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. 2021 Oct;30(10):106053.
doi: 10.1016/j.jstrokecerebrovasdis.2021.106053. Epub 2021 Aug 19.

Medical and Surgical Management of Left Ventricular Assist Device-Associated Intracranial Hemorrhage

Chinwe Ibeh  1 , David L Tirschwell  2 , Claudius Mahr  3 , Claire J Creutzfeldt  4
Affiliations

Medical and Surgical Management of Left Ventricular Assist Device-Associated Intracranial Hemorrhage

Chinwe Ibeh et al. J Stroke Cerebrovasc Dis. 2021 Oct.

Abstract

Objectives: Management of left ventricular assist device (LVAD)-associated intracranial hemorrhage (ICH) is complicated by the competing concerns of hematoma expansion and the risk of thrombosis. Strategies include reversal or withholding of anticoagulation (AC) and neurosurgical (NSG) interventions. The consequences of these decisions can significantly impact both short- and long-term survival. Currently no guidelines exist. We reviewed medical and NSG practices following LVAD-associated ICH and analyzed outcomes.

Materials and methods: Retrospective analysis of data collected between 2012-2018 was performed. Survival probability following ICH was calculated using the Kaplan-Meier method.

Results: Out of 283 patients, 32 (11%) had 34 ICHs: 16 intraparenchymal (IPH, 47%), 4 subdural (SDH, 12%), and 14 subarachnoid (SAH, 41%). IPH tended to occur sooner (median 138 [IQR 48 - 258] days post-LVAD placement) and be more neurologically devastating (mean GCS 11.4 [4.4]). Antithrombotics were reversed in 27 (79%); 1 thrombotic event occurred while off AC. Following resumption, re-hemorrhage occurred in 7 (25%), a median of 13 days (IQR 8-30) post-ICH. Five underwent NSG intervention and 6 (18%) went on to receive heart transplant. Overall, 30-day mortality was 26% (38% in IPH, 0% in SDH, and 29% in SAH), but rose to 44% at 6 months.

Conclusion: ICH is a common post-LVAD complication with high short- and long-term mortality, though ICH subtypes may not be equally devastating. Despite this, some may benefit from neurosurgical intervention and do well following cardiac transplant. Anticoagulation is frequently reversed after ICH. Resumption however should be approached cautiously in patients with LVADs given their possible baseline coagulopathy.

Keywords: Anticoagulation; Heart failure; Intracranial hemorrhage; Left ventricular assist device; Neurosurgery; Stroke; Thrombosis.

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Conflict of interest statement

Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Figures

Figure 1.
Figure 1.
(a) Non-contrast head CT in a patient who developed acute disorientation and hallucinations 6 days after LVAD placement. There is a large (64 cm3) left frontal IPH with multiple fluid levels (consistent with recent anticoagulation) and 6 mm of midline shift. (b) Repeat head CT immediately following emergent hemicraniectomy and hematoma evacuation. Expected postsurgical pneumocephalus and resection bed-extra-axial fluid are seen. The patient improved and eventually underwent cranioplasty 4 months later. (c) Follow-up head CT at 6 months shows left frontal encephalomalacia without residual hemorrhage.
Figure 2.
Figure 2.
Kaplan-Meier analysis of overall survival following LVAD-Associated ICH
Figure 3.
Figure 3.
Kaplan-Meier analysis of overall survival for ICH Subtypes
See this image and copyright information in PMC

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