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Boy Has Life Saving Brain Surgery and Gets a New Heart

Progression of subdural hematoma. A: Initial head CT on hospital day eight, revealing acute and chronic components of R hemispheric subdural hematoma with midline shift. B: Head CT the morning of hospital day nine, showing increased acute and chronic components of the subdural hematoma, with increasing midline shift. C: Immediately after postoperative evacuation of subdural hematoma, showing improving hematoma. D: Five days after evacuation, showing continued resolution of subdural hematoma.

A shining case of interdisciplinary medicine, published in the Journal of Pediatric Transplantation, has come out of Columbia’s Department of Neurosurgery.

The primary author of the published case study is Dr. Raqeeb Haque and he is joined by co-authors Dr. Richard Anderson and Dr. Neil Feldstein from the Pediatric Neurosurgery Center.

The article, Management of Intracranial Hemorrhage in a Child With a Left Ventricular Assist Device, was published in the February 2012 issue of the journal Pediatric Transplantation.

Before we tell the story we’ll define the terms in the title. An intracranial hemorrhage is an incident of bleeding within the skull. A left ventricular assist device (LVAD) is an external mechanical device that does the work of the left ventricle for a failing heart (see the image below right).

The blood thinners prescribed for a pediatric patient on an LVAD put the child at an increased risk of bleeding.  The child must be monitored for a brain hemorrhage.

The bleeding in the brain can result in what is called a subdural hematoma — This is a blood clot that is formed when blood collects underneath the outer covering and on the surface of the brain. When this happens in children it can be fatal.

Drs. Haque, Anderson and Feldstein reported a case of a 5 year old boy with a LVAD who had an intracranial bleed that resulted in a large subdural hematoma.

The boy they reported on already had a diagnosis of dilated cardiomyopathy (DCM), a disease in which the heart muscles become enlarged and weak. In the boy’s case his heart had become so weak that he needed the LVAD to keep him alive.

LVAD

Continued scans of the boy’s brain showed, however, that the brain bleed was getting bigger and putting more and more pressure on his brain. This was life threatening and required immediate surgery. In a case like this, doctors have to make a decision; if they stop the blood thinners to stop the bleeding in the brain, they increase the risk that a clot could form where the blood meets the LVAD.

Pediatric neurosurgeons Haque and Anderson were called in. They turned down the blood thinning medication just enough to decrease the bleeding and through a small opening in the skull they were able to successfully remove the blood clot.

“By evacuating this patient’s subdural hematoma, we facilitated his reinstatement as status 1A on the heart transplant wait list,” says Dr. Haque. Status 1A is the highest priority rating on the transplant wait list. It usually means the patient is in the hospital and dependent on mechanical assistance to keep their heart functioning, as this boy was. The boy had been taken off the 1A list when the brain bleed was discovered.

Thanks to a stellar example of multiple disciplines coming together, including pediatric neurosurgery and heart transplantation, the boy did get his heart transplant and was discharged from the hospital with no brain injury and a new chance at life.

It has been over a year now since the boy’s transplant and he is doing great!

patient journey

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