Highlights
- •Most LVAD patients have available head imaging which may be reviewed
- •LVAD patients are high risk for ICH based on radiographic features on head CT
- •Masses, vascular pathology, and microangiopathy predict intracranial hemorrhage
- •A screening head CT may identify high-risk patients for ICH with LVADs
- •Complete risk stratification with imaging allows medical optimization against ICH
Abstract
Objective
Intracranial hemorrhage (ICH) in patients with left ventricular assist devices (LVAD)
is a devastating complication. Demographic risk factors for ICH in LVAD patients are
defined, however anatomic predispositions to ICH are unknown. We sought to interrogate
intracranial radiographic risk factors for ICH in LVAD patients.
Methods
We reviewed 440 patients who received an LVAD from 2008-2021. We selected patients
with CT scans of the head either before or after LVAD placement, but typically within
5 years. 288 patients (21 ICH, 267 Control) with imaging were included. A detailed
chart review was performed on demographics, radiographic features, and management.
Results
The incidence of ICH in our total cohort was 8.6% (38/440). The presence of pump thrombosis
(p=0.001), driveline infection (p=0.034), other hemorrhage (p=0.001), or previous
placement of a cardio-defibrillator (p=.003) was associated with increased risk for
ICH. An analysis of imaging revealed that the presence of a mass (p=0.006), vascular
pathology (p=0.001), and microangiopathy (p=0.04) was significantly associated with
ICH in LVAD patients. These radiographic features were validated with a multivariate
logistic regression which confirmed presence of a mass (aOR 332.1, 95% CI: 14.7-7485.1,
p<0.001), vascular pathology (aOR 69.7, 95% CI: 1.8-2658.8, p=0.022), and microangiopathy
(aOR 6.5, 95% CI: 1.1-37.6, p=0.035) were independently associated with ICH.
Conclusion
Radiographic evidence of microangiopathy, intracranial mass, and vascular pathology
are independent risk factors for ICH which are readily identified by imaging. We advocate
that CT imaging be used to further stratify patients at highest risk of ICH during
treatment with an LVAD.
Keywords
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References
- Current status of the implantable LVAD.Gen Thorac Cardiovasc Surg. 2016; 64: 501-508
- Present-day hospital readmissions after left ventricular assist device implantation: a large single-center study.Tex Heart Inst J. 2015; 42: 419-429
- Management of intracranial hemorrhage in patients with a left ventricular assist device: a systematic review and meta-analysis.J Stroke Cerebrovasc Dis. 2021; 30105501
- Cerebral hemorrhage in the LVAD patient: a case series and literature review.Clin Neurol Neurosurg. 2020; 197106094
- Trends, predictors and outcomes of ischemic stroke and intracranial hemorrhage in patients with a left ventricular assist device.Ann Transl Med. 2018; 6: 5
- Risk factors, mortality, and timing of ischemic and hemorrhagic stroke with left ventricular assist devices.J Heart Lung Transplant. 2017; 36: 673-683
- Intracranial hemorrhage in patients with a left ventricular assist device.World Neurosurg. 2018; 113: e714-e721
- Mixed-location cerebral hemorrhage/microbleeds: underlying microangiopathy and recurrence risk.Neurology. 2018; 90: e119-e126
- Spontaneous intracerebral hemorrhage.N Engl J Med. 2001; 344: 1450-1460
- Medical and surgical management of left ventricular assist device-associated intracranial hemorrhage.J Stroke Cerebrovasc Dis. 2021; 30106053
- Intracranial Hemorrhage.StatPearls Publishing, Treasure Island (FL)2022
- Cerebrovascular accidents during mechanical circulatory support: new predictors of ischemic and hemorrhagic strokes and outcome.Stroke. 2018; 49: 1197-1203
- The impact of infection and elevated INR in LVAD-associated intracranial hemorrhage: a case-crossover study.Asaio j. 2019; 65: 545-549
- Outcomes after intracranial hemorrhage in patients with left ventricular assist devices: a systematic review of literature.World Neurosurg. 2019; 132: 265-272
- Prevalence, management, and outcomes of haemorrhagic events in left ventricular assist device recipients.ESC Heart Fail. 2022; 9: 1931-1941
- Implantable cardioverter defibrillators and permanent pacemakers: prevalence and patient outcomes after trauma.Am J Surg. 2016; 212: 953-960
- Intracerebral haemorrhage.Baillieres Clin Neurol. 1995; 4: 247-278
- Microbleeds are associated with subsequent hemorrhagic and ischemic stroke in healthy elderly individuals.Stroke. 2011; 42: 1867-1871
- Spontaneous brain microbleeds: systematic review, subgroup analyses and standards for study design and reporting.Brain. 2007; 130: 1988-2003
- Cerebral microbleeds are associated with blood pressure levels in individuals with hypertension.Clin Exp Hypertens. 2020; 42: 328-334
- Heart Failure Association of the European Society of Cardiology position paper on the management of left ventricular assist device-supported patients for the non-left ventricular assist device specialist healthcare provider: Part 2: at the emergency department.ESC Heart Fail. 2021; 8: 4409-4424
- Relationship between anticoagulation intensity and thrombotic or bleeding outcomes among outpatients with continuous-flow left ventricular assist devices.Circ Heart Fail. 2016; 9
- Cerebral microbleeds: relationship to antithrombotic medications.Stroke. 2021; 52: 2347-2355
- Use of coumarin anticoagulants and cerebral microbleeds in the general population.Stroke. 2014; 45: 3436-3439
- Microbleed prevalence and burden in anticoagulant-associated intracerebral bleed.Ann Clin Transl Neurol. 2019; 6: 1546-1551
- Development of multidisciplinary anticoagulation management guidelines for patients receiving durable mechanical circulatory support.Clin Appl Thromb Hemost. 2019; 251076029619837362
- Extracorporeal Life Support Organization Registry International Report 2016.Asaio J. 2017; 63: 60-67
- Blood conservation in extracorporeal membrane oxygenation for acute respiratory distress syndrome.Ann Thorac Surg. 2015; 99: 590-595
- The use of an extracorporeal membrane oxygenation anticoagulation laboratory protocol is associated with decreased blood product use, decreased hemorrhagic complications, and increased circuit life.Pediatr Crit Care Med. 2015; 16: 66-74
- Identification of acquired coagulation disorders and effects of target-controlled coagulation factor substitution on the incidence and severity of spontaneous intracranial bleeding during veno-venous ECMO therapy.Perfusion. 2015; 30: 675-682
- Intracranial hemorrhage in adults on ECMO.Perfusion. 2018; 33: 42-50
- Intracranial hemorrhage in patients with durable mechanical circulatory support devices: Institutional review and proposed treatment algorithm.World Neurosurg. 2017; 108: 826-835
Article info
Publication history
Published online: November 01, 2022
Accepted:
October 26,
2022
Received in revised form:
October 17,
2022
Received:
July 31,
2022
Identification
DOI: https://doi.org/10.1016/j.jstrokecerebrovasdis.2022.106869
Copyright
© 2022 Elsevier Inc. All rights reserved.
