Real-World Practice of Target Temperature Management in Acute Brain Injury: Associations with Coagulopathy and In-Hospital Mortality

Abstract

Target temperature management (TTM) is a neuroprotective strategy widely used in acute brain injury. However, its real-world implementation remains highly heterogenous and the clinical implications of different temperature targets and treatment durations are not well defined. This study aimed to describe real-world TTM practices and to explore associations between TTM characteristics, coagulopathy, and in-hospital mortality in patients with acute brain injury. We retrospectively analyzed 180 patients who underwent TTM between January 2011 and December 2024 at a single tertiary medical center. Patients diagnosed with acute brain injury, including aneurysmal subarachnoid hemorrhage, traumatic brain injury (TBI), intracerebral hemorrhage, or acute infarction, were included. Clinical variables, TTM parameters, complications, comorbidities, and in-hospital outcomes were analyzed. Univariable and multivariable analyses were conducted to identify factors associated with in-hospital mortality and TTM-related coagulopathy. In-hospital mortality occurred in 78 patients (43.3%). In multivariable analysis, post-cardiac arrest state (odds ratio [OR] = 3.99, p = 0.003) and coagulopathy during TTM (OR = 5.31, p = 0.005) were significantly associated with increased in-hospital mortality. Coagulopathy occurred in 21 (11.7%) patients and was significantly associated with type of injury, which showed it was most prevalent in TBI. Prolonged duration of TTM was not associated with an increased risk of coagulopathy and was associated with lower in-hospital mortality (OR = 0.30, p < 0.001). Injury subtype demonstrated significant heterogeneity in mortality risk and was retained as a covariate in the final multivariable model. In this real-world cohort, TTM practices varied substantially across acute brain injury subtypes. Coagulopathy was associated with increased in-hospital mortality and occurred more frequently in patients with TBI. Prolonged TTM was associated with lower in-hospital mortality. However, this finding should be interpreted cautiously given the potential for survivorship bias. Mortality risk differed across injury subtypes. These findings suggest that the clinical context and underlying injury type should be considered when applying TTM in patients with acute brain injury.