Fibrinogen but not factor XIII deficiency is associated with bleeding after craniotomy D. Adelmann 1 , D. A. Klaus 1 , U. M. Illievich 3 , C. G. Krenn 1 , C. Krall 2 , S. Kozek-Langenecker 4 and E. Schaden 1 * 1 Department of Anesthesiology, General Intensive Care and Pain Control and 2 Section for Medical Statistics, Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria 3 Department of Anesthesiology and Intensive Care, Landes-Nervenklinik Wagner-Jauregg, Linz, Austria 4 Department of Anaesthetics and Intensive Care, Evangelical Hospital Vienna, Vienna, Austria * Corresponding author. E-mail: [email protected] Editor’s key points † The authors assessed factor XIII (FXIII) and fibrinogen levels among a cohort of patients undergoing elective craniotomy. † Patients with a history of coagulopathy were excluded. † FXIII levels were similar, while fibrinogen levels were lower among patients suffering a haemorrhage. † Further work is needed to determine whether lower fibrinogen levels were the cause or result of bleeding. Background. Postoperative haemorrhage in neurosurgery is associated with significant morbidity and mortality. There is controversy whether or not factor XIII (FXIII) deficiency leads to bleeding complications after craniotomy. Decreased fibrinogen levels have been associated with an increased incidence of bleeding complications in cardiac and orthopaedic surgery. The aim of this study was to assess perioperative fibrinogen and FXIII levels in patients undergoing elective intracranial surgery with and without severe bleeding events. Methods. Perioperative FXIII and fibrinogen levels were prospectively assessed in 290 patients undergoing elective craniotomy. Patients were divided into two groups according to the presence or absence of severe bleeding requiring surgical revision. Coagulation test results of these groups were compared using Student’s t-test. Results. The incidence of postoperative severe bleeding was 2.4%. No differences in FXIII levels were observed, but postoperative fibrinogen levels were significantly lower in patients suffering from postoperative haematoma compared with those without postoperative intracranial bleeding complications [237 mg dl 21 (standard deviation, SD 86) vs 170 mg dl 21 (SD 35), P¼0.03]. The odds ratio for postoperative haematoma in patients with a postoperative fibrinogen level below 200 mg dl 21 was 10.02 (confidence interval: 1.19–84.40, P¼0.03). Conclusions. This study emphasizes the role of fibrinogen as potentially modifiable risk factor for perioperative bleeding in intracranial surgery. Future randomized controlled trials will be essential to identify patients who might benefit from fibrinogen substitution during neurosurgical procedures. Keywords: blood coagulation disorders, surgery; blood coagulation tests; factor XIII; fibrinogen; haemorrhage; neurosurgery, complications Accepted for publication: 20 January 2014 Postoperative haemorrhage is a serious complication in patients undergoing neurosurgical procedures and is asso- ciated with significant morbidity and mortality. 1 Adequate haemostasis depends on complex interactions of plasmatic and cellular components of the coagulation system. In the final propagation phase of clot formation, thrombin, bound to the platelet surface, activates fibrinogen to form a haemostatic fibrin clot, which is further stabilized through cross-linking by coagulation factor XIII (FXIII). 12 During blood loss and concomitant fluid replacement, fibrinogen is the first coagulation factor to decrease below crit- ical levels. 3 Decreased preoperative fibrinogen levels have been associated with an increased incidence of postoperative bleed- ing complications in coronary artery bypass graft surgery 4 and scoliosis surgery. 5 To date, the role of fibrinogen deficiency in postoperative neurosurgical bleeding remains unclear. The role of FXIII in neurosurgery has been controversially described previously: one study observed FXIII deficiency and described an association with devastating haematoma formation. 6 A more recent study, however, could not reproduce this finding. 7 We hypothesized that perioperative fibrinogen and FXIII levels would differ between patients with and without severe postoperative bleeding. The aim of this study was to assess perioperative fibrinogen and FXIII levels and also their poten- tial association with severe postoperative bleeding in patients undergoing elective intracranial surgery. Methods All patients who underwent elective craniotomy at the depart- ment of neurosurgery of the Landesnervenklinik Wagner- Jauregg, Linz, Austria, from September 2010 to September 2011 British Journal of Anaesthesia 113 (4): 628–33 (2014) Advance Access publication 28 May 2014 . doi:10.1093/bja/aeu133 & The Author 2014. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: [email protected]
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