Article
Surgical treatment of intraparenchymal hemorrhage during mechanical circulatory support – a monocentric case series
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Authors
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Harald Krenzlin
- Klinik für Neurochirurgie, Campus Virchow Klinikum, Charité Universitätsmedizin, Berlin
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Stefan Wolf
- Klinik für Neurochirurgie, Campus Virchow Klinikum, Charité Universitätsmedizin, Berlin
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Wolf Schmidt
- Klinik für Neurologie, Charité Universitätsmedizin Berlin
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Alexander Kowski
- Klinik für Neurologie, Charité Universitätsmedizin Berlin
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Roland Hetzer
- Klinik für Herz-, Thorax- und Gefäßchirurgie, Deutsches Herzzentrum Berlin DHZB
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Peter Vajkoczy
- Klinik für Neurochirurgie, Campus Virchow Klinikum, Charité Universitätsmedizin, Berlin
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Marcus Czabanka
- Klinik für Neurochirurgie, Campus Virchow Klinikum, Charité Universitätsmedizin, Berlin
| Published: | May 13, 2014 |
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Outline
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Objective: Cranial intraparenchymal hemorrhage represents a critical complication of mechanical circulatory support due to required anticoagulation. Surgery of intraparenchymal hemorrhage under anticoagulation represents a challenge and imposes significant risks for patients. It was the aim to analyse surgical and clinical outcome of patients requiring surgical treatment due to space-occupying, life-threatening intraparenchymal hemorrhage under mechanical circuation support and enhanced anticoagulation.
Method: Patients with intraparenchymal hemorrhage were screened in our institution from January 1, 2009 to November 01, 2013. Patients requiring surgical therapy due to space-ocupying lobar supra- or infratentorial hemorrhage were included in our study. Coprimary outcome parameters were extent of hematoma evacuation and 30 day-Modified Rankin Scale. Secondary outcome parameters included rate of recurrent hemorrhage, rate of resurgery, in-hospital mortality, preoperative International Normalized Ratio (INR) values and postoperative anticoagulation.
Results: A total number of 12 patients (mean age 44±18 years, all under warfarin and antiplatelet therapy, 9 supratentorial/3 infratentorial hemorrhages) were included. Surgical hematoma evacuation using a key-hole craniotomy was performed in 11 patients, 1 patient was treated with decompressive hemicraniectomy. Hematoma evacuation was complete in 0 patients, partial in 11 patients. Initial INR was 2,7±1,6. Postoperative anticoagulation was maintained with heparin aiming at a partial thromboplastin time >50 s in 4 patients. In 4 patients normalization of coagulation was performed postoperatively. No postoperative anticoagulation could be analysed in 4 patients due to early decease (<24 hours). Rate of rehemorrhage was 75%. Resurgery was performed 25% of patients achieving partial hematoma evacuation in 2 patients and complete evacuation in 1 patient. 30 day-Modified Rankin Scale was 6 in 9 patients, 5 in 2 patients and 4 in one patient. In-hospital mortality was 75%. 2 out of 3 surviving patients were treated with postoperative normalization of coagulation parameters.
Conclusions: Surgical treatment of life threatening, space occupying intraparenchymal hemorrhage under mechanical circulation support is of limited efficacy with high rates of rehemorrhage and in-hospital mortality. Medical correction of coagulation may lead to improved clinical and surgical outcome.
