Contusion expansion, bifrontal contusions and low platelet count is associated with worse patient outcome following traumatic brain injury - a retrospective single-center study

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Andersson, Iftakher Hossain, Niklas Marklund This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4571926/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 24 Sep, 2024 Read the published version in Acta Neurochirurgica → Version 1 posted 9 You are reading this latest preprint version Abstract Background Cortical contusions are common in moderate-severe traumatic brain injury (TBI). Cortical contusions often expand, potentially causing neuro-worsening several hours to days post-trauma. While contusion expansion (CE) may affect outcome, potential clinical and radiological markers that can predict CE have been insufficiently explored. In the present single-center retrospective observational cohort study, we evaluated clinical outcome by the Glasgow Outcome Scale extended (GOSE) scale and evaluated risk factor for CE. Method Adult TBI patients > 18 years of age, and of all injury severities, were included. Main variables of interest were low platelet count, defined as < 150x10 9 /L, presence of bifrontal contusions and CE, defined as absolute contusion volume increase in cm³. Factors associated with CE and clinical outcome according to GOSE were analyzed. Results Between 2012–2022, 271 patients were included. Contusion size on admission correlated positively with CE, as did the Marshall and Rotterdam radiological classification scores. Bifrontal contusions were significantly larger at admission, experienced larger CE, and had a worse outcome than contusions in other locations. Patients with a platelet count < 150x10 9 /L experienced a greater volume CE and had a worse outcome when compared to patients with a normal platelet count. In a multivariate analysis, CE remained significantly associated with a poor outcome six months post- injury. Conclusion Contusion volume at admission, and Marshall- and Rotterdam scores, positively correlated to CE. Bifrontal contusions and a platelet count < 150x10 9 /L were associated with CE, and a poor clinical outcome. Large CE volumes were associated with a worse clinical outcome, and CE was per se associated with outcome in a multivariate analysis. Management of these risk factors for CE in the acute post-injury setting may be needed to attenuate contusion expansion and to improve clinical outcome in TBI patients suffering from cortical contusion injuries. 1) traumatic brain injury 2) cerebral contusions 3) bifrontal contusions 4) contusion expansion 5) outcome Figures Figure 1 Figure 2 Figure 3 Introduction Traumatic brain injury (TBI) is a leading cause of disability and death amongst younger patients globally, and an increasing cause of mortality amongst the elderly population in high-income countries ( 1 ). The severity of TBI is categorized into three groups based on initial Glasgow Coma Scale (GCS); severe ( 12) ( 2 ). Cerebral contusions (CC), a common type of TBI, are characterized by cortical, intraparenchymal hematomas, resulting from rapid acceleration-deceleration forces, as often seen in traumatic incidents such as motor vehicle accidents or falls ( 3 ). The contusion forms when the intracerebral microvasculature ruptures ( 4 ). Depending on if the contusion formation occurs on the ipsilateral or contralateral side of the insult, it is called coup or contrecoup, respectively. A contrecoup injury is more common than a coup injury, however, they are often seen together ( 5 ). Contusions most often occur in the basal frontal and temporal lobes where the soft brain is damaged by friction against the underlying bony skull base ( 3 ). This makes it an injury with high risk of loss of functions associated with these areas such as personality, language, and executive functions ( 6 ). CC are often accompanied with other intracranial hemorrhages such as epidural-and subdural hematomas (EDH and SDH, respectively) ( 7 ). Contusion expansion (CE), defined as the hematoma volume increases beyond its initial value, occurs in approximately half of CC cases ( 8 , 9 ). CE, visualized on a follow up computed tomography (CT) scan, is often associated with neuroworsening, i.e. reduced consciousness level and/or emergence of focal neurological deficits ( 9 ). The possibility of CE makes CC challenging to manage since an awake patient presenting with minor or no visible lesions on an initial CT scan can rapidly deteriorate several hours post-injury due to increased mass effect. However, not all patient experiencing CE worsen ( 9 – 11 ). The risk of CE is suggested to be the highest during the first 24 hours post trauma ( 12 ). An initial low GCS score and a larger hematoma volume at admission are associated with CE, although no consensus on the volume increase needed to define CE has been established ( 5 ). Other suggested risk factors are male sex, old age, blood alcohol level, high international normalized ratio (INR), low platelet count and hypertension ( 5 , 10 ).The use of antiplatelets, such as aspirin and clopidogrel used to prevent cardiovascular morbidity, complicates CC management ( 13 ). Intake of direct oral anticoagulants (DOAC) and, in particular, Warfarin also increase the risk ( 14 , 15 ). Patients with bifrontal contusions are a common CC subgroup that tend to present with a relatively high GCS score to then rapidly deteriorate later in their clinical course due to CE ( 16 ). This makes them prone to possible undertreatment initially, risking a potentially avoidable negative outcome ( 17 ). Neurosurgical intervention of CC is indicated when increased intracranial pressure (ICP) (> 20 mmHg) is refractory to medical treatment. In localized CC, hematoma removal via a craniotomy is indicated when a patient presents with progressive neurological deterioration and mass effect on CT, marked by significant midline shift and compression of basal cisterns ( 18 ). An alternative is to perform a decompressive craniectomy (DC), especially in the case of diffuse cerebral swelling, although this may per se increase the risk of CE ( 18 , 19 ). However, DC was associated with a higher risk of severe disability at long-term ( 20 ). There is a lack of understanding the pathophysiology of CE to the uncertainties regarding when and how to operate for optimal outcome. There is no consensus on early clinical or laboratory signs that can predict whether a patient would benefit from early surgery or not in the case of CC, and therefor leaves the decision to surgically intervene to the neurosurgeon ( 21 ). The clinical decision making is further complicated by clinical factors such as e.g., patient age, contusion distribution - especially bifrontal contusions- and how to reverse the care of antiplatelet- and anticoagulant- treated patients. With a better understanding of the factors influencing CE and who may benefit from early neurosurgical intervention, a more precise treatment regime can be applied to CC patients with the aim to reduce mortality and morbidity in this group of TBI patients. The aim of this study is to investigate the presence of potential clinical and radiological markers that can predict CE and to measure the impact of coagulopathy and presence of bifrontal contusions on CE and clinical outcome, measured by Glasgow Outcome Scale extended (GOSE). Material and method Patient selection and data collection This is a retrospective study that investigates the clinical course amongst patients with CC admitted to the Neurosurgical clinic at the Skåne University hospital in Lund during the years 2012–2022. Patients who received the ICD-code S.06 (Intracranial injury) were selected to ensure all TBI patients with CC were analyzed, since CC often co-exist with other intracranial injuries. Included patients had CC present on admission CT head imaging, had a follow up CT scan within 72 hours after the initial scan, and were > 18 years of age at admission (Fig. 1 ). Patient information regarding age, sex, GCS, medical history, clinical-and lab parameters, treatment methods, clinical course, and outcome at six months post injury using GOSE, were gathered from medical records accessed via Melior and SieView (Cerner, Kansas City, MO, USA). All data was stored in Microsoft Excel (Microsoft Office, Redmond, WA, USA). Figure 1 legend: Overview of patient inclusion and subgroups. We evaluated 801 patients who received a S.06 ICD-10 code between 2012–2022. After applying exclusion critera, 272 patients were included in the study. Two subgroups were defined using contusion location: bifrontal contusions (n = 85) vs. contusions in other locations (n = 187), and patients with a platelet count higher (N = 236), or lower (n = 30), than 150x10 9 /L blood. CT = Computed tomography. Imaging Radiological data was gathered from imaging archives via Sectra Picture Archiving and Communication System IDS7 (Sectra AB, Linköping, Sweden). Contusion volume was measured using the ABC/2-formula from admission and follow up CT scans of head ( 22 ). The largest and the second largest contusion were measured, if more than one was present, but registered separately as initial and second hematoma. The basal cisterns were registered as normal, compressed, or effaced. Midline shift was categorized as normal, 5 mm. Affected cerebral lobes, presence of bifrontal contusions, and presence of another intracranial hematoma (e.g. EDH or SDH) was registered. Absolute contusion volume increase from first CT scan to follow up CT scan was registered, and data used in the analysis of contusion expansion. TBI severity and outcome The severity of TBI was classified according to GCS at admission and was registered using both the Marshall, and the Rotterdam classification score of TBI using the first CT scan performed upon arrival to the emergency room ( 23 , 24 ). An adjusted version of GOSE was used to evaluate the global functional outcome of the patients six months following TBI (Supplementary tables 1). The patient’s capacity of working, functioning independently at home, neurological deficits and capability of functioning in social relationships were extracted from the physician, physiotherapist and occupational therapist notes in the medical records six months after injury. The extracted data is corresponding to the global scale for functional outcome measurement. The extracted followed data included dead to good recovery scales ( 25 ). Coagulation profile Blood platelet levels, information regarding INR and Activated Partial Thromboplastin Time (APTT) and platelet transfusions were collected. Antithrombotic treatment, for example intake of aspirin, clopidogrel or DOAC, was also extracted from the patient records. Statistical analysis Blood platelet levels were dichotomized into two groups; low, defined as 150x109/L, and the patients were grouped thereafter. Blood platelet transfusion administration was considered a dichotomized variable. The largest contusion is included in the statistical analysis and for bifrontal contusions the one with the greatest volume was used. When performing a multivariate analysis, the GOSE was dichotomized into two categories, unfavorable (GOSE 1–4) and favorable (GOSE 5–8), a dichotomization often used ( 26 ). All continuous data analyzed was non-parametric, assessed by using Kolmogorov-Smirnov test, and therefore expressed in medians with interquartile range (IQ). Mann-Whitney test was used when comparing continuous data between two groups. Kruskal Wallis test was used when analyzing more than two groups. Chi-squared test was used when comparing two or more categorical variables. Spearman's rho was used for correlation analysis between continuous and/or ordinal variables. Multivariate analysis was performed using a binomial regression and is presented as odds with 95% confidence interval (CI). Level of significance was set at p < 0.05. All analyses were performed using SPSS Statistics (29.0) (IBM Corp, Armonk NY). Results There were 801 patients who had an S.06-diagnosis code between the years of 2012–2022. Patients under the age of 18 years at admission and patients who had no contusions were excluded, generating 272 patients who met the inclusion criteria (Fig. 1 ). Of these, 35 patients underwent contusion evacuation surgery, 9 patients had a craniectomy, and three of those had both procedures done. There were 31 patients who had an extra-axial hematoma evacuated, and 202 patients were conservatively treated (Table 1). The most common occurring outcome measure was GOSE 7 and 8, together representing 35% of the patient population where outcome was accessible. GOSE was not accessible due to lack of follow up amongst 21% (n = 58) patients (Table 1). Table 1: Demographics of the study patients. GCS = Glasgow Coma Scale. SBP = Systolic blood pressure. PK-INR = Prothrombin complex-International ratio. APTT = Activated partial thromboplastin time. NICU = Neurointensive care. LMWH = Low-molecular weight heparin. ASA = American Society of Anesthesiology. IQ = Interquartile range. *= Could be evacuation of extra-axial hematoma, or a combination of contusionectomy, evacuation of extra-axial hematoma and decompressive craniectomy. Parameter (n = 272) Median (IQ) / (n. %) Missing (n. %) Age 55 (35–68) Sex Female Male 87 (32%) 185 (68%) GCS at arrival 13 ( 7 – 14 ) Initial treatment Conservative Contusionectomy Craniectomy Evacuation extra-axial hematoma 202 (74%) 35 (13%) 9 (3%) 31 (11%) Conservative or Operative treatment Continous conservative Contusionectomy Craniectomy Other* 172 (85%) 21 (10%) 3 (1%) 6 (3%) Cause of injury Fall from same level Fall from height (> 1m) Road traffic accident Sports related Assault Blunt or penetrating trauma 89 (33%) 58 (21%) 83 (31%) 5 (2%) 15 (6%) 16 (6%) ASA score 1 ( 1 – 2 ) SBP admission 140 (122–160) 17 (6%) Platelet count > 150x10 9 /l 232 (199–288) Platelet count < 150x10 9 /l 137 (110–142) Missing platelet information 6 (2%) PK-INR 1 (1-1.1) 11 (4%) APTT 25 ( 23 – 27 ) 15 (6%) Days spent in NICU 5 ( 2 – 13 ) 3 (1%) 30 days mortality 29 (11%) 4 (1%) Thromboembolic event 10 (4%) Received LMWH 59 (22%) GOSE at 6 months Dead or vegetative Severely disabled Moderately disabled Good Recovery 41 (19%) 37 (17%) 62 (29%) 74 (35%) 58 (21%) Contusion expansion Out of 272, 181 patients experienced contusion expansion (67%). The median contusion volume at admission was 6.8 ml (IQ 2.1–15.9) (Table 2 ). The median absolute contusion volume increase at follow-up CT scan was 4.0 ml (IQ 0–15) (Table 2 ). Admission contusion volume had a significant, positive correlation with absolute contusion volume increase (Spearman's rho coefficient 0.19, p = 0.002 ). The median Marshall score was 2 (IQ 2–3) and the median Rotterdam score was 3 (IQ 2–3). Both Marshall- and Rotterdam score had a significant, positive correlation with absolute contusion volume expansion (Spearman's rho coefficient 0.26, p < 0.001 and 0.24, p < 0.001 , respectively) Table 2 Computer tomography (CT) characteristics of included patients. Parameter (n = 272) Median (IQ) / (n. %) Missing (n. %) Age 55 (35–68) Sex Female Male 87 (32%) 185 (68%) GCS at arrival 13 ( 7 – 14 ) Initial treatment Conservative Contusionectomy Craniectomy Evacuation extra-axial hematoma 202 (74%) 35 (13%) 9 (3%) 31 (11%) Conservative or Operative treatment Continous conservative Contusionectomy Craniectomy Other* 172 (85%) 21 (10%) 3 (1%) 6 (3%) Cause of injury Fall from same level Fall from height (> 1m) Road traffic accident Sports related Assault Blunt or penetrating trauma 89 (33%) 58 (21%) 83 (31%) 5 (2%) 15 (6%) 16 (6%) ASA score 1 ( 1 – 2 ) SBP admission 140 (122–160) 17 (6%) Platelet count > 150x10 9 /l 232 (199–288) Platelet count < 150x10 9 /l 137 (110–142) Missing platelet information 6 (2%) PK-INR 1 (1-1.1) 11 (4%) APTT 25 ( 23 – 27 ) 15 (6%) Days spent in NICU 5 ( 2 – 13 ) 3 (1%) 30 days mortality 29 (11%) 4 (1%) Thromboembolic event 10 (4%) Received LMWH 59 (22%) GOSE at 6 months Dead or vegetative Severely disabled Moderately disabled Good Recovery 41 (19%) 37 (17%) 62 (29%) 74 (35%) 58 (21%) IQR = Interquartile range. CT = Computed tomography. MRI = Magnetic resonance imaging. DAI = Diffuse agonal injury. Table 2 : Computer tomography (CT) characteristics of included patients. IQR = Interquartile range. CT = Computed tomography. MRI = Magnetic resonance imaging. DAI = Diffuse agonal injury. Parameter (n = 272) Median (IQR) / (n. %) Contusion volume at admission (largest contusion) 6,8 ml (2.1–15.9) Absolute volume expansion at follow up CT scan (within 72 hours) 4 ml ( 4 – 15 ) Bifrontal contusions 85 (31%) Location of largest contusion Frontal Temporal Parietal Occipital 150 (55%) 112 (41%) 5 (1.5%) 5 (1.5%) Location of second largest contusion None Frontal Temporal Parietal Occipital Cerebellum 133 (48%) 86 (32%) 46 (17%) 5 (18%) 1 (0.3%) 1 (0.3%) Epidural hematoma 41 (15%) Subdural hematoma 94 (35%) Basal cistern Open Compressed Effaced 181 (67%) 85 (31%) 6 (2%) Midline shift Normal 5 mm shift 156 (57%) 89 (33%) 27 (10%) Marshall Score 2 ( 2 – 3 ) Rotterdam Score 3 ( 2 – 3 ) MRI verified DAI 30 (11%) There was a weak but significant correlation between absolute contusion volume increase and GCS on admission (Spearman's rho coefficient 0.14 p = 0.02 , and Spearman's rho coefficient − 0.14 p = 0.018 , respectively). A significant difference in CE was found between the group of "Good recovery" (1.4 ml, 0-8.2) and "Dead or vegetative" (14.3 ml, IQ 2-44.1), and "moderately disabled" (8.3 ml, IQ 2–18) ( p < 0.001 and p = 0.001 , respectively). The presence of other intracranial hematomas did not significantly correlate to contusion expansion, nor did midline shift at admission, systolic blood pressure, known alcohol abuse, blood ethanol levels, age, or sex. Bifrontal contusions The median contusion volume amongst patients with contusions at other, non-bifrontal brain regions was 4.9 ml (n = 187, IQ 1.7–13.0), and 11.6 ml amongst patients with bifrontal contusions, measuring the largest (n = 85, IQ 4.2–20,7; p < 0.001 ). The absolute contusion volume increase amongst patients without bifrontal contusions was 2,1 ml (n = 187, IQ 0-13.2) compared to 10 ml (n = 83, IQ 2-30.6) in the bifrontal group ( p < 0.001 ). Patients with bifrontal contusions had similar GCS scores upon arrival when compared to patients with contusions in other brain regions, including patients with unilateral frontal contusions. Patients with bifrontal contusions did not undergo contusion evacuation surgery or craniectomy at a greater extent than other contusion patients. The median GOSE in the bifrontal group was equivalent of moderately disabled, which is equivalent of GOSE 5 and 6 (n = 65) which was also the case for the group with contusions in other locations (n = 149). Using Chi-squared test, the bifrontal group had a worse outcome than the group with other-located contusions, χ2 (3, N = 214) = 8.115, p = 0.0043 (Fig. 2, Table 3 ). Table 3 Worse outcome in patients with bifrontal contusions when compared to patients with contusions in other locations Parameter (n = 272) Median (IQR) / (n. %) Contusion volume at admission (largest contusion) 6,8 ml (2.1–15.9) Absolute volume expansion at follow up CT scan (within 72 hours) 4 ml ( 4 – 15 ) Bifrontal contusions 85 (31%) Location of largest contusion Frontal Temporal Parietal Occipital 150 (55%) 112 (41%) 5 (1.5%) 5 (1.5%) Location of second largest contusion None Frontal Temporal Parietal Occipital Cerebellum 133 (48%) 86 (32%) 46 (17%) 5 (18%) 1 (0.3%) 1 (0.3%) Epidural hematoma 41 (15%) Subdural hematoma 94 (35%) Basal cistern Open Compressed Effaced 181 (67%) 85 (31%) 6 (2%) Midline shift Normal 5 mm shift 156 (57%) 89 (33%) 27 (10%) Marshall Score 2 ( 2 – 3 ) Rotterdam Score 3 ( 2 – 3 ) MRI verified DAI 30 (11%) The difference in outcome between patients with bifrontal contusions and patients with contusions in other locations are compared using Chi-square test. A total of 214 patients were included in the study of whom 65 had bifrontal contusions and 149 had contusions in other locations. The difference between the groups was highly significant, p = 0.0044 . 2: Distribution of outcome between patients with bifrontal contusions and patients with contusions in other locations. Figure 2 legend: Distribution of outcome between patients with bifrontal contusions and patients with contusions in other locations. Distribution between patients with bifrontal contusions (n = 65) compared to patients with contusions in other locations (n = 149) with regard to patient outcome at six months post-injury using the Glasgow outcome scale extended (GOSE). Table 3 : Worse outcome in patients with bifrontal contusions when compared to patients with contusions in other locations The difference in outcome between patients with bifrontal contusions and patients with contusions in other locations are compared using Chi-square test. A total of 214 patients were included in the study of whom 65 had bifrontal contusions and 149 had contusions in other locations. The difference between the groups was highly significant, p = 0.0044 . Percentage of total within GOSE category (n) Dead or Vegetative Severely disabled Moderately disabled Good recovery Contusions, bifrontal (n = 65) 46% ( 19 ) 19% ( 7 ) 32% ( 20 ) 26% ( 19 ) Contusions, other locations (n = 149) 54% ( 22 ) 81% ( 30 ) 68% ( 42 ) 74% (55) χ 2 = 8.12, p = 0.044 Coagulation The median blood platelet count was 223 x109/L (IQ 183–276) (Table 1). Neither INR nor APTT was significantly associated with outcome, and only 25 patients had an INR above 1.2. median INR was 1 (IQ 1–1,1) (Table 1). For 237 patients, there was no records of any regular intake of anticoagulant drugs. There were 11 patients on Warfarin, and 25 patients were on aspirin. There was no significant difference in outcome or absolute contusion volume increase in the aspirin-treated group compared to patients not treated with aspirin. The number of patients on any other type of antithrombotic drug was too low for further analysis. Out of all patients, 11% (n = 30) received one or more blood platelet transfusions. Using Chi-square test, the patients who received blood platelet transfusion had a higher-than-expected count in the GOSE group of "dead or vegetative", and none in the group of "good recovery", in comparison to the group who did not receive a blood platelet transfusion where the trend was inverted, χ2 (3, n = 214) = 19.78, p < 0.001). When dichotomized to 150x109/L) (n = 30 and n = 179, respectively), using Chi- square test, the group with a lower platelet count had a significant worse six-month outcome according to GOSE, compared to the group with a higher blood platelet count (χ2 (3, n = 209) = 13.4, p < 0.004) (Fig. 3, Table 4). A difference in absolute contusion volume increase was shown between the patients with a platelet cell count 150x109/L group (15.3 ml versus 3.6 ml, p = 0.003 ). 3: Difference in outcome between patients with a platelet count 150x109/L. Figure 3 legend: Difference in outcome between patients with a platelet count than 150x10 9 /L Distribution in patient outcome according to Glasgow outcome scale extended (GOSE) dichotomizing according to platelet count less than (n = 30) or above (n = 179) 150x10 9 /L. Table 4: The difference in outcome between patients with a low versus a normal platelet count, using Chi-square test. The difference in outcome between patients with a low platelet count versus a higher platelet count, using Chi-square test. A total of 209 patients were included in the study, 30 patients had a platelet count 150x10 9 /L. The difference between the groups was shown significant, p = 0.004 . Percentage of total within GOSE category (n) Dead or Vegetative Severely disabled Moderately disabled Good recovery Platelet count 150x10^9/L (n = 179) 71% ( 29 ) 86% ( 32 ) 84% (51) 96% (67) χ 2 = 13.4, p = 0.004 Multivariate analysis A multivariate regression was performed with six-month outcome as outcome variable. This included contusion volume at admission, absolute contusion volume difference, platelet levels 150x109/L, and whether the contusions were bifrontal or not. In the multivariate analysis, 207 patients were included (76.1%) of whom 61 patients had bifrontal contusions, and 29 patients had a platelet count < 150x109/L. The outcome variable was dichotomized into unfavorable (n = 77) and favorable (130), as described above. The remaining variable that had a significant impact on outcome was contusion expansion (OR 0.975, CI 0.955–0.995) (Table 5 ). Table 5 Multivariate analysis with regards to patient outcome at six months post-injury. A multivariate regression analysis was performed, including variables who on univariate regression had a significant impact (p < 0.05) on patient outcome according to Glasgow outcome scale extended (GOSE) six months post-injury. Contusion expansion was shown significantly impact outcome measured as either unfavourable (GOSE = 1–4; n = 77) or favourable (GOSE = 5–8; n = 130) outcome. Due to missing data on platelet levels upon arrival, 207 out of 272 patients could be included. OR = Odds ratio; CI = Confidence interval. Included variables n = 207 OR (CI) p Contusion volume at admission 0.983 (0.962–1.004) 0.117 Contusion expansion 0.975 (0.955–0.995) 0.013 Contusion location (bifrontal & other) (61 & 146) 0.778 (0.386–1.567) 0.482 Platelet levels (150x10 9 /L) (29 & 178) 0.490 (0.208–1.155) 0.103 Discussion In the present study, we investigated the potential clinical and radiological markers that could predict CE, and the impact of bifrontal contusions and a low platelet count on patient outcome measured by GOSE at 6-months after TBI. The Marshall and Rotterdam CT classification system, and a blood platelet count < 150x109/L correlated significantly with CE. However, platelet transfusion was a negative prognostic factor for poor outcome measured by GOSE. Patients with bifrontal contusions had CE in a larger extent compared to the non-bifrontal group and had worse functional outcome at 6-months. CE was found as the significant variable with a negative impact on outcome 6-months post injury. The Marshall and Rotterdam scores previously showed good predictive accuracy for in-hospital mortality and outcome prediction in patients with TBI ( 27 ). The Marshall score has also been found to be independently associated with neuroworsening ( 28 ). Two major components of the Marshall and Rotterdam scores, basal cistern compression and midline shift, are results of mass effect and can therefore be seen as a secondary effect of a large contusion volume. In our study, a higher Marshall and Rotterdam score significantly correlated with CE and CE was found to have a negative impact on 6-months functional outcome. Coagulopathy is a complicating factor in the management of TBI patients and has in previous studies been reported as a risk factor for CE. The effect of a low platelet count has been shown to have a significant impact on CE ( 29 ). A platelet count ≤ 100 × 10 9 /l is associated with CE and increased mortality and is usually the threshold of accepted platelet levels in elective surgery ( 30 ). A recent Finnish multi-center intensive care study has reported that in-hospital mortality was three times higher and 12-months mortality two times higher in TBI patients with a platelet count ≤ 100 × 10 9 /l ( 31 ). A platelet count of 150 x 10 9 /l is considered normal and was chosen at a cut-off in our study. In most previous papers, a lower platelet count was associated with CE, and our data stress the importance of rigid platelet control in TBI patients. In patients with elevated INR, double anti-platelet therapy, or any other antithrombotic treatment, the risk of CE was not significantly increased. Previously, INR levels > 1.2 were associated with a threefold increased risk for CE. However, due to the small number of patients in these subgroups in our present, there is a risk of a type two error, and an elevated INR should be aggressively corrected ( 5 , 32 ). In our cohort, 11% received one or more blood platelet transfusions and those patients had a worse outcome when compared to patients who did not receive platelet transfusions. The indications varied widely, including as a part of a trauma transfusion protocol, and thus not merely used for a low platelet count. Since platelet transfusions are associated with a number of adverse events its role in TBI patients remains a matter of debate ( 33 ). There is scarce literature on bifrontal contusions, and it often focuses on investigating the optimal surgical approach ( 17 , 34 ). Van de Zande et.al. performed a systematic review investigating the treatment and outcome of patients suffering bifrontal contusions ( 16 ). Six out of seven studies of in total 356 patients measured outcome by GOS, where the average score was 4 (moderately disabled) at one-year post-injury. In the present study we observed that bifrontal contusions had a significantly larger volume when compared to contusions in other brain regions, and significantly larger CE. The median outcome was a GOSE score of 5 and 6 (i.e. moderate disability) in line with previous studies ( 16 ). Although contusion volumes at admission were larger in the bifrontal contusion group, the GCS scores did not differ, it is plausible that patients with bifrontal contusions for anatomical reasons could accommodate a larger hematoma volume before their level of consciousness is affected. In contrast to the earlier findings, we showed that bifrontal contusions had a worse outcome when compared to other-located contusions, and thus that they may be considered an own sub-entity. We investigated whether CE negatively impacts patient outcome. Recently, a single-center retrospective study showed a 6% increased risk in a 1-point deduction on the GOS scale for every 1 ml increase of intracranial hematoma, showing a correlation between hematoma expansion and outcome at 12 months post-injury ( 12 ). A recent multi-center observational study concluded that absolute CE outperformed relative CE in predicting both unfavorable outcome and mortality ( 35 ). These results indicate that CE is a crucial contributor to outcome, consistent with our present findings where CE significantly contributed to a poor outcome both in the univariate and multivariate analysis. One feasible explanation is CE and brain swelling progression could result in increased ICP and decreased cerebral perfusion pressure (CPP), independently associated with a risk of poor outcome and death ( 36 , 37 ). Our study is not without limitations. The GOSE data of this study was gathered from medical journals, and 21% of the patients were unfortunately lost to follow-up. Since GOSE is based on patient activity level in comparison to life pre-injury, the information was easily accessible from the medical records of patients who were in contact with medical professionals at the time for outcome evaluation. The retrospective design of the study is another key limitation. In view of the absence of strict guidelines, the decision to admit, and to perform surgery, is mainly based on the individual neurosurgeon´s decision. Thus, there may be heterogeneity of treatments offered to the patients in our cohort. Dividing the GOSE into a dichotomous scale as favorable and unfavorable is a common division when performing multivariate analysis and is used for statistical reasons ( 26 ). However, valuable nuances of the morbidity spectrum are lost in this simplification. Strengths of the study include that the study population is relatively large, and there is access to highly detailed clinical data. By defining relevant characteristics in bifrontal contusions, and in other-located contusions, we aimed to facilitate decision-making in a clinical setting. We also investigated the important role for coagulopathy for poor outcome and thus we suggest an active role for coagulation management and correction at the early stage to optimize patient outcome ( 38 ). Conclusion The Marshall and Rotterdam CT classification score, a platelet count < 150x109/L, contusion volume at admission and the presence of bifrontal contusions at admission correlated to CE. Patients with bifrontal contusions, a platelet count < 150x109/L and who experienced CE suffered a worse outcome according to GOSE six months after injury, when compared to patients with contusions in other brain regions. On multivariate analysis, CE remained the most significant variable affecting patient outcome. Thus, our results support that CE is a contributing negative factor in patient outcome, and therefore a potential target for therapeutic intervention. Declarations Acknowledgements The authors thank the foundations for the research funding. Iftakher Hossain (IH) and Niklas Marklund (NM). The Finnish Medical Foundation (IH), The Päivikki and Sakari Sohlberg Foundation (IH), The Paulo Foundation (IH), The Finnish Cultural Foundation (IH), Skåne University Hospital ALF funds (NM), Hans-Gabriel af Trolle Wachtmeister Foundation (NM) and Swedish Brain Foundation (NM). Funding The Finnish Medical Foundation (IH), The Päivikki and Sakari Sohlberg Foundation (IH), The Paulo Foundation (IH), The Finnish Cultural Foundation (IH), Skåne University Hospital ALF funds (NM), Hans-Gabriel af Trolle Wachtmeister Foundation (NM), Swedish Brain Foundation (NM) and Elsa Schmitz Foundation (AA). Iftakher Hossain (IH), Niklas Marklund (NM) and Alice Andersson (AA). Competing Interests The authors declare that they have no conflict of interest. Availability of data and material Available upon request. Code availability Available upon request. Authors' contributions All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Alice Andersson. The primary draft of the manuscript was written by Alice Andersson and assisted by Iftakher Hossain. The study was solely supervised by Niklas Marklund and he also designed the methodology. All authors commented on previous versions of the manuscript to prepare the final draft. All authors read and approved the final manuscript before submission. Ethics approval The study has obtained ethical approval from the ethical review board for retrospective evaluation of patients (Dnr 2017/4069). GDPR is adhered to and a separate application is used for access to medical records (Kunskapstyrning, KvB). Consent to participate and consent for publication The individual patients were not informed on their contribution to the present study and did not sign an informed consent. The data cannot be traced to included individuals and was stored on password protected devices. References Majdan M, Plancikova D, Brazinova A, Rusnak M, Nieboer D, Feigin V et al (2016) Epidemiology of traumatic brain injuries in Europe: a cross-sectional analysis. Lancet Public Health 1(2):e76–e83 Teasdale G, Jennett B (1974) Assessment of coma and impaired consciousness. A practical scale. Lancet 2(7872):81–84 McKee AC, Daneshvar DH (2015) The neuropathology of traumatic brain injury. Handb Clin Neurol 127:45–66 Newcombe VF, Williams GB, Outtrim JG, Chatfield D, Gulia Abate M, Geeraerts T et al (2013) Microstructural basis of contusion expansion in traumatic brain injury: insights from diffusion tensor imaging. J Cereb Blood Flow Metab 33(6):855–862 Adatia K, Newcombe VFJ, Menon DK (2021) Contusion Progression Following Traumatic Brain Injury: A Review of Clinical and Radiological Predictors, and Influence on Outcome. Neurocrit Care 34(1):312–324 Martin RM, Wright MJ, Lutkenhoff ES, Ellingson BM, Van Horn JD, Tubi M et al (2017) Traumatic hemorrhagic brain injury: impact of location and resorption on cognitive outcome. J Neurosurg 126(3):796–804 Svedung Wettervik T, Hanell A, Enblad P, Lewen A (2023) Intracranial lesion features in moderate-to-severe traumatic brain injury: relation to neurointensive care variables and clinical outcome. Acta Neurochir (Wien) 165(9):2389–2398 Oertel M, Kelly DF, McArthur D, Boscardin WJ, Glenn TC, Lee JH et al (2002) Progressive hemorrhage after head trauma: predictors and consequences of the evolving injury. J Neurosurg 96(1):109–116 Iaccarino C, Schiavi P, Picetti E, Goldoni M, Cerasti D, Caspani M et al (2014) Patients with brain contusions: predictors of outcome and relationship between radiological and clinical evolution. J Neurosurg 120(4):908–918 Carnevale JA, Segar DJ, Powers AY, Shah M, Doberstein C, Drapcho B et al (2018) Blossoming contusions: identifying factors contributing to the expansion of traumatic intracerebral hemorrhage. J Neurosurg 129(5):1305–1316 Alahmadi H, Vachhrajani S, Cusimano MD (2010) The natural history of brain contusion: an analysis of radiological and clinical progression. J Neurosurg 112(5):1139–1145 Fletcher-Sandersjoo A, Tatter C, Tjerkaski J, Bartek J Jr., Maegele M, Nelson DW et al (2023) Time Course and Clinical Significance of Hematoma Expansion in Moderate-to-Severe Traumatic Brain Injury: An Observational Cohort Study. Neurocrit Care 38(1):60–70 Serebruany VL, Malinin AI, Ziai W, Pokov AN, Bhatt DL, Alberts MJ et al (2005) Effects of clopidogrel and aspirin in combination versus aspirin alone on platelet activation and major receptor expression in patients after recent ischemic stroke: for the Plavix Use for Treatment of Stroke (PLUTO-Stroke) trial. Stroke 36(10):2289–2292 Bonville DJ, Ata A, Jahraus CB, Arnold-Lloyd T, Salem L, Rosati C et al (2011) Impact of preinjury warfarin and antiplatelet agents on outcomes of trauma patients. Surgery 150(4):861–868 Scotti P, Seguin C, Lo BWY, de Guise E, Troquet JM, Marcoux J (2019) Antithrombotic agents and traumatic brain injury in the elderly population: hemorrhage patterns and outcomes. J Neurosurg. :1–10 Van de Zande N, Manivannan S, Sharouf F, Shastin D, Abdulla M, Chumas PD et al (2020) Demographics, presentation, and clinical outcomes after traumatic bifrontal contusions: a systematic review. Neurosurg Rev 43(3):977–986 Devi B, Sarma P, Shukla D (2015) Bifrontal Contusions: What Is the Best Surgical Treatment? Indian J Neurotrauma 12(02):103–106 Bullock MR, Chesnut R, Ghajar J, Gordon D, Hartl R, Newell DW et al (2006) Surgical management of traumatic parenchymal lesions. Neurosurgery 58(3 Suppl):S25–46 discussion Si-iv Cepeda S, Castaño-León AM, Munarriz PM, Paredes I, Panero I, Eiriz C et al (2019) Effect of decompressive craniectomy in the postoperative expansion of traumatic intracerebral hemorrhage: a propensity score-based analysis. J Neurosurg 132(5):1623–1635 Hutchinson PJ, Kolias AG, Timofeev IS, Corteen EA, Czosnyka M, Timothy J et al (2016) Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension. N Engl J Med 375(12):1119–1130 Gregson BA, Mitchell P, Mendelow AD (2019) Surgical Decision Making in Brain Hemorrhage. Stroke 50(5):1108–1115 Kothari RU, Brott T, Broderick JP, Barsan WG, Sauerbeck LR, Zuccarello M et al (1996) The ABCs of measuring intracerebral hemorrhage volumes. Stroke 27(8):1304–1305 Marshall LF, Marshall SB, Klauber MR, Van Berkum Clark M, Eisenberg H, Jane JA et al (1992) The diagnosis of head injury requires a classification based on computed axial tomography. J Neurotrauma 9(Suppl 1):S287–S292 Maas AI, Hukkelhoven CW, Marshall LF, Steyerberg EW (2005) Prediction of outcome in traumatic brain injury with computed tomographic characteristics: a comparison between the computed tomographic classification and combinations of computed tomographic predictors. Neurosurgery 57(6):1173–1182 discussion – 82 Wilson JT, Pettigrew LE, Teasdale GM (1998) Structured interviews for the Glasgow Outcome Scale and the extended Glasgow Outcome Scale: guidelines for their use. J Neurotrauma 15(8):573–585 Alali AS, Vavrek D, Barber J, Dikmen S, Nathens AB, Temkin NR (2015) Comparative study of outcome measures and analysis methods for traumatic brain injury trials. J Neurotrauma 32(8):581–589 Sadighi N, Talari H, Zafarmandi S, Ahmadianfard S, Baigi V, Fakharian E et al (2023) Prediction of In-Hospital Outcomes in Patients with Traumatic Brain Injury Using Computed Tomographic Scoring Systems: A Comparison Between Marshall, Rotterdam, and Neuroimaging Radiological Interpretation Systems. World Neurosurg 175:e271–e7 Fabbri A, Servadei F, Marchesini G, Bronzoni C, Montesi D, Arietta L (2013) Antiplatelet therapy and the outcome of subjects with intracranial injury: the Italian SIMEU study. Crit Care 17(2):R53 Yuan F, Ding J, Chen H, Guo Y, Wang G, Gao WW et al (2012) Predicting progressive hemorrhagic injury after traumatic brain injury: derivation and validation of a risk score based on admission characteristics. J Neurotrauma 29(12):2137–2142 Brown LM, Call MS, Margaret Knudson M, Cohen MJ, Holcomb JB, Wade CE et al (2011) A normal platelet count may not be enough: the impact of admission platelet count on mortality and transfusion in severely injured trauma patients. J Trauma 71(2 Suppl 3):S337–S342 Lillemäe K, Luostarinen T, Reinikainen M, Bendel S, Laitio R, Hoppu S et al (2022) Early thrombocytopenia is associated with an increased risk of mortality in patients with traumatic brain injury treated in the intensive care unit: a Finnish Intensive Care Consortium study. Acta Neurochir (Wien) 164(10):2731–2740 Wan X, Fan T, Wang S, Zhang S, Liu S, Yang H et al (2017) Progressive hemorrhagic injury in patients with traumatic intracerebral hemorrhage: characteristics, risk factors and impact on management. Acta Neurochir (Wien) 159(2):227–235 Moore L, Tardif PA, Lauzier F, Bérubé M, Archambault P, Lamontagne F et al (2020) Low-Value Clinical Practices in Adult Traumatic Brain Injury: An Umbrella Review. J Neurotrauma 37(24):2605–2615 Zhaofeng L, Bing L, Peng Q, Jiyao J (2016) Surgical Treatment of Traumatic Bifrontal Contusions: When and How? World Neurosurg 93:261–269 Fletcher-Sandersjöö A, Svedung Wettervik T, Tatter C, Tjerkaski J, Nelson DW, Maegele M et al (2024) Absolute Contusion Expansion Is Superior to Relative Expansion in Predicting Traumatic Brain Injury Outcomes: A Multi-Center Observational Cohort Study. J Neurotrauma 41(5–6):705–713 Hutchinson PJ, Kolias AG, Tajsic T, Adeleye A, Aklilu AT, Apriawan T et al (2019) Consensus statement from the International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury: Consensus statement. Acta Neurochir (Wien) 161(7):1261–1274 Schizodimos T, Soulountsi V, Iasonidou C, Kapravelos N (2020) An overview of management of intracranial hypertension in the intensive care unit. J Anesth 34(5):741–757 Hossain I, Rostami E, Marklund N (2023) The management of severe traumatic brain injury in the initial postinjury hours - current evidence and controversies. Curr Opin Crit Care 29(6):650–658 Additional Declarations No competing interests reported. Supplementary Files Supplementarytable1.docx Cite Share Download PDF Status: Published Journal Publication published 24 Sep, 2024 Read the published version in Acta Neurochirurgica → Version 1 posted Editorial decision: Revision requested 23 Jun, 2024 Reviews received at journal 23 Jun, 2024 Reviews received at journal 14 Jun, 2024 Reviewers agreed at journal 13 Jun, 2024 Reviewers agreed at journal 13 Jun, 2024 Reviewers invited by journal 13 Jun, 2024 Editor assigned by journal 13 Jun, 2024 Submission checks completed at journal 13 Jun, 2024 First submitted to journal 12 Jun, 2024 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-4571926","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":317915229,"identity":"950abb9c-7da7-42bc-a4c1-80bbae8bd3da","order_by":0,"name":"Alice S. Andersson","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAklEQVRIiWNgGAWjYDACdsYGCOMAhJJj4CGkhRlNizERWmAMqJbEBkJa+JuZGz98YLDL4zve+/jjj4o76fN7Dj978IGhTg6XFonDjM2SMxiSiyXPHDeT5jnzLHfD2TZzwxkMh41xWnOYsY2Zh4E5ccONNDZmxrbDuRv4GYB6GQ4kNuDQIQ/S8oehPnHD/WfMH3+2HU6X72f/Jv2Hoa4elxYDkBagXUBb2BgkeNsOJzCc7TGTBgZLAi53GYL80mNwPHHmmTQ2oF8OG244c6YMKHLYEJctcsfbH374UVGd2Hf8GDMwxA7Ly/ekb5P4UVEnj9P7EOcRITIKRsEoGAWjgAQAADQsV67D1gY7AAAAAElFTkSuQmCC","orcid":"","institution":"Lund University and Skane University Hospital","correspondingAuthor":true,"prefix":"","firstName":"Alice","middleName":"S.","lastName":"Andersson","suffix":""},{"id":317915230,"identity":"181b8a78-34c5-4441-942a-f59f1cecbb1a","order_by":1,"name":"Iftakher Hossain","email":"","orcid":"","institution":"Turku University Hospital and University of Turku","correspondingAuthor":false,"prefix":"","firstName":"Iftakher","middleName":"","lastName":"Hossain","suffix":""},{"id":317915231,"identity":"d4649ec7-6a03-4ee3-b868-ae4974fa8f4a","order_by":2,"name":"Niklas Marklund","email":"","orcid":"","institution":"Lund University and Skane University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Niklas","middleName":"","lastName":"Marklund","suffix":""}],"badges":[],"createdAt":"2024-06-12 17:55:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4571926/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4571926/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00701-024-06269-7","type":"published","date":"2024-09-24T15:57:36+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":59965730,"identity":"c4e569d3-498e-4afe-a451-1ab127830323","added_by":"auto","created_at":"2024-07-10 02:00:44","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":205168,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eOverview of patient inclusion and subgroups.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe evaluated 801 patients who received a S.06 ICD-10 code between 2012-2022. After applying exclusion critera, 272 patients were included in the study. Two subgroups were defined using contusion location: bifrontal contusions (n=85) vs. contusions in other locations (n= 187), and patients with a platelet count higher (N=236), or lower (n=30), than 150x10\u003csup\u003e9\u003c/sup\u003e/L blood.\u003c/p\u003e\n\u003cp\u003eCT = Computed tomography. \u0026nbsp;\u003c/p\u003e","description":"","filename":"Figure1Andersson.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4571926/v1/1c6649d040b2e9cc4b2d8951.jpeg"},{"id":59965726,"identity":"a5c8d8d7-5d13-49e8-bd80-926e50215025","added_by":"auto","created_at":"2024-07-10 02:00:43","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":77790,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of outcome between patients with bifrontal contusions and patients with contusions in other locations.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDistribution between patients with bifrontal contusions (n=65) compared to patients with contusions in other locations (n=149) with regard to patient outcome at six months post-injury using the Glasgow outcome scale extended (GOSE).\u003c/p\u003e","description":"","filename":"Figure2Andersson.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4571926/v1/bfbfdd140c36797cb2445d80.jpeg"},{"id":59965728,"identity":"a80ac0e4-7ffb-4e67-8d9f-65c81fd6767e","added_by":"auto","created_at":"2024-07-10 02:00:44","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":74980,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDifference in outcome between patients with a platelet count \u0026lt;or \u0026gt; than 150x10\u003c/strong\u003e\u003csup\u003e9\u003c/sup\u003e\u003cstrong\u003e/L\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDistribution in patient outcome according to Glasgow outcome scale extended\u003c/p\u003e\n\u003cp\u003e(GOSE) dichotomizing according to platelet count less than (n=30) or above (n=179) 150x10\u003csup\u003e9\u003c/sup\u003e/L.\u003c/p\u003e","description":"","filename":"Figure3Andersson.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4571926/v1/3070e7814aa6a284a0586d50.jpeg"},{"id":65628054,"identity":"8f72834f-d5b9-4b89-984e-e599cd953cf7","added_by":"auto","created_at":"2024-09-30 16:17:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1696174,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4571926/v1/331879dd-7f17-43b2-b8e6-1f4f11e12d58.pdf"},{"id":59966449,"identity":"33549e6c-48b8-4467-b9b3-7c8c107053e6","added_by":"auto","created_at":"2024-07-10 02:08:44","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":15029,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarytable1.docx","url":"https://assets-eu.researchsquare.com/files/rs-4571926/v1/d6edfea8f615e8f538151081.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Contusion expansion, bifrontal contusions and low platelet count is associated with worse patient outcome following traumatic brain injury - a retrospective single-center study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTraumatic brain injury (TBI) is a leading cause of disability and death amongst younger patients globally, and an increasing cause of mortality amongst the elderly population in high-income countries (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The severity of TBI is categorized into three groups based on initial Glasgow Coma Scale (GCS); severe (\u0026lt;\u0026thinsp;9), moderate (\u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) and mild (\u0026gt;\u0026thinsp;12) (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Cerebral contusions (CC), a common type of TBI, are characterized by cortical, intraparenchymal hematomas, resulting from rapid acceleration-deceleration forces, as often seen in traumatic incidents such as motor vehicle accidents or falls (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). The contusion forms when the intracerebral microvasculature ruptures (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Depending on if the contusion formation occurs on the ipsilateral or contralateral side of the insult, it is called coup or contrecoup, respectively. A contrecoup injury is more common than a coup injury, however, they are often seen together (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Contusions most often occur in the basal frontal and temporal lobes where the soft brain is damaged by friction against the underlying bony skull base (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). This makes it an injury with high risk of loss of functions associated with these areas such as personality, language, and executive functions (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). CC are often accompanied with other intracranial hemorrhages such as epidural-and subdural hematomas (EDH and SDH, respectively) (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eContusion expansion (CE), defined as the hematoma volume increases beyond its initial value, occurs in approximately half of CC cases (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). CE, visualized on a follow up computed tomography (CT) scan, is often associated with neuroworsening, \u003cem\u003ei.e.\u003c/em\u003e reduced consciousness level and/or emergence of focal neurological deficits (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). The possibility of CE makes CC challenging to manage since an awake patient presenting with minor or no visible lesions on an initial CT scan can rapidly deteriorate several hours post-injury due to increased mass effect. However, not all patient experiencing CE worsen (\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). The risk of CE is suggested to be the highest during the first 24 hours post trauma (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). An initial low GCS score and a larger hematoma volume at admission are associated with CE, although no consensus on the volume increase needed to define CE has been established (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Other suggested risk factors are male sex, old age, blood alcohol level, high international normalized ratio (INR), low platelet count and hypertension (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).The use of antiplatelets, such as aspirin and clopidogrel used to prevent cardiovascular morbidity, complicates CC management (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Intake of direct oral anticoagulants (DOAC) and, in particular, Warfarin also increase the risk (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePatients with bifrontal contusions are a common CC subgroup that tend to present with a relatively high GCS score to then rapidly deteriorate later in their clinical course due to CE (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). This makes them prone to possible undertreatment initially, risking a potentially avoidable negative outcome (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eNeurosurgical intervention of CC is indicated when increased intracranial pressure (ICP) (\u0026gt;\u0026thinsp;20 mmHg) is refractory to medical treatment. In localized CC, hematoma removal via a craniotomy is indicated when a patient presents with progressive neurological deterioration and mass effect on CT, marked by significant midline shift and compression of basal cisterns (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). An alternative is to perform a decompressive craniectomy (DC), especially in the case of diffuse cerebral swelling, although this may \u003cem\u003eper se\u003c/em\u003e increase the risk of CE (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). However, DC was associated with a higher risk of severe disability at long-term (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThere is a lack of understanding the pathophysiology of CE to the uncertainties regarding when and how to operate for optimal outcome. There is no consensus on early clinical or laboratory signs that can predict whether a patient would benefit from early surgery or not in the case of CC, and therefor leaves the decision to surgically intervene to the neurosurgeon (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). The clinical decision making is further complicated by clinical factors such as e.g., patient age, contusion distribution - especially bifrontal contusions- and how to reverse the care of antiplatelet- and anticoagulant- treated patients. With a better understanding of the factors influencing CE and who may benefit from early neurosurgical intervention, a more precise treatment regime can be applied to CC patients with the aim to reduce mortality and morbidity in this group of TBI patients.\u003c/p\u003e \u003cp\u003eThe aim of this study is to investigate the presence of potential clinical and radiological markers that can predict CE and to measure the impact of coagulopathy and presence of bifrontal contusions on CE and clinical outcome, measured by Glasgow Outcome Scale extended (GOSE).\u003c/p\u003e"},{"header":"Material and method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatient selection and data collection\u003c/h2\u003e \u003cp\u003eThis is a retrospective study that investigates the clinical course amongst patients with CC admitted to the Neurosurgical clinic at the Sk\u0026aring;ne University hospital in Lund during the years 2012\u0026ndash;2022. Patients who received the ICD-code S.06 (Intracranial injury) were selected to ensure all TBI patients with CC were analyzed, since CC often co-exist with other intracranial injuries. Included patients had CC present on admission CT head imaging, had a follow up CT scan within 72 hours after the initial scan, and were \u0026gt;\u0026thinsp;18 years of age at admission (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePatient information regarding age, sex, GCS, medical history, clinical-and lab parameters, treatment methods, clinical course, and outcome at six months post injury using GOSE, were gathered from medical records accessed via Melior and SieView (Cerner, Kansas City, MO, USA). All data was stored in Microsoft Excel (Microsoft Office, Redmond, WA, USA).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e \u003cb\u003elegend: Overview of patient inclusion and subgroups.\u003c/b\u003e\u003c/p\u003e \u003cp\u003eWe evaluated 801 patients who received a S.06 ICD-10 code between 2012\u0026ndash;2022. After applying exclusion critera, 272 patients were included in the study. Two subgroups were defined using contusion location: bifrontal contusions (n\u0026thinsp;=\u0026thinsp;85) vs. contusions in other locations (n\u0026thinsp;=\u0026thinsp;187), and patients with a platelet count higher (N\u0026thinsp;=\u0026thinsp;236), or lower (n\u0026thinsp;=\u0026thinsp;30), than 150x10\u003csup\u003e9\u003c/sup\u003e/L blood.\u003c/p\u003e \u003cp\u003eCT\u0026thinsp;=\u0026thinsp;Computed tomography.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eImaging\u003c/h2\u003e \u003cp\u003eRadiological data was gathered from imaging archives via Sectra Picture Archiving and Communication System IDS7 (Sectra AB, Link\u0026ouml;ping, Sweden). Contusion volume was measured using the ABC/2-formula from admission and follow up CT scans of head (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). The largest and the second largest contusion were measured, if more than one was present, but registered separately as initial and second hematoma. The basal cisterns were registered as normal, compressed, or effaced. Midline shift was categorized as normal, \u0026lt;\u0026thinsp;5 mm and \u0026gt;\u0026thinsp;5 mm. Affected cerebral lobes, presence of bifrontal contusions, and presence of another intracranial hematoma (e.g. EDH or SDH) was registered. Absolute contusion volume increase from first CT scan to follow up CT scan was registered, and data used in the analysis of contusion expansion.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eTBI severity and outcome\u003c/h2\u003e \u003cp\u003eThe severity of TBI was classified according to GCS at admission and was registered using both the Marshall, and the Rotterdam classification score of TBI using the first CT scan performed upon arrival to the emergency room (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). An adjusted version of GOSE was used to evaluate the global functional outcome of the patients six months following TBI (Supplementary tables 1). The patient\u0026rsquo;s capacity of working, functioning independently at home, neurological deficits and capability of functioning in social relationships were extracted from the physician, physiotherapist and occupational therapist notes in the medical records six months after injury. The extracted data is corresponding to the global scale for functional outcome measurement. The extracted followed data included dead to good recovery scales (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eCoagulation profile\u003c/h2\u003e \u003cp\u003eBlood platelet levels, information regarding INR and Activated Partial Thromboplastin Time (APTT) and platelet transfusions were collected. Antithrombotic treatment, for example intake of aspirin, clopidogrel or DOAC, was also extracted from the patient records.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eBlood platelet levels were dichotomized into two groups; low, defined as \u0026lt;\u0026thinsp;150x109/L and normal, i.e. \u0026gt;150x109/L, and the patients were grouped thereafter. Blood platelet transfusion administration was considered a dichotomized variable. The largest contusion is included in the statistical analysis and for bifrontal contusions the one with the greatest volume was used. When performing a multivariate analysis, the GOSE was dichotomized into two categories, unfavorable (GOSE 1\u0026ndash;4) and favorable (GOSE 5\u0026ndash;8), a dichotomization often used (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). All continuous data analyzed was non-parametric, assessed by using Kolmogorov-Smirnov test, and therefore expressed in medians with interquartile range (IQ). Mann-Whitney test was used when comparing continuous data between two groups. Kruskal Wallis test was used when analyzing more than two groups. Chi-squared test was used when comparing two or more categorical variables. Spearman's rho was used for correlation analysis between continuous and/or ordinal variables. Multivariate analysis was performed using a binomial regression and is presented as odds with 95% confidence interval (CI). Level of significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. All analyses were performed using SPSS Statistics (29.0) (IBM Corp, Armonk NY).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThere were 801 patients who had an S.06-diagnosis code between the years of 2012\u0026ndash;2022. Patients under the age of 18 years at admission and patients who had no contusions were excluded, generating 272 patients who met the inclusion criteria (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Of these, 35 patients underwent contusion evacuation surgery, 9 patients had a craniectomy, and three of those had both procedures done. There were 31 patients who had an extra-axial hematoma evacuated, and 202 patients were conservatively treated (Table\u0026nbsp;1). The most common occurring outcome measure was GOSE 7 and 8, together representing 35% of the patient population where outcome was accessible. GOSE was not accessible due to lack of follow up amongst 21% (n\u0026thinsp;=\u0026thinsp;58) patients (Table\u0026nbsp;1).\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable\u0026nbsp;1: Demographics of the study patients.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eGCS\u0026thinsp;=\u0026thinsp;Glasgow Coma Scale. SBP\u0026thinsp;=\u0026thinsp;Systolic blood pressure. PK-INR\u0026thinsp;=\u0026thinsp;Prothrombin complex-International ratio. APTT\u0026thinsp;=\u0026thinsp;Activated partial thromboplastin time. NICU\u0026thinsp;=\u0026thinsp;Neurointensive care. LMWH\u0026thinsp;=\u0026thinsp;Low-molecular weight heparin. ASA\u0026thinsp;=\u0026thinsp;American Society of Anesthesiology. IQ\u0026thinsp;=\u0026thinsp;Interquartile range.\u003c/p\u003e \u003cp\u003e*= Could be evacuation of extra-axial hematoma, or a combination of contusionectomy, evacuation of extra-axial hematoma\u003c/p\u003e \u003cp\u003eand decompressive craniectomy.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter (n\u0026thinsp;=\u0026thinsp;272)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedian (IQ) / (n. %)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMissing (n. %)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55 (35\u0026ndash;68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e87 (32%)\u003c/p\u003e \u003cp\u003e185 (68%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGCS at arrival\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (\u003cspan additionalcitationids=\"CR8 CR9 CR10 CR11 CR12 CR13\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInitial treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConservative\u003c/p\u003e \u003cp\u003eContusionectomy\u003c/p\u003e \u003cp\u003eCraniectomy\u003c/p\u003e \u003cp\u003eEvacuation extra-axial hematoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e202 (74%)\u003c/p\u003e \u003cp\u003e35 (13%)\u003c/p\u003e \u003cp\u003e9 (3%)\u003c/p\u003e \u003cp\u003e31 (11%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eConservative or\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eOperative treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eContinous conservative\u003c/p\u003e \u003cp\u003eContusionectomy\u003c/p\u003e \u003cp\u003eCraniectomy\u003c/p\u003e \u003cp\u003eOther*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e172 (85%)\u003c/p\u003e \u003cp\u003e21 (10%)\u003c/p\u003e \u003cp\u003e3 (1%)\u003c/p\u003e \u003cp\u003e6 (3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCause of injury\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFall from same level\u003c/p\u003e \u003cp\u003eFall from height (\u0026gt;\u0026thinsp;1m)\u003c/p\u003e \u003cp\u003eRoad traffic accident\u003c/p\u003e \u003cp\u003eSports related\u003c/p\u003e \u003cp\u003eAssault\u003c/p\u003e \u003cp\u003eBlunt or penetrating trauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e89 (33%)\u003c/p\u003e \u003cp\u003e58 (21%)\u003c/p\u003e \u003cp\u003e83 (31%)\u003c/p\u003e \u003cp\u003e5 (2%)\u003c/p\u003e \u003cp\u003e15 (6%)\u003c/p\u003e \u003cp\u003e16 (6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eASA score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSBP admission\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e140 (122\u0026ndash;160)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePlatelet count\u0026thinsp;\u0026gt;\u0026thinsp;150x10\u003c/b\u003e\u003csup\u003e\u003cb\u003e9\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e/l\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e232 (199\u0026ndash;288)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePlatelet count\u0026thinsp;\u0026lt;\u0026thinsp;150x10\u003c/b\u003e\u003csup\u003e\u003cb\u003e9\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e/l\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e137 (110\u0026ndash;142)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMissing platelet information\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePK-INR\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1-1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAPTT\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (\u003cspan additionalcitationids=\"CR24 CR25 CR26\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDays spent in NICU\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (\u003cspan additionalcitationids=\"CR3 CR4 CR5 CR6 CR7 CR8 CR9 CR10 CR11 CR12\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e30 days mortality\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (11%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eThromboembolic event\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReceived LMWH\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59 (22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGOSE at 6 months\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDead or vegetative\u003c/p\u003e \u003cp\u003eSeverely disabled\u003c/p\u003e \u003cp\u003eModerately disabled\u003c/p\u003e \u003cp\u003eGood Recovery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (19%)\u003c/p\u003e \u003cp\u003e37 (17%)\u003c/p\u003e \u003cp\u003e62 (29%)\u003c/p\u003e \u003cp\u003e74 (35%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58 (21%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eContusion expansion\u003c/h2\u003e \u003cp\u003eOut of 272, 181 patients experienced contusion expansion (67%). The median contusion volume at admission was 6.8 ml (IQ 2.1\u0026ndash;15.9) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The median absolute contusion volume increase at follow-up CT scan was 4.0 ml (IQ 0\u0026ndash;15) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Admission contusion volume had a significant, positive correlation with absolute contusion volume increase (Spearman's rho coefficient 0.19, \u003cem\u003ep\u0026thinsp;=\u0026thinsp;0.002\u003c/em\u003e). The median Marshall score was 2 (IQ 2\u0026ndash;3) and the median Rotterdam score was 3 (IQ 2\u0026ndash;3). Both Marshall- and Rotterdam score had a significant, positive correlation with absolute contusion volume expansion (Spearman's rho coefficient 0.26, \u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/em\u003e and 0.24, \u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/em\u003e, respectively)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComputer tomography (CT) characteristics of included patients.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter (n\u0026thinsp;=\u0026thinsp;272)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedian (IQ) / (n. %)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMissing (n. %)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55 (35\u0026ndash;68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e87 (32%)\u003c/p\u003e \u003cp\u003e185 (68%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGCS at arrival\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (\u003cspan additionalcitationids=\"CR8 CR9 CR10 CR11 CR12 CR13\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInitial treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConservative\u003c/p\u003e \u003cp\u003eContusionectomy\u003c/p\u003e \u003cp\u003eCraniectomy\u003c/p\u003e \u003cp\u003eEvacuation extra-axial hematoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e202 (74%)\u003c/p\u003e \u003cp\u003e35 (13%)\u003c/p\u003e \u003cp\u003e9 (3%)\u003c/p\u003e \u003cp\u003e31 (11%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eConservative or\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eOperative treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eContinous conservative\u003c/p\u003e \u003cp\u003eContusionectomy\u003c/p\u003e \u003cp\u003eCraniectomy\u003c/p\u003e \u003cp\u003eOther*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e172 (85%)\u003c/p\u003e \u003cp\u003e21 (10%)\u003c/p\u003e \u003cp\u003e3 (1%)\u003c/p\u003e \u003cp\u003e6 (3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCause of injury\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFall from same level\u003c/p\u003e \u003cp\u003eFall from height (\u0026gt;\u0026thinsp;1m)\u003c/p\u003e \u003cp\u003eRoad traffic accident\u003c/p\u003e \u003cp\u003eSports related\u003c/p\u003e \u003cp\u003eAssault\u003c/p\u003e \u003cp\u003eBlunt or penetrating trauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e89 (33%)\u003c/p\u003e \u003cp\u003e58 (21%)\u003c/p\u003e \u003cp\u003e83 (31%)\u003c/p\u003e \u003cp\u003e5 (2%)\u003c/p\u003e \u003cp\u003e15 (6%)\u003c/p\u003e \u003cp\u003e16 (6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eASA score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSBP admission\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e140 (122\u0026ndash;160)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePlatelet count\u0026thinsp;\u0026gt;\u0026thinsp;150x10\u003c/b\u003e\u003csup\u003e\u003cb\u003e9\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e/l\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e232 (199\u0026ndash;288)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePlatelet count\u0026thinsp;\u0026lt;\u0026thinsp;150x10\u003c/b\u003e\u003csup\u003e\u003cb\u003e9\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e/l\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e137 (110\u0026ndash;142)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMissing platelet information\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePK-INR\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1-1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAPTT\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (\u003cspan additionalcitationids=\"CR24 CR25 CR26\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDays spent in NICU\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (\u003cspan additionalcitationids=\"CR3 CR4 CR5 CR6 CR7 CR8 CR9 CR10 CR11 CR12\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e30 days mortality\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (11%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eThromboembolic event\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReceived LMWH\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59 (22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGOSE at 6 months\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDead or vegetative\u003c/p\u003e \u003cp\u003eSeverely disabled\u003c/p\u003e \u003cp\u003eModerately disabled\u003c/p\u003e \u003cp\u003eGood Recovery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (19%)\u003c/p\u003e \u003cp\u003e37 (17%)\u003c/p\u003e \u003cp\u003e62 (29%)\u003c/p\u003e \u003cp\u003e74 (35%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58 (21%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eIQR\u0026thinsp;=\u0026thinsp;Interquartile range. CT\u0026thinsp;=\u0026thinsp;Computed tomography. MRI\u0026thinsp;=\u0026thinsp;Magnetic resonance imaging.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eDAI\u0026thinsp;=\u0026thinsp;Diffuse agonal injury.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e: \u003cb\u003eComputer tomography (CT) characteristics of included patients.\u003c/b\u003e\u003c/p\u003e \u003cp\u003eIQR\u0026thinsp;=\u0026thinsp;Interquartile range. CT\u0026thinsp;=\u0026thinsp;Computed tomography. MRI\u0026thinsp;=\u0026thinsp;Magnetic resonance imaging.\u003c/p\u003e \u003cp\u003eDAI\u0026thinsp;=\u0026thinsp;Diffuse agonal injury.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter (n\u0026thinsp;=\u0026thinsp;272)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedian (IQR) / (n. %)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eContusion volume at admission (largest contusion)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6,8 ml (2.1\u0026ndash;15.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAbsolute volume expansion at follow up CT scan (within 72 hours)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 ml (\u003cspan additionalcitationids=\"CR5 CR6 CR7 CR8 CR9 CR10 CR11 CR12 CR13 CR14\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBifrontal contusions\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85 (31%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLocation of largest contusion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrontal\u003c/p\u003e \u003cp\u003eTemporal\u003c/p\u003e \u003cp\u003eParietal\u003c/p\u003e \u003cp\u003eOccipital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e150 (55%)\u003c/p\u003e \u003cp\u003e112 (41%)\u003c/p\u003e \u003cp\u003e5 (1.5%)\u003c/p\u003e \u003cp\u003e5 (1.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLocation of second largest contusion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003cp\u003eFrontal\u003c/p\u003e \u003cp\u003eTemporal\u003c/p\u003e \u003cp\u003eParietal\u003c/p\u003e \u003cp\u003eOccipital\u003c/p\u003e \u003cp\u003eCerebellum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e133 (48%)\u003c/p\u003e \u003cp\u003e86 (32%)\u003c/p\u003e \u003cp\u003e46 (17%)\u003c/p\u003e \u003cp\u003e5 (18%)\u003c/p\u003e \u003cp\u003e1 (0.3%)\u003c/p\u003e \u003cp\u003e1 (0.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEpidural hematoma\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (15%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSubdural hematoma\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94 (35%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBasal cistern\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOpen\u003c/p\u003e \u003cp\u003eCompressed\u003c/p\u003e \u003cp\u003eEffaced\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e181 (67%)\u003c/p\u003e \u003cp\u003e85 (31%)\u003c/p\u003e \u003cp\u003e6 (2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMidline shift\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;5 mm shift\u003c/p\u003e \u003cp\u003e\u0026gt;\u0026thinsp;5 mm shift\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e156 (57%)\u003c/p\u003e \u003cp\u003e89 (33%)\u003c/p\u003e \u003cp\u003e27 (10%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarshall Score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRotterdam Score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMRI verified DAI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (11%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThere was a weak but significant correlation between absolute contusion volume increase and GCS on admission (Spearman's rho coefficient 0.14 \u003cem\u003ep\u0026thinsp;=\u0026thinsp;0.02\u003c/em\u003e, and Spearman's rho coefficient \u0026minus;\u0026thinsp;0.14 p\u0026thinsp;=\u0026thinsp;\u003cem\u003e0.018\u003c/em\u003e, respectively). A significant difference in CE was found between the group of \"Good recovery\" (1.4 ml, 0-8.2) and \"Dead or vegetative\" (14.3 ml, IQ 2-44.1), and \"moderately disabled\" (8.3 ml, IQ 2\u0026ndash;18) (\u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/em\u003e and \u003cem\u003ep\u0026thinsp;=\u0026thinsp;0.001\u003c/em\u003e, respectively). The presence of other intracranial hematomas did not significantly correlate to contusion expansion, nor did midline shift at admission, systolic blood pressure, known alcohol abuse, blood ethanol levels, age, or sex.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eBifrontal contusions\u003c/h2\u003e \u003cp\u003eThe median contusion volume amongst patients with contusions at other, non-bifrontal brain regions was 4.9 ml (n\u0026thinsp;=\u0026thinsp;187, IQ 1.7\u0026ndash;13.0), and 11.6 ml amongst patients with bifrontal contusions, measuring the largest (n\u0026thinsp;=\u0026thinsp;85, IQ 4.2\u0026ndash;20,7; \u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/em\u003e). The absolute contusion volume increase amongst patients without bifrontal contusions was 2,1 ml (n\u0026thinsp;=\u0026thinsp;187, IQ 0-13.2) compared to 10 ml (n\u0026thinsp;=\u0026thinsp;83, IQ 2-30.6) in the bifrontal group (\u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/em\u003e). Patients with bifrontal contusions had similar GCS scores upon arrival when compared to patients with contusions in other brain regions, including patients with unilateral frontal contusions.\u003c/p\u003e \u003cp\u003ePatients with bifrontal contusions did not undergo contusion evacuation surgery or craniectomy at a greater extent than other contusion patients. The median GOSE in the bifrontal group was equivalent of moderately disabled, which is equivalent of GOSE 5 and 6 (n\u0026thinsp;=\u0026thinsp;65) which was also the case for the group with contusions in other locations (n\u0026thinsp;=\u0026thinsp;149). Using Chi-squared test, the bifrontal group had a worse outcome than the group with other-located contusions, χ2 (3, N\u0026thinsp;=\u0026thinsp;214)\u0026thinsp;=\u0026thinsp;8.115, \u003cem\u003ep\u0026thinsp;=\u0026thinsp;0.0043\u003c/em\u003e (Fig.\u0026nbsp;2, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eWorse outcome in patients with bifrontal contusions when compared to patients with contusions in other locations\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter (n\u0026thinsp;=\u0026thinsp;272)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedian (IQR) / (n. %)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eContusion volume at admission (largest contusion)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6,8 ml (2.1\u0026ndash;15.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAbsolute volume expansion at follow up CT scan (within 72 hours)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 ml (\u003cspan additionalcitationids=\"CR5 CR6 CR7 CR8 CR9 CR10 CR11 CR12 CR13 CR14\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBifrontal contusions\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85 (31%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLocation of largest contusion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrontal\u003c/p\u003e \u003cp\u003eTemporal\u003c/p\u003e \u003cp\u003eParietal\u003c/p\u003e \u003cp\u003eOccipital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e150 (55%)\u003c/p\u003e \u003cp\u003e112 (41%)\u003c/p\u003e \u003cp\u003e5 (1.5%)\u003c/p\u003e \u003cp\u003e5 (1.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLocation of second largest contusion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003cp\u003eFrontal\u003c/p\u003e \u003cp\u003eTemporal\u003c/p\u003e \u003cp\u003eParietal\u003c/p\u003e \u003cp\u003eOccipital\u003c/p\u003e \u003cp\u003eCerebellum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e133 (48%)\u003c/p\u003e \u003cp\u003e86 (32%)\u003c/p\u003e \u003cp\u003e46 (17%)\u003c/p\u003e \u003cp\u003e5 (18%)\u003c/p\u003e \u003cp\u003e1 (0.3%)\u003c/p\u003e \u003cp\u003e1 (0.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEpidural hematoma\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (15%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSubdural hematoma\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94 (35%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBasal cistern\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOpen\u003c/p\u003e \u003cp\u003eCompressed\u003c/p\u003e \u003cp\u003eEffaced\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e181 (67%)\u003c/p\u003e \u003cp\u003e85 (31%)\u003c/p\u003e \u003cp\u003e6 (2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMidline shift\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;5 mm shift\u003c/p\u003e \u003cp\u003e\u0026gt;\u0026thinsp;5 mm shift\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e156 (57%)\u003c/p\u003e \u003cp\u003e89 (33%)\u003c/p\u003e \u003cp\u003e27 (10%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarshall Score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRotterdam Score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMRI verified DAI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (11%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eThe difference in outcome between patients with bifrontal contusions and patients with\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003econtusions in other locations are compared using Chi-square test. A total of 214 patients were included in the study of whom 65 had bifrontal contusions and 149 had contusions in other locations. The difference between the groups was highly significant, \u003cem\u003ep\u0026thinsp;=\u0026thinsp;0.0044\u003c/em\u003e.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e2: Distribution of outcome between patients with bifrontal contusions and\u003c/h2\u003e \u003cp\u003e \u003cb\u003epatients with contusions in other locations.\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure 2 legend: Distribution of outcome between patients with bifrontal contusions and patients with contusions in other locations.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eDistribution between patients with bifrontal contusions (n\u0026thinsp;=\u0026thinsp;65) compared to patients with contusions in other locations (n\u0026thinsp;=\u0026thinsp;149) with regard to patient outcome at six months post-injury using the Glasgow outcome scale extended (GOSE).\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e: \u003cb\u003eWorse outcome in patients with bifrontal contusions when compared to patients with contusions in other locations\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe difference in outcome between patients with bifrontal contusions and patients with\u003c/p\u003e \u003cp\u003econtusions in other locations are compared using Chi-square test. A total of 214 patients were included in the study of whom 65 had bifrontal contusions and 149 had contusions in other locations. The difference between the groups was highly significant, \u003cem\u003ep\u0026thinsp;=\u0026thinsp;0.0044\u003c/em\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabc\" border=\"1\"\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003ePercentage of total within GOSE category (n)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eDead or Vegetative\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eSeverely disabled\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eModerately disabled\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eGood recovery\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eContusions, bifrontal (n\u0026thinsp;=\u0026thinsp;65)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46% (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19% (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32% (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e26% (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eContusions, other locations (n\u0026thinsp;=\u0026thinsp;149)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54% (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e81% (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e68% (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e74% (55)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eχ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;8.12, \u003cem\u003ep\u0026thinsp;=\u0026thinsp;0.044\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eCoagulation\u003c/h2\u003e \u003cp\u003eThe median blood platelet count was 223 x109/L (IQ 183\u0026ndash;276) (Table\u0026nbsp;1). Neither INR nor APTT was significantly associated with outcome, and only 25 patients had an INR above 1.2. median INR was 1 (IQ 1\u0026ndash;1,1) (Table\u0026nbsp;1). For 237 patients, there was no records of any regular intake of anticoagulant drugs. There were 11 patients on Warfarin, and 25 patients were on aspirin. There was no significant difference in outcome or absolute contusion volume increase in the aspirin-treated group compared to patients not treated with aspirin. The number of patients on any other type of antithrombotic drug was too low for further analysis. Out of all patients, 11% (n\u0026thinsp;=\u0026thinsp;30) received one or more blood platelet transfusions. Using Chi-square test, the patients who received blood platelet transfusion had a higher-than-expected count in the GOSE group of \"dead or vegetative\", and none in the group of \"good recovery\", in comparison to the group who did not receive a blood platelet transfusion where the trend was inverted, χ2 (3, n\u0026thinsp;=\u0026thinsp;214)\u0026thinsp;=\u0026thinsp;19.78, \u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/em\u003e\u003c/p\u003e \u003cp\u003eWhen dichotomized to \u0026lt;\u0026thinsp;150- and normal (\u0026gt;\u0026thinsp;150x109/L) (n\u0026thinsp;=\u0026thinsp;30 and n\u0026thinsp;=\u0026thinsp;179, respectively), using Chi- square test, the group with a lower platelet count had a significant worse six-month outcome according to GOSE, compared to the group with a higher blood platelet count (χ2 (3, n\u0026thinsp;=\u0026thinsp;209)\u0026thinsp;=\u0026thinsp;13.4, \u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.004) (Fig.\u0026nbsp;3, Table\u0026nbsp;4).\u003c/em\u003e A difference in absolute contusion volume increase was shown between the patients with a platelet cell count\u0026thinsp;\u0026lt;\u0026thinsp;150x109/L, and the \u0026gt;\u0026thinsp;150x109/L group (15.3 ml versus 3.6 ml, \u003cem\u003ep\u0026thinsp;=\u0026thinsp;0.003\u003c/em\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3: Difference in outcome between patients with a platelet count\u0026thinsp;\u0026lt;\u0026thinsp;150x109/L, and\u003c/h2\u003e \u003cp\u003e \u003cb\u003epatients with a platelet count\u0026thinsp;\u0026gt;\u0026thinsp;150x109/L.\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure 3 legend: Difference in outcome between patients with a platelet count\u0026thinsp;\u0026lt;\u0026thinsp;or \u0026gt;\u0026thinsp;than 150x10\u003c/b\u003e \u003csup\u003e9\u003c/sup\u003e \u003cb\u003e/L\u003c/b\u003e \u003c/p\u003e \u003cp\u003eDistribution in patient outcome according to Glasgow outcome scale extended\u003c/p\u003e \u003cp\u003e(GOSE) dichotomizing according to platelet count less than (n\u0026thinsp;=\u0026thinsp;30) or above (n\u0026thinsp;=\u0026thinsp;179) 150x10\u003csup\u003e9\u003c/sup\u003e/L.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable\u0026nbsp;4: The difference in outcome between patients with a low\u003c/b\u003e \u003cb\u003eversus\u003c/b\u003e \u003cb\u003ea\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003enormal platelet count, using Chi-square test.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe difference in outcome between patients with a low platelet count versus a higher platelet\u003c/p\u003e \u003cp\u003ecount, using Chi-square test. A total of 209 patients were included in the study, 30 patients had a platelet count\u0026thinsp;\u003cb\u003e\u0026lt;\u003c/b\u003e\u0026thinsp;150x10\u003csup\u003e9\u003c/sup\u003e/L, and 179 had a platelet count\u0026thinsp;\u0026gt;\u0026thinsp;150x10\u003csup\u003e9\u003c/sup\u003e/L. The difference between the groups was shown significant, \u003cem\u003ep\u0026thinsp;=\u0026thinsp;0.004\u003c/em\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabd\" border=\"1\"\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003ePercentage of total within GOSE category (n)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eDead or Vegetative\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eSeverely disabled\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eModerately disabled\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eGood recovery\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePlatelet count\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026lt;\u0026thinsp;150x10^9/L (n\u0026thinsp;=\u0026thinsp;30)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29% (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14% (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16% (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4% (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePlatelet count\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026gt;\u0026thinsp;150x10^9/L (n\u0026thinsp;=\u0026thinsp;179)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71% (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86% (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e84% (51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e96% (67)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eχ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;13.4, \u003cem\u003ep\u0026thinsp;=\u0026thinsp;0.004\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eMultivariate analysis\u003c/h2\u003e \u003cp\u003eA multivariate regression was performed with six-month outcome as outcome variable. This included contusion volume at admission, absolute contusion volume difference, platelet levels\u0026thinsp;\u0026lt;\u0026thinsp;and \u0026gt;\u0026thinsp;150x109/L, and whether the contusions were bifrontal or not. In the multivariate analysis, 207 patients were included (76.1%) of whom 61 patients had bifrontal contusions, and 29 patients had a platelet count\u0026thinsp;\u0026lt;\u0026thinsp;150x109/L. The outcome variable was dichotomized into unfavorable (n\u0026thinsp;=\u0026thinsp;77) and favorable (130), as described above. The remaining variable that had a significant impact on outcome was contusion expansion (OR 0.975, CI 0.955\u0026ndash;0.995) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eMultivariate analysis with regards to patient outcome at six months post-injury.\u003c/b\u003e A multivariate regression analysis was performed, including variables who on univariate regression had a significant impact (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) on patient outcome according to Glasgow outcome scale extended (GOSE) six months post-injury. Contusion expansion was shown significantly impact outcome measured as either unfavourable (GOSE\u0026thinsp;=\u0026thinsp;1\u0026ndash;4; n\u0026thinsp;=\u0026thinsp;77) or favourable (GOSE\u0026thinsp;=\u0026thinsp;5\u0026ndash;8; n\u0026thinsp;=\u0026thinsp;130) outcome. Due to missing data on platelet levels upon arrival, 207 out of 272 patients could be included. OR\u0026thinsp;=\u0026thinsp;Odds ratio; CI\u0026thinsp;=\u0026thinsp;Confidence interval.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncluded variables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;207\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOR (CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContusion volume at admission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.983 (0.962\u0026ndash;1.004)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0.117\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContusion expansion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.975 (0.955\u0026ndash;0.995)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0.013\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContusion location (bifrontal \u0026amp; other)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(61 \u0026amp; 146)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.778 (0.386\u0026ndash;1.567)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0.482\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlatelet levels (\u0026lt;/\u0026gt;150x10\u003csup\u003e9\u003c/sup\u003e/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(29 \u0026amp; 178)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.490 (0.208\u0026ndash;1.155)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0.103\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn the present study, we investigated the potential clinical and radiological markers that could predict CE, and the impact of bifrontal contusions and a low platelet count on patient outcome measured by GOSE at 6-months after TBI. The Marshall and Rotterdam CT classification system, and a blood platelet count\u0026thinsp;\u0026lt;\u0026thinsp;150x109/L correlated significantly with CE. However, platelet transfusion was a negative prognostic factor for poor outcome measured by GOSE. Patients with bifrontal contusions had CE in a larger extent compared to the non-bifrontal group and had worse functional outcome at 6-months. CE was found as the significant variable with a negative impact on outcome 6-months post injury.\u003c/p\u003e \u003cp\u003eThe Marshall and Rotterdam scores previously showed good predictive accuracy for in-hospital mortality and outcome prediction in patients with TBI (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). The Marshall score has also been found to be independently associated with neuroworsening (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Two major components of the Marshall and Rotterdam scores, basal cistern compression and midline shift, are results of mass effect and can therefore be seen as a secondary effect of a large contusion volume. In our study, a higher Marshall and Rotterdam score significantly correlated with CE and CE was found to have a negative impact on 6-months functional outcome.\u003c/p\u003e \u003cp\u003eCoagulopathy is a complicating factor in the management of TBI patients and has in previous studies been reported as a risk factor for CE. The effect of a low platelet count has been shown to have a significant impact on CE (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). A platelet count\u0026thinsp;\u0026le;\u0026thinsp;100 \u0026times; 10\u003csup\u003e9\u003c/sup\u003e/l is associated with CE and increased mortality and is usually the threshold of accepted platelet levels in elective surgery (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). A recent Finnish multi-center intensive care study has reported that in-hospital mortality was three times higher and 12-months mortality two times higher in TBI patients with a platelet count\u0026thinsp;\u0026le;\u0026thinsp;100 \u0026times; 10\u003csup\u003e9\u003c/sup\u003e/l (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). A platelet count of 150 x 10\u003csup\u003e9\u003c/sup\u003e/l is considered normal and was chosen at a cut-off in our study. In most previous papers, a lower platelet count was associated with CE, and our data stress the importance of rigid platelet control in TBI patients. In patients with elevated INR, double anti-platelet therapy, or any other antithrombotic treatment, the risk of CE was not significantly increased. Previously, INR levels\u0026thinsp;\u0026gt;\u0026thinsp;1.2 were associated with a threefold increased risk for CE. However, due to the small number of patients in these subgroups in our present, there is a risk of a type two error, and an elevated INR should be aggressively corrected (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). In our cohort, 11% received one or more blood platelet transfusions and those patients had a worse outcome when compared to patients who did not receive platelet transfusions. The indications varied widely, including as a part of a trauma transfusion protocol, and thus not merely used for a low platelet count. Since platelet transfusions are associated with a number of adverse events its role in TBI patients remains a matter of debate (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThere is scarce literature on bifrontal contusions, and it often focuses on investigating the optimal surgical approach (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Van de Zande et.al. performed a systematic review investigating the treatment and outcome of patients suffering bifrontal contusions (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Six out of seven studies of in total 356 patients measured outcome by GOS, where the average score was 4 (moderately disabled) at one-year post-injury. In the present study we observed that bifrontal contusions had a significantly larger volume when compared to contusions in other brain regions, and significantly larger CE. The median outcome was a GOSE score of 5 and 6 (i.e. moderate disability) in line with previous studies (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Although contusion volumes at admission were larger in the bifrontal contusion group, the GCS scores did not differ, it is plausible that patients with bifrontal contusions for anatomical reasons could accommodate a larger hematoma volume before their level of consciousness is affected. In contrast to the earlier findings, we showed that bifrontal contusions had a worse outcome when compared to other-located contusions, and thus that they may be considered an own sub-entity.\u003c/p\u003e \u003cp\u003eWe investigated whether CE negatively impacts patient outcome. Recently, a single-center retrospective study showed a 6% increased risk in a 1-point deduction on the GOS scale for every 1 ml increase of intracranial hematoma, showing a correlation between hematoma expansion and outcome at 12 months post-injury (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). A recent multi-center observational study concluded that absolute CE outperformed relative CE in predicting both unfavorable outcome and mortality (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). These results indicate that CE is a crucial contributor to outcome, consistent with our present findings where CE significantly contributed to a poor outcome both in the univariate and multivariate analysis. One feasible explanation is CE and brain swelling progression could result in increased ICP and decreased cerebral perfusion pressure (CPP), independently associated with a risk of poor outcome and death (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOur study is not without limitations. The GOSE data of this study was gathered from medical journals, and 21% of the patients were unfortunately lost to follow-up. Since GOSE is based on patient activity level in comparison to life pre-injury, the information was easily accessible from the medical records of patients who were in contact with medical professionals at the time for outcome evaluation. The retrospective design of the study is another key limitation. In view of the absence of strict guidelines, the decision to admit, and to perform surgery, is mainly based on the individual neurosurgeon\u0026acute;s decision. Thus, there may be heterogeneity of treatments offered to the patients in our cohort. Dividing the GOSE into a dichotomous scale as favorable and unfavorable is a common division when performing multivariate analysis and is used for statistical reasons (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). However, valuable nuances of the morbidity spectrum are lost in this simplification.\u003c/p\u003e \u003cp\u003eStrengths of the study include that the study population is relatively large, and there is access to highly detailed clinical data. By defining relevant characteristics in bifrontal contusions, and in other-located contusions, we aimed to facilitate decision-making in a clinical setting. We also investigated the important role for coagulopathy for poor outcome and thus we suggest an active role for coagulation management and correction at the early stage to optimize patient outcome (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe Marshall and Rotterdam CT classification score, a platelet count\u0026thinsp;\u0026lt;\u0026thinsp;150x109/L, contusion volume at admission and the presence of bifrontal contusions at admission correlated to CE. Patients with bifrontal contusions, a platelet count\u0026thinsp;\u0026lt;\u0026thinsp;150x109/L and who experienced CE suffered a worse outcome according to GOSE six months after injury, when compared to patients with contusions in other brain regions. On multivariate analysis, CE remained the most significant variable affecting patient outcome. Thus, our results support that CE is a contributing negative factor in patient outcome, and therefore a potential target for therapeutic intervention.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank the foundations for the research funding. Iftakher Hossain (IH) and Niklas Marklund (NM). The Finnish Medical Foundation (IH), The P\u0026auml;ivikki and Sakari Sohlberg Foundation (IH), The Paulo Foundation (IH), The Finnish Cultural Foundation (IH), Sk\u0026aring;ne University Hospital ALF funds (NM), Hans-Gabriel af Trolle Wachtmeister Foundation (NM) and Swedish Brain Foundation (NM).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Finnish Medical Foundation (IH), The P\u0026auml;ivikki and Sakari Sohlberg Foundation (IH), The Paulo Foundation (IH), The Finnish Cultural Foundation (IH), Sk\u0026aring;ne University Hospital ALF funds (NM), Hans-Gabriel af Trolle Wachtmeister Foundation (NM), Swedish Brain Foundation (NM) and Elsa Schmitz Foundation (AA).\u003c/p\u003e\n\u003cp\u003eIftakher Hossain (IH), Niklas Marklund (NM) and Alice Andersson (AA).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAvailable upon request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAvailable upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Alice Andersson. The primary draft of the manuscript was written by Alice Andersson and assisted by Iftakher Hossain. The study was solely supervised by Niklas Marklund and he also designed the methodology. All authors commented on previous versions of the manuscript to prepare the final draft. All authors read and approved the final manuscript before submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study has obtained\u0026nbsp;ethical approval from\u003cem\u003e\u0026nbsp;\u003c/em\u003ethe ethical review board for retrospective evaluation of patients (Dnr 2017/4069). GDPR is adhered to and a separate application is used for access to medical records (Kunskapstyrning, KvB).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate and consent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe individual patients were not informed on their contribution to the present study and did not sign an informed consent. The data cannot be traced to included individuals and was stored on password protected devices.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMajdan M, Plancikova D, Brazinova A, Rusnak M, Nieboer D, Feigin V et al (2016) Epidemiology of traumatic brain injuries in Europe: a cross-sectional analysis. Lancet Public Health 1(2):e76\u0026ndash;e83\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTeasdale G, Jennett B (1974) Assessment of coma and impaired consciousness. A practical scale. Lancet 2(7872):81\u0026ndash;84\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcKee AC, Daneshvar DH (2015) The neuropathology of traumatic brain injury. Handb Clin Neurol 127:45\u0026ndash;66\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNewcombe VF, Williams GB, Outtrim JG, Chatfield D, Gulia Abate M, Geeraerts T et al (2013) Microstructural basis of contusion expansion in traumatic brain injury: insights from diffusion tensor imaging. J Cereb Blood Flow Metab 33(6):855\u0026ndash;862\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdatia K, Newcombe VFJ, Menon DK (2021) Contusion Progression Following Traumatic Brain Injury: A Review of Clinical and Radiological Predictors, and Influence on Outcome. Neurocrit Care 34(1):312\u0026ndash;324\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMartin RM, Wright MJ, Lutkenhoff ES, Ellingson BM, Van Horn JD, Tubi M et al (2017) Traumatic hemorrhagic brain injury: impact of location and resorption on cognitive outcome. J Neurosurg 126(3):796\u0026ndash;804\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSvedung Wettervik T, Hanell A, Enblad P, Lewen A (2023) Intracranial lesion features in moderate-to-severe traumatic brain injury: relation to neurointensive care variables and clinical outcome. Acta Neurochir (Wien) 165(9):2389\u0026ndash;2398\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOertel M, Kelly DF, McArthur D, Boscardin WJ, Glenn TC, Lee JH et al (2002) Progressive hemorrhage after head trauma: predictors and consequences of the evolving injury. J Neurosurg 96(1):109\u0026ndash;116\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIaccarino C, Schiavi P, Picetti E, Goldoni M, Cerasti D, Caspani M et al (2014) Patients with brain contusions: predictors of outcome and relationship between radiological and clinical evolution. J Neurosurg 120(4):908\u0026ndash;918\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarnevale JA, Segar DJ, Powers AY, Shah M, Doberstein C, Drapcho B et al (2018) Blossoming contusions: identifying factors contributing to the expansion of traumatic intracerebral hemorrhage. J Neurosurg 129(5):1305\u0026ndash;1316\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlahmadi H, Vachhrajani S, Cusimano MD (2010) The natural history of brain contusion: an analysis of radiological and clinical progression. J Neurosurg 112(5):1139\u0026ndash;1145\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFletcher-Sandersjoo A, Tatter C, Tjerkaski J, Bartek J Jr., Maegele M, Nelson DW et al (2023) Time Course and Clinical Significance of Hematoma Expansion in Moderate-to-Severe Traumatic Brain Injury: An Observational Cohort Study. Neurocrit Care 38(1):60\u0026ndash;70\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSerebruany VL, Malinin AI, Ziai W, Pokov AN, Bhatt DL, Alberts MJ et al (2005) Effects of clopidogrel and aspirin in combination versus aspirin alone on platelet activation and major receptor expression in patients after recent ischemic stroke: for the Plavix Use for Treatment of Stroke (PLUTO-Stroke) trial. Stroke 36(10):2289\u0026ndash;2292\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBonville DJ, Ata A, Jahraus CB, Arnold-Lloyd T, Salem L, Rosati C et al (2011) Impact of preinjury warfarin and antiplatelet agents on outcomes of trauma patients. Surgery 150(4):861\u0026ndash;868\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eScotti P, Seguin C, Lo BWY, de Guise E, Troquet JM, Marcoux J (2019) Antithrombotic agents and traumatic brain injury in the elderly population: hemorrhage patterns and outcomes. J Neurosurg. :1\u0026ndash;10\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVan de Zande N, Manivannan S, Sharouf F, Shastin D, Abdulla M, Chumas PD et al (2020) Demographics, presentation, and clinical outcomes after traumatic bifrontal contusions: a systematic review. Neurosurg Rev 43(3):977\u0026ndash;986\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDevi B, Sarma P, Shukla D (2015) Bifrontal Contusions: What Is the Best Surgical Treatment? Indian J Neurotrauma 12(02):103\u0026ndash;106\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBullock MR, Chesnut R, Ghajar J, Gordon D, Hartl R, Newell DW et al (2006) Surgical management of traumatic parenchymal lesions. Neurosurgery 58(3 Suppl):S25\u0026ndash;46 discussion Si-iv\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCepeda S, Casta\u0026ntilde;o-Le\u0026oacute;n AM, Munarriz PM, Paredes I, Panero I, Eiriz C et al (2019) Effect of decompressive craniectomy in the postoperative expansion of traumatic intracerebral hemorrhage: a propensity score-based analysis. J Neurosurg 132(5):1623\u0026ndash;1635\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHutchinson PJ, Kolias AG, Timofeev IS, Corteen EA, Czosnyka M, Timothy J et al (2016) Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension. N Engl J Med 375(12):1119\u0026ndash;1130\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGregson BA, Mitchell P, Mendelow AD (2019) Surgical Decision Making in Brain Hemorrhage. Stroke 50(5):1108\u0026ndash;1115\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKothari RU, Brott T, Broderick JP, Barsan WG, Sauerbeck LR, Zuccarello M et al (1996) The ABCs of measuring intracerebral hemorrhage volumes. Stroke 27(8):1304\u0026ndash;1305\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarshall LF, Marshall SB, Klauber MR, Van Berkum Clark M, Eisenberg H, Jane JA et al (1992) The diagnosis of head injury requires a classification based on computed axial tomography. J Neurotrauma 9(Suppl 1):S287\u0026ndash;S292\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaas AI, Hukkelhoven CW, Marshall LF, Steyerberg EW (2005) Prediction of outcome in traumatic brain injury with computed tomographic characteristics: a comparison between the computed tomographic classification and combinations of computed tomographic predictors. Neurosurgery 57(6):1173\u0026ndash;1182 discussion \u0026ndash;\u0026thinsp;82\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilson JT, Pettigrew LE, Teasdale GM (1998) Structured interviews for the Glasgow Outcome Scale and the extended Glasgow Outcome Scale: guidelines for their use. J Neurotrauma 15(8):573\u0026ndash;585\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlali AS, Vavrek D, Barber J, Dikmen S, Nathens AB, Temkin NR (2015) Comparative study of outcome measures and analysis methods for traumatic brain injury trials. J Neurotrauma 32(8):581\u0026ndash;589\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSadighi N, Talari H, Zafarmandi S, Ahmadianfard S, Baigi V, Fakharian E et al (2023) Prediction of In-Hospital Outcomes in Patients with Traumatic Brain Injury Using Computed Tomographic Scoring Systems: A Comparison Between Marshall, Rotterdam, and Neuroimaging Radiological Interpretation Systems. World Neurosurg 175:e271\u0026ndash;e7\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFabbri A, Servadei F, Marchesini G, Bronzoni C, Montesi D, Arietta L (2013) Antiplatelet therapy and the outcome of subjects with intracranial injury: the Italian SIMEU study. Crit Care 17(2):R53\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYuan F, Ding J, Chen H, Guo Y, Wang G, Gao WW et al (2012) Predicting progressive hemorrhagic injury after traumatic brain injury: derivation and validation of a risk score based on admission characteristics. J Neurotrauma 29(12):2137\u0026ndash;2142\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrown LM, Call MS, Margaret Knudson M, Cohen MJ, Holcomb JB, Wade CE et al (2011) A normal platelet count may not be enough: the impact of admission platelet count on mortality and transfusion in severely injured trauma patients. J Trauma 71(2 Suppl 3):S337\u0026ndash;S342\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLillem\u0026auml;e K, Luostarinen T, Reinikainen M, Bendel S, Laitio R, Hoppu S et al (2022) Early thrombocytopenia is associated with an increased risk of mortality in patients with traumatic brain injury treated in the intensive care unit: a Finnish Intensive Care Consortium study. Acta Neurochir (Wien) 164(10):2731\u0026ndash;2740\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWan X, Fan T, Wang S, Zhang S, Liu S, Yang H et al (2017) Progressive hemorrhagic injury in patients with traumatic intracerebral hemorrhage: characteristics, risk factors and impact on management. Acta Neurochir (Wien) 159(2):227\u0026ndash;235\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoore L, Tardif PA, Lauzier F, B\u0026eacute;rub\u0026eacute; M, Archambault P, Lamontagne F et al (2020) Low-Value Clinical Practices in Adult Traumatic Brain Injury: An Umbrella Review. J Neurotrauma 37(24):2605\u0026ndash;2615\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhaofeng L, Bing L, Peng Q, Jiyao J (2016) Surgical Treatment of Traumatic Bifrontal Contusions: When and How? World Neurosurg 93:261\u0026ndash;269\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFletcher-Sandersj\u0026ouml;\u0026ouml; A, Svedung Wettervik T, Tatter C, Tjerkaski J, Nelson DW, Maegele M et al (2024) Absolute Contusion Expansion Is Superior to Relative Expansion in Predicting Traumatic Brain Injury Outcomes: A Multi-Center Observational Cohort Study. J Neurotrauma 41(5\u0026ndash;6):705\u0026ndash;713\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHutchinson PJ, Kolias AG, Tajsic T, Adeleye A, Aklilu AT, Apriawan T et al (2019) Consensus statement from the International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury: Consensus statement. Acta Neurochir (Wien) 161(7):1261\u0026ndash;1274\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchizodimos T, Soulountsi V, Iasonidou C, Kapravelos N (2020) An overview of management of intracranial hypertension in the intensive care unit. J Anesth 34(5):741\u0026ndash;757\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHossain I, Rostami E, Marklund N (2023) The management of severe traumatic brain injury in the initial postinjury hours - current evidence and controversies. Curr Opin Crit Care 29(6):650\u0026ndash;658\u003c/span\u003e\u003c/li\u003e \u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"acta-neurochirurgica","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"anch","sideBox":"Learn more about [Acta Neurochirurgica](http://link.springer.com/journal/701)","snPcode":"701","submissionUrl":"https://submission.springernature.com/new-submission/701/3","title":"Acta Neurochirurgica","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"1) traumatic brain injury, 2) cerebral contusions, 3) bifrontal contusions, 4) contusion expansion, 5) outcome","lastPublishedDoi":"10.21203/rs.3.rs-4571926/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4571926/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\u003eCortical contusions are common in moderate-severe traumatic brain injury (TBI). Cortical contusions often expand, potentially causing neuro-worsening several hours to days post-trauma. While contusion expansion (CE) may affect outcome, potential clinical and radiological markers that can predict CE have been insufficiently explored. In the present single-center retrospective observational cohort study, we evaluated clinical outcome by the Glasgow Outcome Scale extended (GOSE) scale and evaluated risk factor for CE.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethod\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAdult TBI patients\u0026thinsp;\u0026gt;\u0026thinsp;18 years of age, and of all injury severities, were included. Main variables of interest were low platelet count, defined as \u0026lt;\u0026thinsp;150x10\u003csup\u003e9\u003c/sup\u003e/L, presence of bifrontal contusions and CE, defined as absolute contusion volume increase in cm\u0026sup3;. Factors associated with CE and clinical outcome according to GOSE were analyzed.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eBetween 2012\u0026ndash;2022, 271 patients were included. Contusion size on admission correlated positively with CE, as did the Marshall and Rotterdam radiological classification scores. Bifrontal contusions were significantly larger at admission, experienced larger CE, and had a worse outcome than contusions in other locations. Patients with a platelet count\u0026thinsp;\u0026lt;\u0026thinsp;150x10\u003csup\u003e9\u003c/sup\u003e/L experienced a greater volume CE and had a worse outcome when compared to patients with a normal platelet count. In a multivariate analysis, CE remained significantly associated with a poor outcome six months post- injury.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eContusion volume at admission, and Marshall- and Rotterdam scores, positively correlated to CE. Bifrontal contusions and a platelet count\u0026thinsp;\u0026lt;\u0026thinsp;150x10\u003csup\u003e9\u003c/sup\u003e/L were associated with CE, and a poor clinical outcome. Large CE volumes were associated with a worse clinical outcome, and CE was \u003cem\u003eper se\u003c/em\u003e associated with outcome in a multivariate analysis. Management of these risk factors for CE in the acute post-injury setting may be needed to attenuate contusion expansion and to improve clinical outcome in TBI patients suffering from cortical contusion injuries.\u003c/p\u003e","manuscriptTitle":"Contusion expansion, bifrontal contusions and low platelet count is associated with worse patient outcome following traumatic brain injury - a retrospective single-center study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-10 02:00:33","doi":"10.21203/rs.3.rs-4571926/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-06-23T15:09:59+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-23T07:11:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-14T05:58:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"304522404752398331322121662971007084262","date":"2024-06-13T14:22:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"327800257612973023984035695790054451224","date":"2024-06-13T13:01:25+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-06-13T12:57:27+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-13T04:49:13+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-13T04:48:22+00:00","index":"","fulltext":""},{"type":"submitted","content":"Acta Neurochirurgica","date":"2024-06-12T17:53:52+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"acta-neurochirurgica","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"anch","sideBox":"Learn more about [Acta Neurochirurgica](http://link.springer.com/journal/701)","snPcode":"701","submissionUrl":"https://submission.springernature.com/new-submission/701/3","title":"Acta Neurochirurgica","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"9f170340-3d96-430d-8319-d04659b52c8d","owner":[],"postedDate":"July 10th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-09-30T16:10:25+00:00","versionOfRecord":{"articleIdentity":"rs-4571926","link":"https://doi.org/10.1007/s00701-024-06269-7","journal":{"identity":"acta-neurochirurgica","isVorOnly":false,"title":"Acta Neurochirurgica"},"publishedOn":"2024-09-24 15:57:36","publishedOnDateReadable":"September 24th, 2024"},"versionCreatedAt":"2024-07-10 02:00:33","video":"","vorDoi":"10.1007/s00701-024-06269-7","vorDoiUrl":"https://doi.org/10.1007/s00701-024-06269-7","workflowStages":[]},"version":"v1","identity":"rs-4571926","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4571926","identity":"rs-4571926","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}