Management of a Case of Acute Ischaemic Stroke with Large Vessel Occlusion in an LVAD Patient; A UK Secondary Medical Center Experience

Abstract

Introduction: Left ventricular assist devices (LVADs) are getting more popular in managing advanced heart failure patients. The implantation of LVADs is associated with neurological complications, including ischemic stroke or intracranial hemorrhage. There are no current guidelines on how to manage these neurological complications. In this report, we presented an LVAD patient with a large ischemic cerebral infarct and subarachnoid hemorrhage simultaneously and outlined our approach to managing these complications without affecting the LVAD function. Case presentation: A 34- year-old gentleman with an LVAD to bridge him to heart transplantation presented with acute left-sided body weakness of an undetermined time of onset. His CT head showed a large right middle cerebral artery infarct. He was not a thrombolysis candidate due to the undetermined onset of his stroke, the anticoagulation he was on for the LVAD, and the signs of infarct maturation in the CT head. We managed him in a multidisciplinary team approach holding the Aspirin and Warfarin he was taking and doing serial CT imaging of his brain to monitor the development of brain edema. The patient developed a small subarachnoid hemorrhage on day 2, that spontaneously resolved on day 5. We started him on unfractionated heparin on day 7 and Warfarin on day 10. We made an excellent recovery of his neurological function without impairment of the function on the LVAD. Conclusion: Simultaneous ischemic stroke and brain hemorrhage are a challenge in LVAD patients. A closely monitored stoppage of antithrombotics and serial brain imaging can guide the treatment. Regular assessment of LVAD function is mandated. Antithrombotics could be carefully reintroduced under surveillance brain scanning to maintain the LVAD function.