Effect of Progesterone Therapy In Traumatic Subarachinoid Haemorrhage On Clinical Outcome, Resistive Vascular Indices of Middle Cerebral Artery Transcranial Doppler And Thromboelastometry. A Promising Layout.

. Recent evidence questions for a safe approach to resuscitate population with traumatic sub-arachinoid hemorrhage (tSAH). Progesterone neuro-protective actions are a matter of debate among literatures. This was the epitome of the current research. Primary outcome was to investigate progesterone actions on cerebral blood ow velocimetry using trans-cranial doppler and on visco-elastic properties of the coagulation and brinolytic system by rotational thrombo-elastometry (ROTEM) scanning. Secondary outcome were tracking mortality rate and length of ICU stay. Methods. The current research was a prospective, randomized, double-blind, placebo controlled mono-centeric study. Three hundred thirty two (332) adult patients of both sexes aged years, recruited with solo tSAH Exclusion criteria included Glasgow coma cell hematochrit Two groups were Control group and PR group once daily from hospital admission, while Control group received isotonic saline daily for seven days as a placebo. Trans-cranial doppler was performed on admission, two days and seven days post-admission. ROTEM exploited on admission and seven days after admission. over-brinolytic activation


Introduction Background
Page 3/16 Secondary brain insult after tSAH formal as cerebral ischemia and coagulopathy are considered preventable causes of mortality and poor neurological outcome. Both lesions can leave survivors with permanent in rmity as motor de cits and cognitive dysfunction [1]. The risk of both is primarily related to the severity of the initial hemorrhage [2] Many drugs used to offer pharmacological neuroprotection but yet no solid evidence to rely on. Examples include but not limited to, aspirin (3), magnesuim (4), erythropoietin (5) and progesterone can offer neuroprotective effects via pleiotropic pathways. Progesterone decreases cerebral edema, restores blood-brain barrier integrity, reduces the in ammatory response and prevents cellular necrosis and apoptosis.
TCD ultrasonography is an operator dependant tool [6] and cannot be a sole tool for assessment of tSAH [7]. In fact, half of patients with progression of TICH have been shown to exhibit normal routine coagulation tests. In contrast, ROTEM a point-of-care visco-elastic assay of whole blood, provides a dynamic scanning of coagulation and clot formation, re ecting the contribution of clotting factors, platelets, and red blood cells. (8) Material And Methods Three hindered thirty two (332) adult patients of both sexes with solo traumatic tSAH. All candidates passed TRIAGE section before ICU admission, Abdominal ultrasound, Brain CT, Chest CT accomplished in all candidates. Traumatic subarachinoid hemorrhage was diagnosed after brain CT. Candidates with GCS from 9 to 12 were admitted to intermediate care unit with mechanical ventilation stand-by near every candidate, Patients with GCS from 12 to 15 were admitted to ward. Exclusion criteria included polytrauma patients, GCS less than 8, massive SAH, red blood cell transfusion during the rst 6 hours after admission, recombinant factor VIIa administered during resuscitation, history of clopidogrel or warfarin use within 10 days of injury, known coagulation disorder, pregnancy. Routine coagulation measures (prothrombin time, partial thromboplastin time) and arterial blood gas analysis were performed concurrently. Severe hypoperfusion was diagnosed by the presence of an arterial base de cit greater than 6mmol/L by arterial blood gas. n the current research, coagulopathy was diagnosed if 2 or more of the following was found ( platelets number less than 100,000 per mm 3 , international normalized ratio < 1.3, prolonged activated partial thromboplastin time > 36 seconds and serum brinogen < 150mg/dl any time throughout study period).

2.4.Legality.
An informed written consent was obtained from all participant next of kinn.
Computerized randomization was performed using variable block sizes. Opaque sealed envelopes were used for allocation concealment. After a written informed consent, patients were randomized to receive either progesterone (100mg, intramuscular) or sterile saline for one week after admission. Boxes with patient numbers containing unlabeled coded vials were provided for all patients. Saline prepared for injection was in equi-volume with progesterone. Both injectate, progesterone and placebo are similar regarding color, duration of therapy and route of injection. Serum progesterone was checked twice, rst immediately before initiating rst dose and the second one was taken at one week after therapy. Double blind fashion disputed (neither the principal investigator nor patient next to kin was aware of patient allocation). Neither of them was aware who was taking progesterone nor who was taking placebo. Participants enrollment and their assignment to intervention tasked by two anesthetics assistant lecturers. The statistics physician was responsible for generating the random allocation sequence and assigned participants to interventions. Candidates were assigned in two equal groups, Control group received intramuscular saline (2ml-NaCL0.9%) as a placebo for seven days daily ,while progesterone group (PR group) received intramuscular progesterone (100mg/ 2 ml) for seven days daily from admission. Using methodology published in the manufacturer's insert for (ROTEM) 2008 machine, a citrated kaolin-activated device (ROTEM Delta, Instrumental laboratory, Bedford, MA, USA) was performed using 1 ml of whole blood. Sample was automated pipetting. This was performed two hours from admission and one week after admission due to high cost of scanning. A trans-cranial doppler ( Sonosite, energy, USA) probe ( 2 Mega hertz) used to insonate the M1 ( rst 4 cm of the middle cerebral artery) portion of the middle cerebral artery by means of the trans-temporal approach then pulstality index, resistive index and mean ow velocity values were recorded. Reading taken 2 hours after admission (basal), two days and one week serially..

Study endpoint.
Primary endpoint was observing the effect of intramuscular progesterone on cerebral blood ow indices of middle cerebral artery and blood visco-elastic dynamics by thromboelastometry. Secondary endpoint was impact on mortality rate and length of ICU stay. Before the study runover, the number of patients required in each group was determined according to data obtained by a Pilot study performed on twenty consented candidates next to kin, ten in each group. In that study, Pilot study reported the mean one week post-traumatic PI level is 1.49 in control group , 0.99 in PR group (SD within each group was 0.1). A sample size of 166 patients in each group was determined to provide 99% power at the level of 5% signi cance using G Power 3.1 9.2 software.

Statistical analysis
The collected data were coded, tabulated, and statistically analyzed using SPSS program (Statistical Package for Social Sciences) software version 20.
-Descriptive statistics were done for Parametric quantitative data by mean, standard deviation and minimum & maximum of the range, while they were done for categorical data by number and percentage.
-Analyses were done for parametric quantitative data between two groups using independent t test between each two groups. Analyses within each group were done for parametric quantitative data using paired sample t test.
-The level of signi cance was taken at (P value < 0.05).

1-Transcranial Doppler indices:
A•Pulsitaility index (PI): There was a statistical signi cant difference between studied groups at two days and seven days postadmission with (p value =0.001 in both readings ) for the Rt side and (0.003 and , 0.004) for the Lt side.
There was also a signi cant difference between the PI values inside (PR) group at two days and seven days compared with basal value on both sides. There was no signi cant difference in between or within studied groups by comparing the MFV. There was a signi cant difference between studied groups at two days and seven days post-admission with (p value <0.001 ,) for the Rt and left side side. There was also a signi cant difference between the RI values inside (PR) group at two days and seven days compared with basal value on both sides.  insu ciency is diagnosed in nine cases in PR group and thirty six case in control group. Coagulopathy was diagnosed in 22 population in PR group and in 62 in controlgroup. *: signi cant difference between two studied groups at < 0.05 Table 5 showing the new intra-axial injury by ROTEM (Control group).
No statistical signi cant difference between ROTEM readings at admission and one week after . R time (re ecting clotting factor activity and initial brin formation), K (re ecting the interaction of clotting factors, brin, and platelets), α-angle (re ecting the rate of brin cross-linking and brinogen function), maximum amplitude (the widest amplitude of the TEG tracing, re ecting overall clot strength and platelet function), and LY30 (the percent of clot lysis at 30 min after start of the assay, re ecting brinolysis). CI = con dence interval.
Analysis of quantitative data by independent sample t-test.
*: signi cant difference between two studied groups at < 0.05  R time (re ecting clotting factor activity and initial brin formation), K (re ecting the interaction of clotting factors, brin, and platelets), α-angle (re ecting the rate of brin cross-linking and brinogen function), maximum amplitude (the widest amplitude of the TEG tracing, re ecting overall clot strength and platelet function), and LY30 (the percent of clot lysis at 30 min after start of the assay, re ecting brinolysis).

Discussion
Vascular impedence and coagulopathy are the point of concern being attributed to new brain insult. Hemostasis includes both normal serum level and functional inter-balance between co-agulation and brinolytic system., Coagulopathy after TBI has been shown to include abnormalities of both coagulation and brinolysis. Coagulopathic derangement after tSAH is linked to consumption, dilution of coagulation factors, thromb-athenia and increase in brinolysis. the brinolytic product D-dimer and brinogen degradation products are rst detected within minutes of injury (9). This rapid response raises the ego of the mechanism that brain injury can trigger early hyper brinolytic state. Under non traumatic state, Tissue plasminogen activator (tPA) proteolytically activates plasminogen to plasmin, which cleaves and dissolves brin polymers. This brinolytic process is dynamically slow and local during normal hemostasis because tPA has limited access to brin polymers trapped in a platelet clot (10). Nested randomized studies pointed to the use of anti brinolytic treatment in signi cant traumatic intracranial hemorrhage with improved outcomes, if administered soon after injury. Another route for coagulopathy derangement is deliberate hypothermia which is in use to decrease cerebral metabolism-can aggrevate coagulopathy. Thromboplastin that enters the circulation released from astrocytes is incriminated in activation of extrinsic coagulation pathway to produce a brin clot, leading to disseminated intravascular coagulopathy and hyper brinolysis (11).
Dose choice was based upon a previous randomized controlled trial that used progesterone in traumatic brain injury in a dose 100mg intramusculer for 5 days (Hassan et al., 2017 ). (12) In the current research, coagulopathy was diagnosed if 2 or more of the following was found ( platelets number less than 100,000 per mm 3 , international normalized ratio < 1.3, prolonged activated partial thromboplastin time > 36 seconds and serum brinogen < 150mg/dl any time throughout study period).
Hypoperfusion was de ned as arterial base de cit > 6 mmol/L. (13) All candidates in the current study who experienced coagulopathy showed criteria for hypoperfusion. Our results ran hand by hand with Thomas etal.,2010(13) who conducted a retrospective analysis of a prospectively collected cohort study recruited 132 patients from June 2005 to December 2007 about the incidence of tissue hypoperfusion in victims of severe traumatic brain injury and to determine the associations and links between hypoperfusion and TBI coagulopathy. They used the same diagnostic protocol in con rming post-TBIs coagulopathy and hypoperfusion as we did. They concluded that hypoperfusion is an independent risk factor for the development of early coagulopathy in patients with isolated TBI.
Zhao etal 2019 (14), in a wide spectrum meta-analysis consisting of eight randomized clinical trial hosting 2251 patients searching for both safety and e cacy of injected progesterone on TIBs population. T he regimen included 1 mg/kg intramuscular progesterone every 12 hours for ve days. Their results are compliant with us regarding candidates with progesterone group had less ICU time, better neurologic outcomes (RR = 1.51;, P = 0.007) than those who received placebo. Progesterone offered neuroprotection till 3 months after impact.
Another experimental study conducted by Jacob etal.,2008 (15) focused on effect of progesterone on blood coagulability declared that progesterone prevented TBI induced brinolysis and hypocagulability.
Adult male Sprague -Dawley rats were given bilateral contusions of the medial frontal cortex followed by treatments with PROG (16 mg/kg),, or vehicle (22.5% hydroxypropyl-β-cyclodextrin).. Progesterone generally maintained procoagulant (thrombin, brinogen, and coagulation factor XIII),. In addition, PROG signi cantly increased the ratio of tPA bound to neuroserpin, a serine protease inhibitor that can reduce the activity of tPA.
Cerebral vasospasm -is a quite common complication that occurs in up to two thirds of patients.
Cerebral vasospasm can occur as early as rst 24 hours of TBI event but more frequently begins 48 hours after trauma, reaching a peak after 7 days. New brain insult was de ned as persistent newly presented motor or sensory de cit or acute decrease of GCS of 2 points or new CT nding Vascular derangement after TBI -explained by-but not niched to -oxy-hemoglobin and the potent vasoconstrictor-endothelin-in particular, are incriminated to play a key role. The prominent action is attributed to nitric oxide scavenging, direct vasoconstriction, and induction of cytotoxic free oxygen radicals. Activation of protein kinase C, another proposed item, interacts with myosin light chain kinase, nitric oxide, intracellular Ca 2+ , protein tyrosine kinase, mediating cerebral vasoconstrictions. Since vasospasm is an angiographic phenomena, all population were prone to CT angiography provided that serum creatinine is less than 1mg/dl .
Progesterone failed to guard against cerebral vasospasm. This may be explained by that prominent interaction of ptn C and myosin light chain interaction that lead to increased cerebro-vasculer resistant.
Our results are compatible with Hassan etal., 2017 regarding progesterone induced shortened neurocritical ICU stay. They conducted prospective, randomized trial hosting 100 patients with severe TBI. The selected patients were categorized at random into two equal groups − the control group and the progesterone group. In the control group, patients were given conventional therapy. The progesterone group was given 1 mg/kg progesterone by intramuscular injection within 8 h of admission and then every 12 hours for 5 consecutive days in addition to the conventional therapy. The neurological outcome after 30 days was evaluated using the Glasgow Outcome Scale score as well as duration of ICU stay. Length of ICU stay had a mean value of 10.88 ± 7.98 days in the progesterone group versus 19.96 ± 10.36 days in the control group (P < 0.001).
On the other hand, Our results are in contrary with sumit etal.,2017 (16) who conducted a randomized placebo controlled trial, the primary objective of this study was to evaluate the e cacy of progesterone with or without prophylactic hypothermia in acute TBIs patients.
It was a prospective, statistician blinded, randomized, and placebo-controlled phase II trial of progesterone with or without hypothermia (factorial design). All adult patients (18- Despite the multifactorial bene ts of progesterone obtained in the experimental models of TBI and the promising results of two Phase II clinical trials [17,18], two Phase III clinical trials failed to show bene ts of progesterone [19,20]. Among the concerns that have been raised and cited: diversity of the enrolled patients concerning sex, age, and severity of TBI; the multiple doses of progesterone used; the lack of strati cation of patients; the subjective outcome measures.

Conclusion
Progesterone can resist hyper-brinolysis after tSAH and impede development on coagulopathy. Mortality and length of ICU stay was also signi cantly decreased.