Hemorrhage Associated Mechanisms of Neuroinflammation in Experimental Traumatic Brain Injury

  • Xiaotang Ma
  • Yiming Cheng
  • Ricardo Garcia
  • James HaorahEmail author


Traumatic brain injury (TBI) is a major health problem for over 3.17 million people in the US, attracting increasing public attentions. Understanding the underlying mechanism of TBI is urgent for better diagnosis and treatment. Here, we examined the hypothesis that cerebral hemorrhagic coagulation and subsequent immune cells infiltration causes the progressive mechanisms of brain injury in moderate fluid percussion injury model. This represents a subdural hematoma and hemorrhagic head injury. We found increased hemorrhagic lesions and infarct volume in the injured brain with increment of pressure. The extent of hemorrhage was also validated by the bio-distribution of fluorescent tracer in cerebrospinal fluid (CSF) pathway after the injury. Bio-distribution of tracer was specifically diminished at the site of hemorrhage resulting from coagulation, which blocked the interstitial and CSF movement of the tracer. Increased expression of coagulation factor XII and necrotic cell death in and around the impact site confirmed the reason for this blockade. Different biomarkers, including immune cells accumulation and neuronal death showed that blood-brain barrier disruption played an important role for induction of neuroinflammation and neurodegeneration around the impact site. Our results suggest that instant hemorrhagic injury resulting from rupturing the brain blood vessels intertwined with coagulation causes onsite perivascular inflammation and neurodegeneration. Understanding of this sequential event should be valuable for development of therapeutic treatment in TBI.

Graphical Abstract

Underlying mechanisms in moderate/severe blunt TBI: hemorrhage following cerebrovascular disruption results in coagulation, thrombotic necrosis, and acute immune cell infiltration.


Traumatic brain injury Hemorrhage CSF Coagulation Neuronal death 



We thank Dr. Eun Jung Lee, Dr. Namas Chandra and Daniel Younger for help of imaging and section scanning. This work was supported by grant 1R21AA022734-01A1 (to JH) from National Institutes of Health.

Authors Contributions

XM carried out the studies, performed the data acquisition and writing in manuscript preparation. YC assisted XM in surgery and data analysis. RG assisted in animal care and surgery. JH supervised the development of work, gave critical revisions and edited the manuscript. All authors read and approved the final manuscript.

Compliance with Ethical Standards

Ethical Approval and Consent to Participate

All procedures performed in studies involving animals followed the National Institutes of Health guidelines for the ethical care of laboratory animals, and the Institutional Animal Care and Use Committee (IACUC) at the animal facility of Rutgers-Newark University.

Conflict of Interest

The authors have declared that no competing interests exist.


  1. Abdul-Muneer PM, Schuetz H, Wang F, Skotak M, Jones J, Gorantla S, Zimmerman MC, Chandra N, Haorah J (2013) Induction of oxidative and nitrosative damage leads to cerebrovascular inflammation in an animal model of mild traumatic brain injury induced by primary blast. Free Radic Biol Med 60:282–291. CrossRefPubMedPubMedCentralGoogle Scholar
  2. Albert-Weissenberger C, Hopp S, Nieswandt B, Siren AL, Kleinschnitz C, Stetter C (2019) How is the formation of microthrombi after traumatic brain injury linked to inflammation? J Neuroimmunol 326:9–13. CrossRefPubMedGoogle Scholar
  3. Allingstrup M, Wetterslev J, Ravn FB, Moller AM, Afshari A (2016) Antithrombin III for critically ill patients: a systematic review with meta-analysis and trial sequential analysis. Intensive Care Med 42:505–520. CrossRefPubMedGoogle Scholar
  4. Alluri H, Wiggins-Dohlvik K, Davis ML, Huang JH, Tharakan B (2015) Blood-brain barrier dysfunction following traumatic brain injury. Metab Brain Dis 30:1093–1104. CrossRefPubMedGoogle Scholar
  5. Bailes JE, Cantu RC (2001) Head injury in athletes. Neurosurgery 48:26–45; discussion 45-26. CrossRefPubMedGoogle Scholar
  6. Bazarian JJ, McClung J, Shah MN, Cheng YT, Flesher W, Kraus J (2005) Mild traumatic brain injury in the United States, 1998--2000. Brain Inj 19:85–91CrossRefGoogle Scholar
  7. Bhowmick S, D'Mello V, Caruso D, Wallerstein A, Abdul-Muneer PM (2019) Impairment of pericyte-endothelium crosstalk leads to blood-brain barrier dysfunction following traumatic brain injury. Exp Neurol 317:260–270. CrossRefPubMedGoogle Scholar
  8. Cantu RC et al (2006) Overview of concussion consensus statements since 2000. Neurosurg Focus 21:E3CrossRefGoogle Scholar
  9. Charolidi N, Schilling T, Eder C (2015) Microglial Kv1.3 channels and P2Y12 receptors differentially regulate cytokine and chemokine release from brain slices of young adult and aged mice. PLoS One 10:e0128463. CrossRefPubMedPubMedCentralGoogle Scholar
  10. Dietrich WD, Alonso O, Busto R, Prado R, Dewanjee S, Dewanjee MK, Ginsberg MD (1996) Widespread hemodynamic depression and focal platelet accumulation after fluid percussion brain injury: a double-label autoradiographic study in rats journal of cerebral blood flow and metabolism. J Cerebr Blood F Met 16:481–489. CrossRefGoogle Scholar
  11. Dijkland SA, Foks KA, Polinder S, Dippel DWJ, Maas A, Lingsma H, Steyerberg EW (2019) Prognosis in moderate and severe traumatic brain injury: a systematic review of contemporary models and validation studies. J Neurotrauma.
  12. Edlow BL et al (2017) Early detection of consciousness in patients with acute severe traumatic brain injury brain. A journal of neurology 140:2399–2414. CrossRefGoogle Scholar
  13. Faul M, Coronado V (2015) Epidemiology of traumatic brain injury. Handb Clin Neurol 127:3–13. CrossRefPubMedGoogle Scholar
  14. Faust K, Horn P, Schneider UC, Vajkoczy P (2014) Blood pressure changes after aneurysmal subarachnoid hemorrhage and their relationship to cerebral vasospasm and clinical outcome. Clin Neurol Neurosurg 125:36–40. CrossRefPubMedGoogle Scholar
  15. Fleminger S, Oliver DL, Lovestone S, Rabe-Hesketh S, Giora A (2003) Head injury as a risk factor for Alzheimer's disease: the evidence 10 years on; a partial replication. J Neurol Neurosurg Psychiatry 74:857–862CrossRefGoogle Scholar
  16. Frost RB, Farrer TJ, Primosch M, Hedges DW (2013) Prevalence of traumatic brain injury in the general adult population: a meta-analysis. Neuroepidemiology 40:154–159. CrossRefPubMedGoogle Scholar
  17. Gaasch JA, Lockman PR, Geldenhuys WJ, Allen DD, Van der Schyf CJ (2007) Brain iron toxicity: differential responses of astrocytes, neurons, and endothelial cells. Neurochem Res 32:1196–1208. CrossRefPubMedGoogle Scholar
  18. Godoy DA, Rubiano A, Rabinstein AA, Bullock R, Sahuquillo J (2016) Moderate traumatic brain injury: the Grey zone of Neurotrauma. Neurocrit Care 25:306–319. CrossRefPubMedGoogle Scholar
  19. Goldberg AS, Moroz L, Smith A, Ganley T (2007) Injury surveillance in young athletes. Sports Med 37(3):265-278. CrossRefGoogle Scholar
  20. Goldstein LE et al (2012) Chronic traumatic encephalopathy in blast-exposed military veterans and a blast neurotrauma mouse model. Sci Transl Med 4:134–160. CrossRefGoogle Scholar
  21. Grenander A, Bredbacka S, Rydvall A, Aroch R, Edner G, Koskinen LO, Olivecrona M (2001) Antithrombin treatment in patients with traumatic brain injury: a pilot study. J Neurosurg Anesthesiol 13:49–56CrossRefGoogle Scholar
  22. Guo Z, Cupples LA, Kurz A, Auerbach SH, Volicer L, Chui H, Green RC, Sadovnick AD, Duara R, DeCarli C, Johnson K, Go RC, Growdon JH, Haines JL, Kukull WA, Farrer LA (2000) Head injury and the risk of AD in the MIRAGE study. Neurology 54:1316–1323CrossRefGoogle Scholar
  23. Hochstadter E, Stewart TC, Alharfi IM, Ranger A, Fraser DD (2014) Subarachnoid hemorrhage prevalence and its association with short-term outcome in pediatric severe traumatic brain injury. Neurocrit Care 21:505–513. CrossRefPubMedGoogle Scholar
  24. Hopp S, Albert-Weissenberger C, Mencl S, Bieber M, Schuhmann MK, Stetter C, Nieswandt B, Schmidt PM, Monoranu CM, Alafuzoff I, Marklund N, Nolte MW, Sirén AL, Kleinschnitz C (2016) Targeting coagulation factor XII as a novel therapeutic option in brain trauma. Ann Neurol 79:970–982. CrossRefPubMedPubMedCentralGoogle Scholar
  25. Iliff JJ et al (2013) Cerebral arterial pulsation drives paravascular CSF-interstitial fluid exchange in the murine brain the journal of neuroscience. J Neurosci 33:18190–18199. CrossRefPubMedPubMedCentralGoogle Scholar
  26. Iverson KM, Dardis CM, Pogoda TK (2017) Traumatic brain injury and PTSD symptoms as a consequence of intimate partner violence. Compr Psychiatry 74:80–87. CrossRefPubMedGoogle Scholar
  27. Johnson VE, Stewart W, Smith DH (2012) Widespread tau and amyloid-beta pathology many years after a single traumatic brain injury in humans. Brain Pathol 22:142–149. CrossRefPubMedGoogle Scholar
  28. Kooijman E, Nijboer CH, van Velthoven CT, Mol W, Dijkhuizen RM, Kesecioglu J, Heijnen CJ (2014) Long-term functional consequences and ongoing cerebral inflammation after subarachnoid hemorrhage in the rat. PLoS One 9:e90584. CrossRefPubMedPubMedCentralGoogle Scholar
  29. Leibson CL, Brown AW, Ransom JE, Diehl NN, Perkins PK, Mandrekar J, Malec JF (2011) Incidence of traumatic brain injury across the full disease spectrum: a population-based medical record review study. Epidimiology 22:836–844. CrossRefGoogle Scholar
  30. Levin HS, Diaz-Arrastia RR (2015) Diagnosis, prognosis, and clinical management of mild traumatic brain injury. Lancet Neurol 14:506–517. CrossRefPubMedGoogle Scholar
  31. Lifshitz J, Rowe RK, Griffiths DR, Evilsizor MN, Thomas TC, Adelson PD, McIntosh TK (2016) Clinical relevance of midline fluid percussion brain injury: acute deficits, chronic morbidities and the utility of biomarkers. Brain Inj 30:1293–1301. CrossRefPubMedPubMedCentralGoogle Scholar
  32. Liu DZ, Sharp FR, van K, Ander BP, Ghiasvand R, Zhan X, Stamova B, Jickling GC, Lyeth BG (2014) Inhibition of SRC family kinases protects hippocampal neurons and improves cognitive function after traumatic brain injury. J Neurotrauma 31:1268–1276. CrossRefPubMedPubMedCentralGoogle Scholar
  33. Lyeth BG (2016) Historical review of the fluid-percussion TBI model. Front Neurol 7:217. CrossRefPubMedPubMedCentralGoogle Scholar
  34. Ma X, Aravind A, Pfister BJ, Chandra N, Haorah J (2019) Animal models of traumatic brain injury and assessment of injury severity. Mol Neurobiol 56:5332–5345. CrossRefPubMedGoogle Scholar
  35. Maegele M, Schochl H, Menovsky T, Marechal H, Marklund N, Buki A, Stanworth S (2017) Coagulopathy and haemorrhagic progression in traumatic brain injury: advances in mechanisms, diagnosis, and management. Lancet Neurol 16:630–647. CrossRefPubMedGoogle Scholar
  36. McKee AC, Cantu RC, Nowinski CJ, Hedley-Whyte ET, Gavett BE, Budson AE, Santini VE, Lee HS, Kubilus CA, Stern RA (2009) Chronic traumatic encephalopathy in athletes: progressive tauopathy after repetitive head injury. J Neuropathol Exp Neurol 68:709–735. CrossRefPubMedPubMedCentralGoogle Scholar
  37. Merlini M, Wanner D, Nitsch RM (2016) Tau pathology-dependent remodelling of cerebral arteries precedes Alzheimer's disease-related microvascular cerebral amyloid angiopathy. Acta Neuropathol 131:737–752. CrossRefPubMedPubMedCentralGoogle Scholar
  38. Merlini M et al (2019) Fibrinogen induces microglia-mediated spine elimination and cognitive impairment in an Alzheimer's disease model. Neuron. CrossRefGoogle Scholar
  39. Morales DM, Marklund N, Lebold D, Thompson HJ, Pitkanen A, Maxwell WL, Longhi L, Laurer H, Maegele M, Neugebauer E, Graham DI, Stocchetti N, McIntosh T (2005) Experimental models of traumatic brain injury: do we really need to build a better mousetrap? Neuroscience 136:971–989. CrossRefPubMedGoogle Scholar
  40. Morganti JM, Riparip LK, Chou A, Liu S, Gupta N, Rosi S (2016) Age exacerbates the CCR2/5-mediated neuroinflammatory response to traumatic brain injury. J Neuroinflammation 13:80. CrossRefPubMedPubMedCentralGoogle Scholar
  41. Ndode-Ekane XE, Matthiesen L, Banuelos-Cabrera I, Palminha CAP, Pitkanen A (2018) T-cell infiltration into the perilesional cortex is long-lasting and associates with poor somatomotor recovery after experimental traumatic brain injury. Restor Neurol Neurosci 36:485–501. CrossRefPubMedGoogle Scholar
  42. Nguyen R, Fiest KM, McChesney J, Kwon CS, Jette N, Frolkis AD, Atta C, Mah S, Dhaliwal H, Reid A, Pringsheim T, Dykeman J, Gallagher C (2016) The international incidence of traumatic brain injury: a systematic review and meta-analysis. Can J Neurol Sci 43:774–785. CrossRefPubMedGoogle Scholar
  43. Ofengeim D, Mazzitelli S, Ito Y, DeWitt J, Mifflin L, Zou C, Das S, Adiconis X, Chen H, Zhu H, Kelliher MA, Levin JZ, Yuan J (2017) RIPK1 mediates a disease-associated microglial response in Alzheimer's disease. Proc Natl Acad Sci U S A 114:E8788–e8797. CrossRefPubMedPubMedCentralGoogle Scholar
  44. Omalu B, Hammers JL, Bailes J, Hamilton RL, Kamboh MI, Webster G, Fitzsimmons RP (2011) Chronic traumatic encephalopathy in an Iraqi war veteran with posttraumatic stress disorder who committed suicide. Neurosurg Focus 31:E3CrossRefGoogle Scholar
  45. Otis JD, McGlinchey R, Vasterling JJ, Kerns RD (2011) Complicating factors associated with mild traumatic brain injury: impact on pain and posttraumatic stress disorder treatment. J Clin Psychol Med Settings 18:145–154. CrossRefPubMedGoogle Scholar
  46. Perel P, Roberts I, Bouamra O, Woodford M, Mooney J, Lecky F (2009) Intracranial bleeding in patients with traumatic brain injury: a prognostic study. BMC Emerg Med 9:15. CrossRefPubMedPubMedCentralGoogle Scholar
  47. Persidsky Y, Ramirez SH, Haorah J, Kanmogne GD (2006) Blood-brain barrier: structural components and function under physiologic and pathologic conditions. J Neuroimmune Pharm 1:223–236. CrossRefGoogle Scholar
  48. Ray JW, Hwang C, Baine J, Fredericson M, Keane GP (2017) Current Concepts in Concussion: A Review. J Calif Dent Assoc 45:285–289PubMedGoogle Scholar
  49. Rhind SG, Crnko NT, Baker AJ, Morrison LJ, Shek PN, Scarpelini S, Rizoli SB (2010) Prehospital resuscitation with hypertonic saline-dextran modulates inflammatory, coagulation and endothelial activation marker profiles in severe traumatic brain injured patients. J Neuroinflammation 7:5. CrossRefPubMedPubMedCentralGoogle Scholar
  50. Robba C, Bertuetti R, Rasulo F, Bertuccio A, Matta B (2017) Coagulation management in patients undergoing neurosurgical procedures. Curr Opin Anaesthesiol 30:527–533. CrossRefPubMedGoogle Scholar
  51. Salib E, Hillier V (1997) Head injury and the risk of Alzheimer's disease: a case control study. Int J Geriatr Psychiatry 12:363–368CrossRefGoogle Scholar
  52. Schwarzmaier SM, Kim SW, Trabold R, Plesnila N (2010) Temporal profile of thrombogenesis in the cerebral microcirculation after traumatic brain injury in mice. J Neurotrauma 27:121–130. CrossRefPubMedGoogle Scholar
  53. Schwarzmaier SM, de Chaumont C, Balbi M, Terpolilli NA, Kleinschnitz C, Gruber A, Plesnila N (2016) The Formation of Microthrombi in Parenchymal Microvessels after Traumatic Brain Injury Is Independent of Coagulation Factor XI. J Neurotrauma 33:1634–1644. CrossRefPubMedPubMedCentralGoogle Scholar
  54. Shen X, Dutcher SK, Palmer J, Liu X, Kiptanui Z, Khokhar B, al-Jawadi MH, Zhu Y, Zuckerman IH (2015) A systematic review of the benefits and risks of anticoagulation following traumatic brain injury. J Head Trauma Rehabil 30:E29–E37. CrossRefPubMedPubMedCentralGoogle Scholar
  55. Skrifvars MB, Bailey M, Presneill J, French C, Nichol A, Little L, Duranteau J, Huet O, Haddad S, Arabi Y, McArthur C, Cooper DJ, Bellomo R, EPO-TBI investigators and the ANZICS Clinical Trials Group (2017) Venous thromboembolic events in critically ill traumatic brain injury patients. Intensive Care Med 43:419–428. CrossRefPubMedGoogle Scholar
  56. Stein SC, Chen XH, Sinson GP, Smith DH (2002) Intravascular coagulation: a major secondary insult in nonfatal traumatic brain injury. J Neurosurg 97:1373–1377. CrossRefPubMedGoogle Scholar
  57. Stein SC, Graham DI, Chen XH, Smith DH (2004) Association between intravascular microthrombosis and cerebral ischemia in traumatic brain injury. Neurosurgery 54:687–691 discussion 691CrossRefGoogle Scholar
  58. Stein SC et al (2009) Erythrocyte-bound tissue plasminogen activator is neuroprotective in experimental traumatic brain injury. J Neurotrauma 26:1585–1592. CrossRefPubMedPubMedCentralGoogle Scholar
  59. Su X, Wang H, Kang D, Zhu J, Sun Q, Li T, Ding K (2015) Necrostatin-1 ameliorates intracerebral hemorrhage-induced brain injury in mice through inhibiting RIP1/RIP3 pathway. Neurochem Res 40:643–650. CrossRefPubMedGoogle Scholar
  60. Tang Q, Lei J, Gao G, Feng J, Mao Q, Jiang J (2017) Prevalence of persistent vegetative state in patients with severe traumatic brain injury and its trend during the past four decades: a meta-analysis. NeuroRehabilitation 40:23–31. CrossRefPubMedGoogle Scholar
  61. Taylor CA, Bell JM, Breiding M J, Xu L (2017) Traumatic brain injury–related emergency department visits, hospitalizations, and deaths—United States, 2007 and 2013. MMWR Surveill Summ 66(9):1. CrossRefGoogle Scholar
  62. Timaru-Kast R, Luh C, Gotthardt P, Huang C, Schafer MK, Engelhard K, Thal SC (2012) Influence of age on brain edema formation, secondary brain damage and inflammatory response after brain trauma in mice. PLoS One 7:e43829. CrossRefPubMedPubMedCentralGoogle Scholar
  63. Vanderploeg RD, Belanger HG, Horner RD, Spehar AM, Powell-Cope G, Luther SL, Scott SG (2012) Health outcomes associated with military deployment: mild traumatic brain injury, blast, trauma, and combat associations in the Florida National Guard. Arch Phys Med Rehabil 93:1887–1895. CrossRefPubMedGoogle Scholar
  64. Xiong Y, Mahmood A, Chopp M (2013) Animal models of traumatic brain injury. Nat Rev Neurosci 14:128–142. CrossRefPubMedPubMedCentralGoogle Scholar
  65. Xiong Y, Mahmood A, Chopp M (2018) Current understanding of neuroinflammation after traumatic brain injury and cell-based therapeutic opportunities. Chin J Traumatol 21:137–151. CrossRefPubMedPubMedCentralGoogle Scholar
  66. Zehtabchi S, Soghoian S, Liu Y, Carmody K, Shah L, Whittaker B, Sinert R (2008) The association of coagulopathy and traumatic brain injury in patients with isolated head injury. Resuscitation 76:52–56. CrossRefPubMedGoogle Scholar
  67. Zhou H, Chen L, Gao X, Luo B, Chen J (2012) Moderate traumatic brain injury triggers rapid necrotic death of immature neurons in the hippocampus. J Neuropathol Exp Neurol 71:348–359. CrossRefPubMedPubMedCentralGoogle Scholar

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Authors and Affiliations

  1. 1.Laboratory of Neurovascular Inflammation and Neurodegeneration, Department of Biomedical Engineering, Center for Injury Bio-Mechanics, Materials and MedicineNew Jersey Institute of TechnologyNewarkUSA

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