Coagulation Differences Detectable in Deep and Lobar Primary Intracerebral Hemorrhage Using Thromboelastography

Abstract

BACKGROUND There are radiographic and clinical outcome differences between patients with deep and lobar intracerebral hemorrhage (ICH) locations. Pilot studies suggest that there may be functional coagulation differences between these locations detectable using whole blood coagulation testing. OBJECTIVE To confirm the presence of interlocation functional coagulation differences using a larger cohort of deep and lobar ICH patients receiving whole blood coagulation testing: thromboelastography (TEG; Haemonetics). METHODS Clinical and laboratory data were prospectively collected between 2009 and 2018 for primary ICH patients admitted to a tertiary referral medical center. Deep and lobar ICH patients receiving admission TEG were analyzed. Patients with preceding anticoagulant use and/or admission coagulopathy (using prothrombin time/partial thromboplastin time/platelet count) were excluded. Linear regression models assessed the association of ICH location (independent variable) with TEG and traditional plasma coagulation test results (dependent variable) after adjusting for baseline hematoma size, age, sex, and stroke severity. RESULTS We identified 154 deep and 53 lobar ICH patients who received TEG. Deep ICH patients were younger and had smaller admission hematoma volumes (median: 16 vs 29 mL). Adjusted multivariable linear regression analysis revealed longer TEG R times (0.57 min; 95% CI: 0.02-1.11; P = .04), indicating longer clot formation times, in deep compared to lobar ICH. No other TEG parameter or plasma-based coagulation differences were seen. CONCLUSION We identified longer clot formation times, suggesting relative coagulopathy in deep compared to lobar ICH confirming results from prior work. Further work is required to elucidate mechanisms for these differences and whether ICH location should be considered in future coagulopathy treatment paradigms for ICH.

Viscoelastic Testing in the Clinical Management of Subarachnoid Hemorrhage and Intracerebral Hemorrhage

“…Full-text screening was performed on 87 studies and of these, 24 were included for analysis. The 24 studies were then subdivided into the following: studies including (1) SAH patients prior to stenting or coiling (n ¼ 12), 14,25,[28][29][30][31][32][33][34][35][36][37] (2) ICH patients not taking anticoagulant or antiplatelet medications (n ¼ 4), 30,[38][39][40] (3) ICH patients on antiplatelet or anticoagulant medications (n ¼ 4), [41][42][43][44] (4) SAH patients undergoing stenting or coiling or ischemic stroke patients following thrombolysis or thrombectomy, developing ICH as a complication to treatment (n ¼ 5). 26,[45][46][47][48] One study contained data on both ICH and SAH patients.…”

“…Four studies included ICH patients taking anticoagulant or antiplatelet medication. [41][42][43][44] Roh et al investigated differences in viscoelastic parameters between ICH patients with lobar or deep hemorrhage. 41 They allowed patients on antiplatelet therapy to be included in the study.…”

“…[41][42][43][44] Roh et al investigated differences in viscoelastic parameters between ICH patients with lobar or deep hemorrhage. 41 They allowed patients on antiplatelet therapy to be included in the study. Bliden et al included 90 patients admitted to the emergency room with signs of stroke and investigated if viscoelastic testing could distinguish ischemic stroke from hemorrhagic stroke.…”

Prediction of Hematoma Expansion in Patients With Intracerebral Hemorrhage Using Thromboelastography With Platelet Mapping: A Prospective Observational Study

“…Exclusion criteria were as follows: (1) the presence of vascular malformation, aneurysm, traumatic, brain tumor, ischemic stroke with hemorrhagic transformation, or any other cause of secondary ICH; (2) primary intraventricular hemorrhage; (3) preceding use of antiplatelet or anticoagulant drugs; (4) receiving any hemostatic agents before TEG-PM draw; (5) surgery or other neurosurgical intervention before follow-up CT scan; (6) evidence of coagulopathy on traditional laboratory testing (14), such as activated partial thromboplastin time (APTT) >50 s, international normalized ratio (INR) >1.5, or platelet (PLT) count <50 × 10 3 /µl; and (7) lost to follow-up. The Institutional Review Board of our hospital approved this study, and written informed consent was obtained from each patient or close relatives.…”

Letter to the Editor Regarding “Viscoelastic Hemostatic Assays and Outcomes in Traumatic Brain Injury: A Systematic Literature Review”

“… 21 As a result, some centers have used VHAs to detect functional differences in coagulation among patients with hemorrhagic stroke, which were not identifiable on CCAs but appeared responsible for hematoma expansion in their respective series. 18 , 22 , 23 , 24 …”