Intracranial Hemorrhage in Patients with Durable Mechanical Circulatory Support Devices: Institutional Review and Proposed Treatment Algorithm

Abstract

Background: Spontaneous intracranial hemorrhage (ICH) is frequently managed in neurosurgery. Patients with durable mechanical circulatory support devices, including total artificial heart (TAH) and left ventricular assist device (LVAD), are often encountered in the setting of ICH. Although durable mechanical circulatory support devices have improved survival and quality of life for patients with advanced heart failure, ICH is one of the most feared complications following LVAD and TAH implantation. Owing to anticoagulation and clinically relevant acquired coagulopathies, ICH should be treated promptly by neurosurgeons and cardiac critical care providers. We provide an analysis of ICH in patients with mechanical circulatory support and propose a treatment algorithm.

Methods: We retrospectively reviewed medical records from 2013-2016 for patients with a durable mechanical circulatory device at Banner-University of Arizona Medical Center Tucson. All patients with suspected ICH underwent computed tomography scan of the brain. Anticoagulation was managed by the cardiothoracic surgeon.

Results: In 58 patients, an LVAD (n = 49), TAH (n = 10), or both (n = 1) were implanted. Both acquired von Willebrand disease and spontaneous ICH were diagnosed in 5 patients (8.6%) who underwent LVAD implantation. Seven neurosurgical procedures were performed in 2 patients. The overall mortality rate was 60%. Two patients had little or no deficits after treatment with modified Rankin Scale score of 1 and 2, respectively.

Conclusions: We propose a novel treatment algorithm to manage patients with a LVAD or TAH and ICH, implemented in a multidisciplinary manner to best avoid neurologic and cardiovascular complications.

Keywords: Coagulopathy; Intracranial hemorrhage; Intraparenchymal hemorrhage.