Intracranial hemorrhage surgery on patients on mechanical circulatory support: a case series

Cardiac disease is the leading cause of death in the United States and late-stage heart failure is associated with a high level of morbidity and mortality. The ventricular assist devices and extracorporeal membrane oxygenators are the mainstay of mechanical circulatory support devices for the patients with extremely low cardiac output. However, they come at a price of significant risk factors, including intracranial hemorrhage. The incidence of intracranial hemorrhage on extracorporeal membrane oxygenators and on ventricular assist devices is 37% and 13% to 14%, respectively.

The cases in this series focus on the risks of ICH and the decompressive craniotomies that were carried out on patients while they were on mechanical circulatory support. The intraoperative anesthetic management for patients on mechanical circulatory support for the noncardiothoracic anesthesiologist is highlighted.

The results of recent cardiothoracic surgery trials have led to an increase of surgical management instead of medical management in the treatment of heart failure. Although most agree with the immediate reversal of anticoagulation and antiplatelet therapy, there is no standard protocol for restarting anticoagulation or antiplatelet therapy after craniotomy in this population. The standard practices of resuscitation and ACLS including inotropes, vasopressors, and vasodilators (with the exception of chest compressions that can dislodge the devices), can be used as needed. The identification of cardiothoracic surgeons and perfusionists who are available for immediate assistance as and when required during the surgery and transportation is an important factor.