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The Impact of Infection and Elevated INR in LVAD-Associated Intracranial Hemorrhage

A Case-Crossover Study

Cho, Sung-Min*; Lee, Tiffany; Starling, Randall C.; Thompson, Nicolas R.; Uchino, Ken

doi: 10.1097/MAT.0000000000000887
Original Article: PDF Only

Despite the common occurrence left ventricular assist device (LVAD)–associated intracranial hemorrhage, the etiology of intracranial hemorrhage is uncertain. We aim to explore the impact of infection and international normalized ratio (INR) on intracranial hemorrhage in a case-crossover study. We reviewed consecutive patients with intracranial hemorrhage in a prospectively collected data of LVAD patients from a single, tertiary center from October 2004 to December 2016. Information on infection and INR values were collected at the time and 1 month before the intracranial hemorrhage as controls. Of 477 persons with LVAD, 47 (10%) developed intracranial hemorrhage (27 intracerebral, 14 subarachnoid, and six subdural hemorrhages). Of 47 (median age 58; 39 males), 27 (54%) persons had active infection at the time of intracranial hemorrhage; seven (21%) of 44 LVADs had infection at 1 month before intracranial hemorrhage. The relative risk of intracranial hemorrhage because of active infection compared with the infections at 1 month was 2.3 (95% CI: 1.5–3.4; p < 0.0001). The mean INRs at the time of intracranial hemorrhage were also significantly higher at the time of hemorrhage compared with those at 1 month (2.6 ± 1.9 vs. 1.8 ± 0.8; p = 0.01). Of 13 persons with cerebral angiogram (seven subarachnoid and six intracerebral hemorrhages), four (57%) infectious intracranial aneurysms were identified only in patients with subarachnoid hemorrhage (SAH) who also had bloodstream infections. Active infection and elevated INR were associated with LVAD-associated intracranial hemorrhage. The occurrence of both bloodstream infection and subarachnoid hemorrhage may indicate the presence of infectious intracranial aneurysm in LVAD.

From the *Departments of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland

Neurological Institute, Cleveland Clinic, Cleveland, Ohio

Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.

Submitted for consideration April 2018; accepted for publication in revised form August 2018.

Disclosure: Ken Uchino serves on data safety monitoring board for device study by EVAHEART, Incorporated.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML and PDF versions of this article on the journal’s Web site (

Sung-Min Cho and Ken Uchino contributed to study concept and design. Sung-Min Cho and Tiffany Lee contributed to data acquisition and analysis. Nicolas R. Thompson reviewed and finalized the statistical analysis. Sung-Min Cho prepared the first draft of the manuscript. Ken Uchino and Randall C. Starling contributed to drafting the manuscript. Sung-Min Cho and Ken Uchino finalized the manuscript.

Correspondence: Sung-Min Cho, Department of Anesthesiology, CCM Division of NCCU, Johns Hopkins Medical Institutions, 600 North Wolfe Street, Phipps 455, Baltimore, MD 21287. Email:

Copyright © 2019 by the American Society for Artificial Internal Organs