Our next speaker is Dr. Grace Yi-Yen Lai, who's going to present Outcomes and Management of Intracranial Hemorrhage in Patients with Ventricular Assist Devices. And it's also an honor to actually present her with the Louise Eisenhardt Research Award on behalf of the Section of Women in Neurosurgery. Thank you. Thank you for giving me this opportunity to present our work. I also want to thank Dr. Potts and Dr. Jeromey, our vascular attendings, who have been a great support. So, this topic, I think, is relevant to all neurosurgeons about how to manage patients who present with ICH, patients who have ventricular assist devices. Heart disease is actually one of the leading causes of death in the United States. And VADs are devices that are placed in patients with heart failure who require transplant, and they are attached to the ventricle and divert blood to the aorta through a pump. These pumps do tend to clot. The pumps are worn. There's a driveline that comes out of it that's attached to batteries, and those are also at risk of infection. So, these patients are on lifelong, ongoing anticoagulation. According to the registry for all FDA-approved VAD placements, there are over 25,000 placed a year, and this is not including all the VADs that are placed for clinical trials. The total is about 70% at one year, and about 50% of these patients have these VADs as kind of a destination therapy. They're not transplant candidates. One of the most devastating complications of VADs is stroke. It is actually one of the – stroke, which is ischemic stroke, in addition to hemorrhagic stroke, and intracranial hemorrhage is the number one cause of death after the first six months for these patients. In terms of neurosurgical management, a lot of neurosurgeons are going to be required to manage these patients when they come in with brain bleeds. First is, how do we manage the anticoagulation? There's the risk of the pump thrombosing if we reverse them, but there's also the risk of the hematoma expanding when we don't reverse them. There's not much literature out there to help guide our management decisions. The other thing is when to resume the anticoagulation. How long is it safe to hold it? And then in terms of surgical management, these patients are at risk for pump thrombosis. We have to hold their anticoagulation. We also have to discuss with the families what the goal of management is. Is it to extend life, or is it to provide quality of life? A lot of these patients, if they have neurologic deficits, are not candidates for transplant. And then the surgical options. So we did a retrospective analysis of all patients who had VADs placed at Northwestern between 2007 and 2017. We had about 300 total. Heart rate 2 and heart wear are the most common ones that are placed. There were 281. And of those, we looked at patients who had neurological events based on imaging. Twenty-two had intraparenchymal hemorrhage, six had subdural hemorrhage, and nine had subarachnoid hemorrhage. And all nine of those were small traumatic subarachnoid hemorrhages. We did not exclude ischemic stroke in this study. Our patient characteristics. We looked at sex and the type of VAD that was placed, why they had the VAD placed, whether they're transplant-eligible or they're destination therapy. Patients who eventually got transplant, as well as VAD complications that put patients at risk for bleed, for thrombosis as well as stroke, which is infection, thrombus, and GI bleed. These patients actually develop AVMs in their stomach and their GI tract that tend to bleed. The only things that we found that were significantly different amongst controls in patients with intracranial hemorrhage are obviously the patients with hemorrhage receive, eventually receive transplants at a lot lower rate. And they also had a history of a VAD thrombosis, even after they had their VADs replaced. Survival for the three different groups is, again, not surprising. The intraparenchymal hemorrhage group had very low survival, while the subdural and the subarachnoid hemorrhage survived pretty well. Okay, we also looked at their quality of life after discharge. So discharge home or an inpatient acute rehab where they can undergo three hours of therapy. You can see that the subdural and subarachnoid hemorrhage actually have pretty good outcomes in terms of quality of life. In terms of neurosurgical management, we had four patients with IPH with EVDs and three with cranies, subdurals, three cranies, one burr hole, no patients with subarachnoid had procedures. And again, not surprisingly, the patients with IPH, regardless of whether they got surgery or not, ended up doing poorly. And the patients with subdurals, regardless of whether they got surgery or not, did well. And surgery was based on, you know, clinical judgment. In terms of anticoagulation, the average INR actually didn't differ between the groups. And interestingly, a majority of the intraparenchymal hemorrhage actually had a subtherapeutic INR. A majority of the intraparenchymal hemorrhage were reversed, both anticoagulation and antiplatelet, whereas very few of our subarachnoid hemorrhage patients were reversed. The anticoagulation was resumed between two and 14 days. And interestingly, none of these patients had that thrombus. So, in summary, we did come up with kind of a management guideline, which is patients with intraparenchymal hemorrhage, we should reverse right away. Surgery is only done as a lifesaving measure. Subdurals, we can reverse safely as well and can consider surgery of eligible, whereas subarachnoids, if they're within therapeutic range, may not require reversal. And most importantly, the risk of vanthrombosis is very low. In our series, as well as the literature that's out there, there has been no reported cases of vanthrombosis after reversal for ICH. Okay. So, I just wanted to thank our cardiothoracic colleagues as well who helped with this study. Thank you. Thank you very much. Congratulations again.

Dr. Grace Yi-Yen Lai

intracranial hemorrhage

ventricular assist devices

management

outcomes