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Yousefi O, Farrokhi A, Taheri R, Ghasemi H, Zoghi S, Eslami A, Niakan A, Khalili H. Effect of low fibrinogen level on in-hospital mortality and 6-month functional outcome of TBI patients, a single center experience. Neurosurg Rev 2024; 47:95. [PMID: 38413402 DOI: 10.1007/s10143-024-02326-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/04/2024] [Accepted: 02/18/2024] [Indexed: 02/29/2024]
Abstract
In patients affected by traumatic brain injury (TBI), hypofibrinogenemia within the initial hours of trauma can be expected due to vascular and inflammatory changes. In this study, we aimed to evaluate the effect of hypofibrinogenemia on the in-hospital mortality and 6-month functional outcomes of TBI patients, admitted to Rajaee Hospital, a referral trauma center in Shiraz, Iran. This study included all TBI patients admitted to our center who had no prior history of coagulopathy or any systemic disease, were alive on arrival, and had not received any blood product before admission. On admission, hospitalization, imaging, and 6-month follow-up information of included patients were extracted from the TBI registry database. The baseline characteristics of patients with fibrinogen levels of less than 150 mg/dL were compared with the cases with higher levels. To assess the effect of low fibrinogen levels on in-hospital mortality, a uni- and multivariate was conducted between those who died in hospital and survivors. Based on the 6-month GOSE score of patients, those with GOSE < 4 (unfavorable outcome) were compared with those with a favorable outcome. A total of 3049 patients (84.3% male, 15.7% female), with a mean age of 39.25 ± 18.87, met the eligibility criteria of this study. 494 patients had fibrinogen levels < 150 mg/dl, who were mostly younger and had lower average GCS scores in comparison to cases with higher fibrinogen levels. By comparison of the patients who died during hospitalization and survivors, it was shown that fibrinogen < 150 mg/dl is among the prognostic factors for in-hospital mortality (OR:1.75, CI: 1.32:2.34, P-value < 0.001), while the comparison between patients with the favorable and unfavorable functional outcome at 6-month follow-up, was not in favor of prognostic effect of low fibrinogen level (OR: 0.80, CI: 0.58: 1.11, P-value: 0.19). Hypofibrinogenemia is associated with in-hospital mortality of TBI patients, along with known factors such as higher age and lower initial GCS score. However, it is not among the prognostic factors of midterm functional outcome.
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Affiliation(s)
- Omid Yousefi
- Trauma Research Center, Department of Neurosurgery, Shahid Rajaee Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amirmohammad Farrokhi
- Trauma Research Center, Department of Neurosurgery, Shahid Rajaee Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Reza Taheri
- Trauma Research Center, Department of Neurosurgery, Shahid Rajaee Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hadis Ghasemi
- Trauma Research Center, Department of Neurosurgery, Shahid Rajaee Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
- Institute of Biology and Medicine, Taras Shevchenko National University of Kyiv (KNU), Kyiv, Ukraine
| | - Sina Zoghi
- Trauma Research Center, Department of Neurosurgery, Shahid Rajaee Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Asma Eslami
- Trauma Research Center, Department of Neurosurgery, Shahid Rajaee Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amin Niakan
- Trauma Research Center, Department of Neurosurgery, Shahid Rajaee Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hosseinali Khalili
- Trauma Research Center, Department of Neurosurgery, Shahid Rajaee Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran.
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Nathwani R, Proumen A, Blaine KP. Etiology and management of hypofibrinogenemia in trauma. Curr Opin Anaesthesiol 2023; 36:382-387. [PMID: 36994749 DOI: 10.1097/aco.0000000000001265] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
PURPOSE OF REVIEW Fibrin polymerization is essential for stable clot formation in trauma, and hypofibrinogenemia reduces hemostasis in trauma. This review considers fibrinogen biology, the changes that fibrinogen undergoes after major trauma, and current evidence for lab testing and treatment. RECENT FINDINGS Fibrinogen is a polypeptide that is converted to fibrin by the action of thrombin. During trauma, fibrinogen levels are consumed and reduce within the first few hours because of consumption, dilution, and fibrinolysis. Fibrinogen levels usually rebound within 48 hours of injury and can contribute to thrombotic events. The Clauss fibrinogen assay is the gold standard test for fibrinogen levels, although viscoelastic hemostatic assays are often used when a lab delay is anticipated. An evidence-based threshold for fibrinogen replacement is not well established in the literature, but expert opinion recommends maintaining a level above 150 mg/dl. SUMMARY Hypofibrinogenemia is an important cause of nonanatomic bleeding in trauma. Despite multiple pathologic causes, the cornerstone of treatment remains fibrinogen replacement with cryoprecipitate or fibrinogen concentrates.
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Affiliation(s)
- Rajen Nathwani
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Adrian Proumen
- State University of New York (SUNY) Upstate University Hospital, Syracuse, New York
| | - Kevin P Blaine
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, UHN2, Portland, Orlando, USA
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Shammassian BH, Ronald A, Smith A, Sajatovic M, Mangat HS, Kelly ML. Viscoelastic Hemostatic Assays and Outcomes in Traumatic Brain Injury: A Systematic Literature Review. World Neurosurg 2022; 159:221-236.e4. [PMID: 34844010 DOI: 10.1016/j.wneu.2021.10.180] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 10/27/2021] [Accepted: 10/28/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Coagulopathy in traumatic brain injury (TBI) occurs frequently and is associated with poor outcomes. Conventional coagulation assays (CCA) traditionally used to diagnose coagulopathy are often not time sensitive and do not assess complete hemostatic function. Viscoelastic hemostatic assays (VHAs) including thromboelastography and rotational thromboelastography provide a useful rapid and comprehensive point-of-care alternative for identifying coagulopathy, which is of significant consequence in patients with TBI with intracranial hemorrhage. METHODS A systematic review was performed in accordance with PRISMA guidelines to identify studies comparing VHA with CCA in adult patients with TBI. The following differences in outcomes were assessed based on ability to diagnose coagulopathy: mortality, need for neurosurgical intervention, and progression of traumatic intracranial hemorrhage (tICH). RESULTS Abnormal reaction time (R time), maximum amplitude, and K value were associated with increased mortality in certain studies but not all studies. This association was reflected across studies using different statistical parameters with different outcome definitions. An abnormal R time was the only VHA parameter found to be associated with the need for neurosurgical intervention in 1 study. An abnormal R time was also the only VHA parameter associated with progression of tICH. Overall, many studies also reported abnormal CCAs, mainly activated partial thromboplastin time, to be associated with poor outcomes. CONCLUSIONS Given the heterogenous nature of the available evidence including methodology and study outcomes, the comparative difference between VHA and CCA in predicting rates of neurosurgical intervention, tICH progression, or mortality in patients with TBI remains inconclusive.
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Affiliation(s)
- Berje H Shammassian
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA; Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.
| | - Andrew Ronald
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Arvin Smith
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Martha Sajatovic
- Neurological and Behavioral Outcomes Center, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Halinder S Mangat
- Department of Neurology, Division of Neurocritical Care, University of Kansas Medical Center Kansas City, Kansas, USA
| | - Michael L Kelly
- Metrohealth Medical Center, Department of Neurological Surgery, Cleveland, Ohio, USA
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High fibrinogen γ' levels in patient plasma increase clot formation at arterial and venous shear. Blood Adv 2021; 5:3468-3477. [PMID: 34438442 DOI: 10.1182/bloodadvances.2020003346] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 03/26/2021] [Indexed: 12/27/2022] Open
Abstract
Fibrinogen γ' accounts for 3% to 40% of plasma fibrinogen. Earlier studies indicated that fibrinogen γ' forms altered fibrin clots under static conditions, whereas clinically, altered plasma γ' levels are associated with arterial and venous thrombosis. However, the effects of static vs flow conditions on the role of γ' throughout the pathophysiological range is unknown. This study explores the effects of γ' levels on clot formation and structure in static and flow conditions. Coagulation of plasma samples with low (n = 41; 3%), normal (n = 45; 10%), or high (n = 33; 30%) γ' levels were compared with that of purified fibrinogen mixtures with increasing ratios of γ' (3%, 10%, 30%). Clots were analyzed by confocal microscopy, permeation, turbidity, and lysis techniques. In a novel 2-step flow-perfusion model, fibrinogen-deficient plasma repleted with increasing ratios of γ' (3%, 10%, 30%) or plasmas with low (n = 5, 3%) or high (n = 5, 30%) γ' were flowed over preformed platelet aggregates at arterial (500 s-1) and venous (150 s-1) shear rates. Increasing γ' percentages within the pathophysiological range (3%-30%) did not result in any change in clot-formation rates; however, it led to significantly higher clot density, thinner fibers, and slower lysis in static conditions. Under flow at arterial shear, high γ' (30%) led to faster (+44.1%-75.3%) and increased (+104%-123%) fibrin deposition, with clots exhibiting a larger volume (+253%-655%) and height (+130%-146%). These trends were magnified at venous shear. Overall, our findings demonstrate the significant impact of pathophysiological fibrinogen γ' levels on clot structure and provide new flow-dependent mechanisms to explain how γ' increases thrombosis risk.
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