The Discriminative Ability of ROTEM for Delayed Cerebral Ischemia and Poor Clinical Outcome Following Aneurysmal Subarachnoid Haemorrhage

Introduction Aneurysmal subarachnoid haemorrhage (aSAH) and delayed cerebral ischemia (DCI) have been associated with hypercoagulability as detected by viscoelastic testing. In this study, we evaluate temporal alterations in rotational thromboelastography (ROTEM-) coagulation profiles and the discriminative ability of ROTEM-parameters for DCI and poor clinical outcome following aSAH. Materials and Methods ROTEM-parameters were measured on days 0, 3-5 and 9-11 after aSAH and compared between patients with and without DCI, radiological DCI and 6-months’ poor clinical outcome (modified Rankin Scale 4-6). ROC-curve analyses were used to calculate areas-under-the-curve (AUC) and to determine optimal cut-off values with a sensitivity of >90% and highest possible specificity for DCI and radiological DCI. For poor outcome, a specificity >90% with highest possible sensitivity was used. Results Of 160 aSAH patients, 31 (19%) had DCI, 16 (10%) radiological DCI and 68 (44%) had poor outcome at six months. DCI, radiological DCI and poor clinical outcome were associated with hypercoagulability. The ROTEM-parameter with the best discriminative ability for radiological DCI was INTEM CT (AUC: 0.75), with optimal cut-off value <153 seconds (sensitivity 94%, specificity 59%). For poor outcome, this was FIBTEM A10, (AUC: 0.85), with optimal cut-off value >27 mm (specificity 94%, sensitivity 49%). Conclusions Hypercoagulability, as detected by ROTEM-parameters, is an excellent marker of poor clinical outcome after aSAH and might be useful for stratifying patients for inclusion in future trials on therapeutic interventions. Conversely, the absence of hypercoagulability on ROTEM may be used to identify patients at low risk of DCI for early hospital discharge. ### Competing Interest Statement NPJ reported that the institution has received honoraria of Octapharma for unrestricted investigator initiated research and lectures, and that she is an editor in chief of Intensive Care Medicine. NPJ and WPV reported to have received a PoC grant of Amsterdam Neuroscience for this study. All other authors have disclosed that they do not have any conflicts of interest. ### Clinical Trial n/a ### Funding Statement A proof of concept grant for this study was received from Amsterdam Neuroscience. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Institutional Review Board of Amsterdam UMC(MEC 2017_318). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data are available on request, with the request submitted to the corresponding author for consideration.