Unexpected fibrinogen impairment detected by rotational thromboelastometry in a 76-year-old patient undergoing brain...

Fibrinogen abnormalities pose significant challenge in neurosurgical patients, where even subtle coagulation defects may lead to catastrophic bleeding. Viscoelastic hemostasis assays (VHSa) can reveal functional disturbances not captured by conventional coagulation tests.

We report a 76‑year‑old woman undergoing resection of a brain tumor who presented with mildhypofibrinogenemia (162 mg dL⁻¹) and severely impaired fibrin‑based clot firmness (FIBTEM MCF 5 mm) detected by rotational thromboelastometry (ROTEM). The patient exhibited laboratory evidence of liver dysfunction, suggesting secondary fibrinogen impairment. Cryoprecipitate was administered postoperatively due to the inability to exclude factor XIII deficiency. Fibrinogen concentration and ROTEM parameters normalized; however, the patient developed a postoperative hematoma.

This case highlights the diagnostic value of ROTEM in identifying functional fibrinogen abnormalities but also underscores its limitations. The discrepancy between normalized coagulation parameters and subsequent hematoma formation emphasizes the need for cautious interpretation of single‑time‑point results. Decisions regarding fibrinogen supplementation should integrate viscoelastic findings, clinical context, and the dynamic coagulation profile.

Fibrinogen impairment is a multifaceted risk factor in neurosurgical patients. Viscoelastic testing serves as a valuable adjunct to standard assays, but its limitations must be recognized. Management of fibrinogen abnormalities-particularly in the presence of liver dysfunction or malignancy-requires individualized, context‑dependent decision‑making.