1
|
Pîrlog BO, Grotta JC. The Applicability of Thromboelastography in Acute Ischemic Stroke: A Literature Review. Semin Thromb Hemost 2022. [PMID: 36063851 DOI: 10.1055/s-0042-1757134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Acute ischemic stroke (AIS) due to cerebral artery occlusion is often treated by thrombolytics or antithrombotic drugs. Thromboelastography (TEG) is a noninvasive test that provides a dynamic overview of the coagulation process. TEG may help guide thrombolytic and antithrombotic therapy in AIS. This article aims to highlight the potential use of TEG in AIS patients by reviewing available studies. We conducted a literature review, including PubMed and Cochrane library databases. The following keywords were used to find relevant studies: thromboelastography, TEG, acute ischemic stroke, stroke, coagulopathy, antiplatelet, and anticoagulant treatment. We identified 142 papers and after abstract review, we included 24 studies in this report. TEG identified a hypercoagulable state in AIS patients represented by short R, K, and greater α: angle in all papers included. Modification of TEG parameters induced by intravenous thrombolysis was inconsistent but prolonged lysis (increased LY30) and weaker clots (lower maximum amplitude) were most frequent. TEG detected hypo-coagulopathy induced by dual antiplatelet therapy as well as antiplatelet drug resistance, with ticagrelor and aspirin having greater inhibition of platelet activity. A prolonged R-value seems to be the most reliable TEG parameter in detecting the anticoagulant effect of factor Xa inhibitor treatment. TEG might represent a useful point-of-care test for emergency decision-making in AIS patients and a tool for individualized treatment options. This hypothesis needs validation in a large cohort of prospectively studied AIS patients.
Collapse
Affiliation(s)
- Bianca O Pîrlog
- Department of Neurology, County Emergency Hospital, Cluj-Napoca, Romania.,University of Medicine and Pharmacy "Iuliu Hațieganu" Cluj-Napoca, Romania
| | - James C Grotta
- Memorial Hermann Hospital-Texas Medical Center, Houston, Texas
| |
Collapse
|
2
|
Pîrlog BO, Grotta JC. The Applicability of Thromboelastography in Acute Ischemic Stroke: A Literature Review. Semin Thromb Hemost 2022; 48:842-849. [PMID: 36055271 DOI: 10.1055/s-0042-1753529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Acute ischemic stroke (AIS) due to cerebral artery occlusion is often treated by thrombolytics or antithrombotic drugs. Thromboelastography (TEG) is a noninvasive test that provides a dynamic overview of the coagulation process. TEG may help guide thrombolytic and antithrombotic therapy in AIS. This article aims to highlight the potential use of TEG in AIS patients by reviewing available studies. We conducted a literature review, including PubMed and Cochrane library databases. The following keywords were used to find relevant studies: thromboelastography, TEG, acute ischemic stroke, stroke, coagulopathy, antiplatelet, and anticoagulant treatment. We identified 142 papers and after abstract review, we included 24 studies in this report. TEG identified a hypercoagulable state in AIS patients represented by short R, K, and greater α: angle in all papers included. Modification of TEG parameters induced by intravenous thrombolysis was inconsistent but prolonged lysis (increased LY30) and weaker clots (lower maximum amplitude) were most frequent. TEG detected hypo-coagulopathy induced by dual antiplatelet therapy as well as antiplatelet drug resistance, with ticagrelor and aspirin having greater inhibition of platelet activity. A prolonged R-value seems to be the most reliable TEG parameter in detecting the anticoagulant effect of factor Xa inhibitor treatment. TEG might represent a useful point-of-care test for emergency decision-making in AIS patients and a tool for individualized treatment options. This hypothesis needs validation in a large cohort of prospectively studied AIS patients.
Collapse
Affiliation(s)
- Bianca O Pîrlog
- Department of Neurology, County Emergency Hospital, Cluj-Napoca, Romania.,University of Medicine and Pharmacy "Iuliu Hațieganu" Cluj-Napoca, Romania
| | - James C Grotta
- Memorial Hermann Hospital-Texas Medical Center, Houston, Texas
| |
Collapse
|
3
|
Real-time monitoring of intravenous thrombolysis in acute ischemic stroke using rotational thromboelastometry: a feasibility pilot study. J Neurol 2022; 269:6129-6138. [PMID: 35852602 PMCID: PMC9553850 DOI: 10.1007/s00415-022-11271-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 07/03/2022] [Accepted: 07/04/2022] [Indexed: 11/03/2022]
Abstract
Abstract
Introduction
Rotational thromboelastometry (ROTEM) records whole blood coagulation in vitro. Data on dynamic changes of clot patterns during intravenous thrombolysis (IVT) in acute ischemic stroke is scarce. We investigated the feasibility of ROTEM as a potential point-of-care assessment tool for IVT.
Methods
In this prospective pilot study, patients with acute stroke symptoms received IVT. Whole blood coagulation was tracked on the ROTEM analyzer. Blood samples were analyzed before, and then 2, 15, 30 and 60 min after beginning IVT. In vitro clots (iCLs) were described by their maximum clot firmness (MCF), the time needed to reach MCF (MCF-t), as well as the area under the curve (AR10). National Institutes of Health Stroke Scale (NIHSS) was used as early clinical outcome parameter.
Results
We analyzed 288 iCLs from 12 patients undergoing IVT. In all iCLs, an early fibrinolysis (91% within the first 10 min) was detected during IVT. Three different curve progression patterns were observed: a low-responder pattern with a continuous clot increase, a high-responder pattern with a sustained clot decrease or total clotting suppression and an intermediate-responder pattern with alternating clot characteristics. There was a difference among these groups in early clinical outcome (AR10 and MCF each p = 0.01, MCF-t p = 0.02, Kruskal–Wallis Test).
Conclusion
The fibrinolysis patterns determined using ROTEM allow for the monitoring of IVT in patients with acute ischemic stroke. This pilot study found a correlation between the in vitro fibrinolysis patterns and early clinical outcomes. These findings support a potential for individualization of IVT in the future.
Collapse
|
4
|
Pavoni V, Gianesello L, Pazzi M, Dattolo P, Prisco D. Questions about COVID-19 associated coagulopathy: possible answers from the viscoelastic tests. J Clin Monit Comput 2022; 36:55-69. [PMID: 34264472 PMCID: PMC8280589 DOI: 10.1007/s10877-021-00744-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 07/09/2021] [Indexed: 12/30/2022]
Abstract
Abnormal coagulation parameters are often observed in patients with coronavirus disease 2019 (COVID-19) and the severity of derangement has been associated with a poor prognosis. The COVID-19 associated coagulopathy (CAC) displays unique features that include a high risk of developing thromboembolic complications. Viscoelastic tests (VETs), such as thromboelastometry (ROTEM), thromboelastography (TEG) and Quantra Hemostasis Analyzer (Quantra), provide "dynamic" data on clot formation and dissolution; they are used in different critical care settings, both in hemorrhagic and in thrombotic conditions. In patients with severe COVID-19 infection VETs can supply to clinicians more information about the CAC, identifying the presence of hypercoagulable and hypofibrinolysis states. In the last year, many studies have proposed to explain the underlying characteristics of CAC; however, there remain many unanswered questions. We tried to address some of the important queries about CAC through VETs analysis.
Collapse
Affiliation(s)
- Vittorio Pavoni
- Emergency Department and Critical Care Area, Anesthesia and Intensive Care Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Lara Gianesello
- Department of Anesthesia and Intensive Care, Orthopedic Anesthesia, University-Hospital Careggi, Largo Palagi, 1, 50139, Florence, Italy.
| | - Maddalena Pazzi
- Emergency Department and Critical Care Area, Anesthesia and Intensive Care Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Pietro Dattolo
- Nephrology Unit Florence 1, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| |
Collapse
|
5
|
Görlinger K, Almutawah H, Almutawaa F, Alwabari M, Alsultan Z, Almajed J, Alwabari M, Alsultan M, Shahwar D, Yassen KA. The role of rotational thromboelastometry during the COVID-19 pandemic: a narrative review. Korean J Anesthesiol 2021; 74:91-102. [PMID: 33440114 PMCID: PMC8024216 DOI: 10.4097/kja.21006] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 01/11/2021] [Indexed: 02/08/2023] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic is currently recognized as a global health crisis. This viral infection is frequently associated with hypercoagulability, with a high incidence of thromboembolic complications that can be fatal. In many situations, the standard coagulation tests (SCT) fail to detect this state of hypercoagulability in patients with COVID-19 since clotting times are either not or only mildly affected. The role of viscoelastic tests such as rotational thromboelastometry (ROTEM®) during this pandemic is explored in this review. COVID-19-associated coagulopathy, as measured using the rotational thromboelastometry parameters, can vary from hypercoagulability due to increased fibrin polymerization and decreased fibrinolysis to bleeding from hypocoagulability. The use of a multimodal diagnostic and monitoring approach, including both rotational thromboelastometry and SCT, such as plasma fibrinogen and D-dimer concentrations, is recommended. Rotational thromboelastometry provides comprehensive information about the full coagulation status of each patient and detects individual variations. Since COVID-19-associated coagulopathy is a very dynamic process, the phenotype can change during the course of infection and in response to anticoagulation therapy. Data from published literature provide evidence that the combination of rotational thromboelastometry and SCT analysis is helpful in detecting hemostasis issues, guiding anticoagulant therapy, and improving outcomes in COVID-19 patients. However, more research is needed to develop evidence-based guidelines and protocols.
Collapse
Affiliation(s)
- Klaus Görlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany.,Tem Innovations, Munich, Germany
| | - Hawra Almutawah
- College of Medicine, King Faisal University, Al-Ahsa, Hofuf, Saudi Arabia
| | - Fatimah Almutawaa
- College of Medicine, King Faisal University, Al-Ahsa, Hofuf, Saudi Arabia
| | - Maryam Alwabari
- College of Medicine, King Faisal University, Al-Ahsa, Hofuf, Saudi Arabia
| | - Zahra Alsultan
- College of Medicine, King Faisal University, Al-Ahsa, Hofuf, Saudi Arabia
| | - Jumanah Almajed
- College of Medicine, King Faisal University, Al-Ahsa, Hofuf, Saudi Arabia
| | - Mahmoud Alwabari
- College of Medicine, King Faisal University, Al-Ahsa, Hofuf, Saudi Arabia
| | - Maryam Alsultan
- College of Medicine, King Faisal University, Al-Ahsa, Hofuf, Saudi Arabia
| | - Duri Shahwar
- Division of Anesthesia, Department of Surgery, College of Medicine, King Faisal University, Al-Ahsa, Hofuf, Saudi Arabia
| | - Khaled Ahmed Yassen
- Division of Anesthesia, Department of Surgery, College of Medicine, King Faisal University, Al-Ahsa, Hofuf, Saudi Arabia
| |
Collapse
|
6
|
Görlinger K, Dirkmann D, Gandhi A, Simioni P. COVID-19-Associated Coagulopathy and Inflammatory Response: What Do We Know Already and What Are the Knowledge Gaps? Anesth Analg 2020; 131:1324-1333. [PMID: 33079850 PMCID: PMC7389937 DOI: 10.1213/ane.0000000000005147] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Patients with coronavirus disease 2019 (COVID-19) frequently experience a coagulopathy associated with a high incidence of thrombotic events leading to poor outcomes. Here, biomarkers of coagulation (such as D-dimer, fibrinogen, platelet count), inflammation (such as interleukin-6), and immunity (such as lymphocyte count) as well as clinical scoring systems (such as sequential organ failure assessment [SOFA], International Society on Thrombosis and Hemostasis disseminated intravascular coagulation [ISTH DIC], and sepsis-induced coagulopathy [SIC] score) can be helpful in predicting clinical course, need for hospital resources (such as intensive care unit [ICU] beds, intubation and ventilator therapy, and extracorporeal membrane oxygenation [ECMO]) and patient's outcome in patients with COVID-19. However, therapeutic options are actually limited to unspecific supportive therapy. Whether viscoelastic testing can provide additional value in predicting clinical course, need for hospital resources and patient's outcome or in guiding anticoagulation in COVID-19-associated coagulopathy is still incompletely understood and currently under investigation (eg, in the rotational thromboelastometry analysis and standard coagulation tests in hospitalized patients with COVID-19 [ROHOCO] study). This article summarizes what we know already about COVID-19-associated coagulopathy and-perhaps even more importantly-characterizes important knowledge gaps.
Collapse
Affiliation(s)
- Klaus Görlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany, and Medical Director, Tem Innovations GmbH, Martin-Kollar-Strasse 15, 81829 Munich, Germany, mobile: +49 1726596069, e-mail:
| | - Daniel Dirkmann
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany, mobile: +49 201 723 84423,
| | - Ajay Gandhi
- Clinical Affairs, Instrumentation Laboratory India Private Limited, New Delhi, India, 1471-76, Agrawal Millennium Tower II, Plot Number E-4, Netaji Subhash Place, Pitampura, New Delhi, India 110034, mobile: +91 9826870517, e-mail:
| | - Paolo Simioni
- General Internal Medicine and Thrombotic and Haemorrhagic Diseases Units, Department of Medicine, Padova University Hospital, Via Ospedale Civile 105, 35100 Padova, Italy, phone: +39 0498212667, e-mail:
| |
Collapse
|
7
|
Kong R, Hutchinson N, Görlinger K. Hyper- and hypocoagulability in COVID-19 as assessed by thromboelastometry -two case reports. Korean J Anesthesiol 2020; 74:350-354. [PMID: 32773727 PMCID: PMC8342838 DOI: 10.4097/kja.20327] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 08/05/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Coronavirus disease (COVID-19)-associated coagulopathy is most often characterized by elevated D-dimer, interleukin-6, and plasma fibrinogen concentrations as well as hypercoagulability in thromboelastometry with increased clot firmness in the EXTEM, INTEM, and FIBTEM assays. Clinically, it manifests with a very high incidence of thrombosis, particularly in the pulmonary system, whereas bleeding complications are infrequent. CASE Here, we describe two critically ill patients with COVID-19 admitted to our intensive care unit demonstrating different thromboelastometry and biomarker patterns. One patient presented with hypercoagulability and the other patient with hypocoagulability and fibrinolysis shutdown in thromboelastometry. The pathophysiology and the potential impact on treatment options are discussed. CONCLUSIONS A combination of biomarkers and thromboelastometry results can be helpful in the future to decide which therapeutic strategy might be most appropriate for critically ill patients with COVID-19. This would be an important step to establish precision medicine in this high-risk patient population.
Collapse
Affiliation(s)
- Robert Kong
- Department of Anesthesia, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Nevil Hutchinson
- Department of Anesthesia, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Klaus Görlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, and Tem Innovations, Munich, Germany
| |
Collapse
|
8
|
Long MT, Gallo PD, Hammel LL, Coursin DB. A Misguided Contraindication. A A Pract 2019; 12:99-102. [DOI: 10.1213/xaa.0000000000000856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
9
|
Bonnard T, Law LS, Tennant Z, Hagemeyer CE. Development and validation of a high throughput whole blood thrombolysis plate assay. Sci Rep 2017; 7:2346. [PMID: 28539608 PMCID: PMC5443825 DOI: 10.1038/s41598-017-02498-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 04/11/2017] [Indexed: 12/26/2022] Open
Abstract
The objective of this work was to develop a high throughput assay for testing in vitro the thrombolytic activity using citrated whole blood samples, and to overcome the limitations of currently available techniques. We successfully developed a method that involves forming halo shaped, tissue factor induced, whole blood clots in 96 well plates, and then precisely measuring the thrombolysis process with a spectrophotometer plate reader. We here describe the implementation of this novel method, which we refer to as halo assay, and its validation with plasmin, urokinase and tissue plasminogen activator at different doses. The resulting data is a highly detailed thrombolysis profile, allowing comparison of different fibrinolytic agents. The time point analysis allows kinetic data to be collected and calculated to determine key parameters such as the activation time and the rate of fibrinolysis. We also assessed the capacity of the model to study the effect of clot maturation time on the fibrinolytic rate, an aspect of thrombosis rather unexplored with currently available methods, but of increasing importance in drug development. This novel thrombolysis assay could be an extremely useful research tool; to study the complex process of thrombolysis, and a valuable translational clinical tool; as a screening device to rapidly identify hypo- or hyper-fibrinolysis.
Collapse
Affiliation(s)
- T Bonnard
- NanoBiotechnology Laboratory, Australian Centre for Blood Diseases, Monash University, Melbourne, Australia.,VascularBiotechnology Laboratory, Baker Heart and Diabetes Institute, Melbourne, Australia
| | - L S Law
- VascularBiotechnology Laboratory, Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Z Tennant
- NanoBiotechnology Laboratory, Australian Centre for Blood Diseases, Monash University, Melbourne, Australia.,VascularBiotechnology Laboratory, Baker Heart and Diabetes Institute, Melbourne, Australia
| | - C E Hagemeyer
- NanoBiotechnology Laboratory, Australian Centre for Blood Diseases, Monash University, Melbourne, Australia. .,VascularBiotechnology Laboratory, Baker Heart and Diabetes Institute, Melbourne, Australia. .,RMIT University, Melbourne, Australia.
| |
Collapse
|
10
|
Thromboelastometry hypercoagulable profiles and portal vein thrombosis in cirrhotic patients with hepatocellular carcinoma. Dig Liver Dis 2017; 49:440-445. [PMID: 28109767 DOI: 10.1016/j.dld.2016.12.019] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 12/04/2016] [Accepted: 12/07/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Cirrhotic patients with hepatocellular carcinoma (HCC) exhibit hypercoagulability. AIM We investigated whether thromboelastometry can detect hypercoagulability in these patients and the association with portal vein thrombosis (PVT). METHODS At baseline, cirrhotic patients with and without HCC underwent thromboelastometry. PVT onset was recorded over a 12-month follow-up period. RESULTS Seventy-six patients (41 with and 35 without HCC) were included. Vital tumor volume (VTV) was >5cm3 in 18 patients. Fibrinogen was higher in HCC patients with VTV>5cm3 as compared to those with VTV≤5cm3 and those without HCC. Mean platelet count was significantly increased in HCC patients compared with non-HCC. At baseline thromboelastometry, HCC patients showed shorter CTF and higher MCF than non-HCC. PVT incidence was 24,4% and 11.4% in patients with (10/41) and without (4/35) HCC, respectively. Among HCC, 50% of PVT occurred in Child A patients. In HCC, FIBTEM MCF>25mm was associated with a 5-fold increased PVT risk [RR: 4.8 (2-11.3); p=0.0001]. Cox multivariate analysis confirmed HCC and increased MCF (FIBTEM) to be independently associated with increased PVT risk. CONCLUSIONS Hypercoagulability in HCC which can be detected by thromboelastometry is associated with increased risk of PVT even in Child A patients. The clinical implication of these findings deserves further investigation.
Collapse
|
11
|
Jansohn E, Bengzon J, Kander T, Schött U. A pilot study on the applicability of thromboelastometry in detecting brain tumour-induced hypercoagulation. Scandinavian Journal of Clinical and Laboratory Investigation 2017; 77:289-294. [DOI: 10.1080/00365513.2017.1306877] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
|