title: Surgical treatment of intraparenchymal hemorrhage during mechanical circulatory support for heart-failure--a single-centre experience.
abstract: BACKGROUND
  Cranial intraparenchymal hemorrhage represents a critical complication of mechanical circulatory support requiring constant antithrombotic treatment. 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 intraparenchymal hemorrhage.
  
  
  METHODS
  Patients with mechanical circulatory support requiring surgical therapy due to space-occupying lobar supratentorial or infratentorial hemorrhage from January 1, 2009 to January 1, 2014 were included in our study. Baseline parameters are preoperative International Normalized Ratio (INR) values, postoperative anticoagulation regiment, bleeding size and localization. Co-primary outcome parameters were the extent of hematoma evacuation and the Modified Rankin Scale at discharge from hospital. Secondary outcome parameters included rate of recurrent hemorrhage, rate of revision surgery and in-hospital mortality.
  
  
  RESULTS
  Twelve patients (mean age 44 ± 18 years, nine supratentorial-/three infratentorial hemorrhages, 11 left ventricular assist devices, and one extracorporeal membrane oxygenation) were included. Surgical hematoma evacuation was performed in 11 patients, one patient received decompressive hemicraniectomy. Hematoma evacuation was complete in no patients, and partial in 11 patients. Initial INR was 2,7 ± 1,6. Rate of recurrent hemorrhage was 75 %. Revision surgery was performed in three patients achieving partial hematoma evacuation in two patients and complete evacuation in one patient. Modified Rankin Scale at discharge from hospital was six in nine patients (in-hospital mortality of 75 %), five in two patients and four in one patient.
  
  
  CONCLUSIONS
  Surgical treatment of life threatening, space-occupying intraparenchymal hemorrhage under mechanical circulation support is of limited efficacy with high rates of recurrent hemorrhage and in-hospital mortality. We provide additional data that postponing anticoagulation is feasible and may lead to improved clinical outcome and survival.
authors.affiliation: Department of Neurosurgery, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
authors.forename: Harald
authors.initials: H
authors.lastname: Krenzlin
authors.forename: Christoph
authors.initials: C
authors.lastname: Rosenthal
authors.forename: Stefan
authors.initials: S
authors.lastname: Wolf
authors.forename: Juliane
authors.initials: J
authors.lastname: Vierecke
authors.forename: Alexander
authors.initials: A
authors.lastname: Kowski
authors.forename: Roland
authors.initials: R
authors.lastname: Hetzer
authors.forename: Peter
authors.initials: P
authors.lastname: Vajkoczy
authors.forename: Marcus
authors.initials: M
authors.lastname: Czabanka
mesh_terms: D000328:Adult; D000368:Aged; D019299:Decompression, Surgical; D015199:Extracorporeal Membrane Oxygenation; D005260:Female; D006333:Heart Failure / Q000628:therapy*; D006353:Heart-Assist Devices; D017052:Hospital Mortality; D006801:Humans; D020300:Intracranial Hemorrhages / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology / Q000401:mortality / Q000601:surgery; D012008:Recurrence