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003ePedestrian TA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e53 (8.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eVHD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e25 (3.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eDriver TA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e17 (2.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTn elevation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e159 (24.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eWork related\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e9 (1.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePulmonary complication\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e125 (19.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eSports\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e3 (0.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eARDS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e22 (3.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eViolence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e2 (0.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003ePleural effusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e60 (9.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e157 (24.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003ePneumonia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e85 (13.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003ePulmonary edema\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e6 (0.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGOSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e1-2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e149 (23.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e3-4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e199 (31.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e5-6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e219 (34.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e7-8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e74 (11.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 184px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 2. Comparison of clinical characteristics, complications and outcomes between patients with and without post-traumatic cardiac wall motion abnormalities\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"633\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003eUnivariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eMultivariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003eWall motion abnormality after trauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003eOR(95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eOR(95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eNo, N=600 (n, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eYes, N=41 (n, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e65.23 (\u0026plusmn;16.66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e67.15 (\u0026plusmn;13.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.235\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eGOSE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e4.19 (\u0026plusmn;1.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e3.78 (\u0026plusmn;1.904)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.085\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eISS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e24.43 (\u0026plusmn;10.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e24.68 (\u0026plusmn;10.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.441\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eTn elevation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e146 (25.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e13 (32.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e1.421(0.715-2.827)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.314\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eSevere TBI (GCS\u003cstrong\u003e\u0026le;\u003c/strong\u003e8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e223 (37.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e11 (26.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e0.620(0.305-1.261)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.183\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eMajor trauma (ISS\u003cstrong\u003e\u0026ge;\u003c/strong\u003e15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e504 (84.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e36 (87.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e1.371(0.525-3.584)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.518\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eHypotension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e21 (3.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e2 (4.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e1.414(0.320-6.250)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.646\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eIsolated TBI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e236 (39.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e16 (39.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e0.987(0.516-1.888)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.969\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eChest injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e235 (39.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e15 (36.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e0.896(0.465-1.727)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.743\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eMannitol\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e229 (39.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e14 (35.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e0.832(0.426-1.628)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.591\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eHypertonic saline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e90 (15.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e7 (17.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e1.167(0.502-2.713)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.720\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eDecompressive surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e282 (47.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e22 (53.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e1.306(0.692-2.462)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.409\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall pulmonary complication\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e112 (18.7%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e13 (31.7%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2.023(1.016-4.030)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.041\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.863(0.912-3.806)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.088\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eARDS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e19 (3.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e3 (7.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e2.414(0.684-8.520)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.158\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003ePleural effusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e53 (8.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e7 (17.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e2.125(0.898-5.026)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.080\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003ePneumonia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e76 (12.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e9 (22.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e1.939(0.891-4.220)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.090\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePulmonary edema\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3 (0.5%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3 (7.3%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e15.711(3.067-80.470)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCardiovascular comorbidity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e336 (56.0%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e31 (75.6%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2.436(1.173-5.058)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.014\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eHTN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e289 (48.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e23 (56.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e1.375(0.727-2.601)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.326\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCAOD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e70 (11.7%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e12 (29.3%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.133(1.529-6.420)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2.912(1.386-6.119)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.005\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eArrythmia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e58 (9.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e4 (9.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e1.010(0.348-2.935)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.985\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eVHD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e22 (3.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e3 (7.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e2.074(0.594-7.241)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.243\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 3. Univariate and Multivariate Analyses of Factors associated with unfavorable functional outcomes following traumatic brain injury\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"822\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eUnivariate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eMultivariate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eFavorable outcome, N=492 (n, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eUnfavorable outcome (GOSE=1or2), N=149 (n, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eOR (95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eOR (95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e355 (72.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e113 (75.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e1.211(0.793-1.851)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.375\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003eWall motion abnormality after trauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e28 (5.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e13 (8.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e1.584(0.799-3.142)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.185\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003eTn elevation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e118 (24.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e41 (28.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e1.213(0.798-1.842)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.365\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSevere TBI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e129 (26.3%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e104 (69.8%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6.485(4.333-9.708)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e5.728(3.718-8.824)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMajor Trauma\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e396 (80.5%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e144 (96.6%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6.982(2.785-17.503)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2.506(0.956-6.570)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.062\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePulmonary complication\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e75 (15.2%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e50 (33.6%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2.808(1.846-4.272)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2.433(1.520-3.896)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003eARDS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e10 (2.0%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e12 (8.1%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4.222(1.786-9.981)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003ePleural effusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e35 (7.1%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e25 (16.8%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2.632(1.518-4.564)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003ePneumonia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e52 (10.6%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e33 (22.1%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2.407(1.487-3.897)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003ePulmonary edema\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e5 (1.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e1 (0.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.658(0.076-5.678)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.702\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003eHypotension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e12 (2.4%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e11 (7.4%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.188(1.377-7.384)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.004\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003eChest injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e174 (35.4%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e76 (51.0%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.903(1.313-2.756)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Brain Injuries, Traumatic, Cardiomyopathies, Myocardial Stunning, Echocardiography, Multiple Trauma, Comorbidity, Glasgow Outcome Scale, Critical Care, Pleural Effusion","lastPublishedDoi":"10.21203/rs.3.rs-7092075/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7092075/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eCardiac injury is a well-recognized extracranial complication in patients with acute brain injury, yet limited data exist on its occurrence and clinical implications in traumatic brain injury (TBI). This study aimed to evaluate the incidence, associated risk factors, and outcomes of cardiac wall motion abnormalities (WMA) detected by echocardiography in patients with TBI.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA retrospective observational study was conducted at a regional trauma center in South Korea. Patients admitted with TBI between 2019 and 2023 who underwent transthoracic echocardiography (TTE) were included. Cardiac injury was defined as newly appeared WMA on TTE. Demographics, clinical characteristics, cardiovascular comorbidities, complications, and Glasgow Outcome Scale-Extended (GOSE) scores were analyzed. Comparative analyses between WMA and non-WMA groups were performed using chi-square and t-tests, and univariate/multivariable logistic regression analyses were conducted to identify predictors of post-traumatic WMA and unfavorable outcomes.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAmong 1,942 TBI patients, 659 underwent TTE, and after excluding preexisting WMA, 641 were analyzed. Of these, 41 patients (6.4%) demonstrated post-traumatic WMA. Patients with WMA had a significantly higher prevalence of cardiovascular comorbidities (75.6% vs. 56.0%, OR\u0026thinsp;=\u0026thinsp;2.436, p\u0026thinsp;=\u0026thinsp;0.014) and pulmonary complications (31.7% vs. 18.7%, OR\u0026thinsp;=\u0026thinsp;2.023, p\u0026thinsp;=\u0026thinsp;0.041). Severe TBI and major trauma were not significantly associated with WMA. The WMA group had lower mean GOSE scores (3.78\u0026thinsp;\u0026plusmn;\u0026thinsp;1.90 vs. 4.19\u0026thinsp;\u0026plusmn;\u0026thinsp;1.86), and a higher proportion of patients with poor outcomes (GOSE 1\u0026ndash;2: 31.7% vs. 20.7%). Pulmonary complication was significantly associated with poor outcomes (OR\u0026thinsp;=\u0026thinsp;2.433, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eCardiac WMA is not uncommon in TBI patients and may be associated with preexisting cardiovascular disease, increased pulmonary complications, and poor neurological outcomes. Early screening for cardiac injury in high-risk TBI patients may enable tailored treatment strategies and improve clinical outcomes.\u003c/p\u003e","manuscriptTitle":"Prognostic impact of cardiac wall motion abnormalities after TBI: Association with pulmonary complications and cardiovascular comorbidities","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-17 14:14:48","doi":"10.21203/rs.3.rs-7092075/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"93ec4d27-da2c-461c-8cc1-e1a5737f0562","owner":[],"postedDate":"August 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-25T09:12:31+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-17 14:14:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7092075","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7092075","identity":"rs-7092075","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}