Introduction:
Since its inception in 1948, thromboelastography (TEG) has been utilized as a diagnostic and therapy-guiding tool for coagulopathies. It is frequently used in cardiac and transplant surgery for determining a patient’s coagulation profile outside of the prothrombin time (PT), international normalized ratio (INR), and partial thromboplastin time (PTT). More recently, it has garnered attention for its utility in trauma-associated coagulopathy. However, there remains a paucity of literature regarding using TEG in neurosurgical patients. Given the ability of TEG to identify coagulopathies based on etiology, quantify and determine both presence and degree of platelet inhibition, and guide therapy, it is an under-utilized tool in a neurosurgeon’s arsenal. We present our initial experience using TEG and showcase two cases from a series of twenty-five patients that exhibit its functionality.
Methods:
Advancing beyond conventional coagulation labs, TEG can identify the time to clot formation, clot strength, clot stability, and both percentage and mechanism of platelet inhibition. We present selected patients presenting to our institution with cerebrovascular disease who were found to have abnormal clotting ability on TEG, which was not identified with routine conventional coagulation labs (PT,INR,PTT).
Results:
In these two cases TEG provided additional information regarding patient coagulation profile in a setting of subarachnoid hemorrhage and a hypo-responder to antiplatelet therapy for a flow diverting stent. The TEG information allowed for therapeutic decision making and insight into an initially unexplainable clinical scenario.
Conclusions:
TEG is useful in identifying antiplatelet medication hyper- or hypo-responders, recognizing platelet inhibition in patients from whom a medication history cannot be obtained, and guiding transfusion protocols when conventional coagulation tests are equivocal. It can also select and potentially prevent complications from thrombosis. TEG is an under-utilized tool that neurosurgeons need to gain more widespread use and a more facile understanding.
Patient Care:
1) By elucidating the ability of thromboelastography to provide a more complete coagulation profile picture beyond conventional coagulation labs for neurosurgical patients, 2) By identifying coagulopathies discovered on thromboelastography that otherwise were not discovered through conventional coagulation labs, 3) By identifying the ability of thromboelastography to potentially avoid disastrous neurosurgical complications, and 4) By identifying thromboelastography as a vastly under-utilized tool in the field of neurosurgery that could greatly benefit patients, and one which deserves further experience and investigation.
Learning Objectives:
By the conclusion of this session, participants should be able to 1) Describe the role and unique advantages of thromboelastography in determining a patient's overall coagulation profile beyond conventional labs 2) Describe the unique advantages of obtaining thromboelastography information in cerebrovascular neurosurgical patients, 3) Identify neurosurgical complications that could potentially be avoided by utilizing information gained from thromboelastography, 4) Identify the role of thromboelastography in guiding therapy for cerebrovascular neurosurgical patients, and 5) Understand the necessity for more data regarding the role of thromboelastography in neurosurgical patients