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Platelet activation and dysfunction in a large-animal model of traumatic brain injury and hemorrhage

Sillesen, Martin MD; Johansson, Pär I. MD, DMsc; Rasmussen, Lars S. MD, PhD, DMsc; Jin, Guang MD, PhD; Jepsen, Cecilie H. MD; Imam, Ayehsa M. MD; Hwabejire, John MD, MPH; Lu, Jennifer BS; Duggan, Michael DVM; Velmahos, George MD, PhD; deMoya, Marc MD; Alam, Hasan B. MD

Journal of Trauma and Acute Care Surgery: May 2013 - Volume 74 - Issue 5 - p 1252–1259
Original Articles

BACKGROUND: Traumatic brain injury (TBI) and hemorrhage are the leading causes of trauma-related mortality. Both TBI and hemorrhage are associated with coagulation disturbances, including platelet dysfunction. We hypothesized that platelet dysfunction could be detected early after injury, and that this dysfunction would be associated with early activation, as measured by circulating levels of platelet activation markers.

METHODS: A total of 33 swine were allocated to TBI and hypotension (n = 27, TBI and volume-controlled 40% blood loss) or controls (n = 6, anesthesia and instrumentation only). Animals in the TBI/Hemorrhage group were left hypotensive, defined as mean arterial pressure of 35 mm Hg, for 2 hours. Blood samples were drawn at baseline and 3 minutes and 15 minutes following injury as well as following 2 hours of shock. Samples were analyzed for platelet aggregation using impedance aggregometry with agonists collagen, arachidonic acid, and adenosine diphosphate (ADP) and thromboelastography (TEG) and circulating levels of platelet activation markers transforming growth factor-[beta] (TGF-[beta]), CD40 ligand, and sP-selectin.

RESULTS: Platelet ADP aggregation was significantly lower in the TBI/Hemorrhage group when compared with the control group 15 minutes following injury (62.4 vs. 80.4 U, p = 0.03) as well as following 2 hours of hypotension (59.9 vs. 73.5 U, p < 0.01). The latter was associated with lower TEG measured clot strength (TEG-MA, 74.1 vs. 79.4 mm, p = 0.05). No difference in collagen or arachidonic acid aggregation was observed. TGF-[beta] levels were significantly higher in the TBI/Hemorrhage group following 2 hours of hypotension (1,764 vs. 1,252 pg/mL, p = 0.01). No differences in CD40 ligand or sP-selectin levels were observed.

CONCLUSION: In this combined model of TBI and hemorrhage, a significantly lower ADP-induced platelet aggregation was detected 15 minutes following injury that was further aggravated during the 2-hour shock period. This dysfunction was associated with an increase in platelet activation marker TGF-[beta].

From the Department of Anesthesia (M.S., L.S.R.), Center of Head and Orthopedics, and Capital Region Blood Bank (P.I.J., C.H.J.), Copenhagen University Hospital, Rigshospitalet, Denmark; Department of Surgery (M.S., C.H.J., A.M.I., J.H., J.L., M.D., G.V., M.d.M, H.B.A), Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts; Department of Surgery (P.I.J.), University of Texas Medical School at Houston, Houston, Texas; and Department of Surgery (G.J., H.B.A.), University of Michigan, Ann Arbor, Michigan.

Submitted: December 3, 2012, Revised: January 13, 2013, Accepted: January 14, 2013.

Address for reprints: Hasan B. Alam, MD, General Surgery, 2920 Taubman Center, University of Michigan Hospital, 1500 E. Medical Center Dr, Ann Arbor, MI 48109; email:

© 2013 Lippincott Williams & Wilkins, Inc.