Confusion in the ICU: Anticoagulated VAD Patient with MS Changes

  • Agnieszka A. ArdeltEmail author
Part of the Difficult Decisions in Surgery: An Evidence-Based Approach book series (DDSURGERY)


In an anticoagulated cardiothoracic intensive care unit (ICU) patient with a ventricular assist device (VAD), acute confusion may be a sign of a serious complication requiring rapid diagnosis and management. There is a paucity of data on the assessment of patients with VADs in the cardiothoracic ICU presenting with confusion; however, based on data from general hospitalized patient populations, rapid assessment by providers with stroke expertise is recommended.


Stroke Acute neurologic change Intracranial hemorrhage Ischemic stroke Seizure Delirium Encephalopathy Confusion Lethargy Unresponsiveness Stupor Hypoglycemia 


  1. 1.
    Saver JL. Time is brain – quantified. Stroke. 2006;37:263–6.CrossRefGoogle Scholar
  2. 2.
    Stroke Unit Trialists’ Collaboration. Organised inpatient (stroke unit) care for stroke. Cochrane Database Syst Rev. 2013;(9):CD000197.Google Scholar
  3. 3.
    Alberts MJ, Latchaw RE, Jagoda A, et al. Revised and updated recommendations for the establishment of primary stroke centers: a summary statement from the brain attack coalition. Stroke. 2011;42:2651–65.CrossRefGoogle Scholar
  4. 4.
    Alberts MJ, Latchaw RE, Selman WR, et al. Recommendations for comprehensive stroke centers: a consensus statement from the Brain Attack Coalition. Stroke. 2005;36:1597–616.CrossRefGoogle Scholar
  5. 5.
    Cumbler E. In-hospital ischemic stroke. Neurohospitalist. 2015;5:173–81.CrossRefGoogle Scholar
  6. 6.
    Cumbler E, Simpson J. Code stroke: multicenter experience with in-hospital stroke alerts. J Hosp Med. 2015;10:179–83.CrossRefGoogle Scholar
  7. 7.
    El Husseini N, Goldstein LB. “Code stroke”: hospitalized versus emergency department patients. J Stroke Cerebrovasc Dis. 2013;22:345–8.CrossRefGoogle Scholar
  8. 8.
    Emiru T, Adil MM, Suri MF, Qureshi AI. Thrombolytic treatment for in-hospital ischemic strokes in United States. J Vasc Interv Neurol. 2014;7:28–34.PubMedPubMedCentralGoogle Scholar
  9. 9.
    Kelley RE, Kovacs AG. Mechanism of in-hospital cerebral ischemia. Stroke. 1986;17:430–3.CrossRefGoogle Scholar
  10. 10.
    Kimura K, Minematsu K, Yamaguchi T. Characteristics of in-hospital onset ischemic stroke. Eur Neurol. 2006;55:155–9.CrossRefGoogle Scholar
  11. 11.
    Masjuan J, Simal P, Fuentes B, et al. In-hospital stroke treated with intravenous tissue plasminogen activator. Stroke. 2008;39:2614–6.CrossRefGoogle Scholar
  12. 12.
    Park HJ, Cho HJ, Kim YD, et al. Comparison of the characteristics for in-hospital and out-of-hospital ischaemic strokes. Eur J Neurol. 2009;16:582–8.CrossRefGoogle Scholar
  13. 13.
    Thomas CE, Jichici D, Petrucci R, Urrutia VC, Schwartzman RJ. Neurologic complications of the Novacor left ventricular assist device. Ann Thorac Surg. 2001;72:1311–5.CrossRefGoogle Scholar
  14. 14.
    Genovese EA, Dew MA, Teuteberg JJ, et al. Incidence and patterns of adverse event onset during the first 60 days after ventricular assist device implantation. Ann Thorac Surg. 2009;88:1162–70.CrossRefGoogle Scholar
  15. 15.
    Kato TS, Schulze PC, Yang J, et al. Pre-operative and post-operative risk factors associated with neurologic complications in patients with advanced heart failure supported by a left ventricular assist device. J Heart Lung Transplant. 2012;31:1–8.CrossRefGoogle Scholar
  16. 16.
    Coffin ST, Haglund NA, Davis ME, et al. Adverse neurologic events in patients bridged with long-term mechanical circulatory support: a device-specific comparative analysis. J Heart Lung Transplant. 2015;34:1578–85.CrossRefGoogle Scholar
  17. 17.
    Parikh NS, Cool J, Karas MG, Boehme AK, Kamel H. Stroke risk and mortality in patients with ventricular assist devices. Stroke. 2016;47:2702–6.CrossRefGoogle Scholar
  18. 18.
    Holman WL, Kormos RL, Naftel DC, et al. Predictors of death and transplant in patients with a mechanical circulatory support device: a multi-institutional study. J Heart Lung Transplant. 2009;28:44–50.CrossRefGoogle Scholar
  19. 19.
    Sakaguchi M, Kitagawa K, Okazaki S, et al. Sulcus subarachnoid hemorrhage is a common stroke subtype in patients with implanted left ventricular assist devices. Eur J Neurol. 2015;22:1088–93.CrossRefGoogle Scholar
  20. 20.
    Willey JZ, Gavalas MV, Trinh PN, et al. Outcomes after stroke complicating left ventricular assist device. J Heart Lung Transplant. 2016;35:1003–9.CrossRefGoogle Scholar
  21. 21.
    Al-Mufti F, Bauerschmidt A, Claassen J, Meyers PM, Colombo PC, Willey JZ. Neuroendovascular interventions for acute ischemic strokes in patients supported with left ventricular assist devices: a single-center case series and review of the literature. World Neurosurg. 2016;88:199–204.CrossRefGoogle Scholar
  22. 22.
    Benavente L, Larrosa D, Garcia-Cabo C, et al. Safety and efficacy of mechanical thrombectomy in acute ischemic stroke of anticoagulated patients-a prospective observational study. J Stroke Cerebrovasc Dis. 2016;25:2093–8.CrossRefGoogle Scholar
  23. 23.
    Wong JK, Chen PC, Falvey J, et al. Anticoagulation reversal strategies for left ventricular assist device patients presenting with acute intracranial hemorrhage. ASAIO J. 2016;62:552–7.CrossRefGoogle Scholar
  24. 24.
    Bilotta F, Lauretta MP, Borozdina A, Mizikov VM, Rosa G. Postoperative delirium: risk factors, diagnosis and perioperative care. Minerva Anestesiol. 2013;79:1066–76.PubMedGoogle Scholar
  25. 25.
    Willey JZ, Demmer RT, Takayama H, Colombo PC, Lazar RM. Cerebrovascular disease in the era of left ventricular assist devices with continuous flow: risk factors, diagnosis, and treatment. J Heart Lung Transplant. 2014;33:878–87.CrossRefGoogle Scholar
  26. 26.
    Health Quality O. Left ventricular assist devices: an evidence-based analysis. Ont Health Technol Assess Ser. 2004;4:1–69.Google Scholar
  27. 27.
    Trachtenberg BH, Cordero-Reyes AM, Aldeiri M, et al. Persistent blood stream infection in patients supported with a continuous-flow left ventricular assist device is associated with an increased risk of cerebrovascular accidents. J Card Fail. 2015;21:119–25.CrossRefGoogle Scholar
  28. 28.
    Dunne JW, Leedman PJ, Edis RH. Inobvious stroke: a cause of delirium and dementia. Aust NZ J Med. 1986;16:771–8.CrossRefGoogle Scholar
  29. 29.
    Lietz K, Brown K, Ali SS, et al. The role of cerebral hyperperfusion in postoperative neurologic dysfunction after left ventricular assist device implantation for end-stage heart failure. J Thorac Cardiovasc Surg. 2009;137:1012–9.CrossRefGoogle Scholar
  30. 30.
    Heverly DN, Prayson RA. Neuropathology associated with ventricular assist devices: an autopsy series of 33 patients. Ann Diagn Pathol. 2001;5:67–73.CrossRefGoogle Scholar
  31. 31.
    Powers WJ, Derdeyn CP, Biller J, et al. 2015 American Heart Association/American Stroke Association focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46:3020–35.CrossRefGoogle Scholar
  32. 32.
    Hemphill JC 3rd, Greenberg SM, Anderson CS, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46:2032–60.CrossRefGoogle Scholar
  33. 33.
    Tarnutzer AA, Lee SH, Robinson KA, Wang Z, Edlow JA, Newman-Toker DE. ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: a meta-analysis. Neurology. 2017;88:1468–77.CrossRefGoogle Scholar
  34. 34.
    Demaerschalk BM, Berg J, Chong BW, et al. American Telemedicine Association: telestroke guidelines. Telemed J E Health. 2017;23:376–89.CrossRefGoogle Scholar
  35. 35.
    Dorsey ER, Topol EJ. State of telehealth. N Engl J Med. 2016;375:154–61.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of NeurosurgeryMetroHealth SystemClevelandUSA

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