Management of Intracranial Hemorrhage in Patients with a Left Ventricular Assist Device: A Systematic Review and Meta- Analysis Austin H. Carroll, BA,* Michael P. Ramirez, BS,† Ehsan Dowlati, MD,‡ Kyle B. Mueller, MD,§ Ali Borazjani, PhD,{ Jason J. Chang, MD,# and Daniel R. Felbaum, MDk , ** Background: Intracranial hemorrhage (ICH) has been reported to occur in up to 23% of patients with left ventricular assist devices (LVADs). Currently, limited data exists to guide neurosurgical management strategies to optimize outcomes in patients with an LVAD who develop ICH. Methods: A systematic review and meta-analysis of the literature was performed to evaluate the mortality rate in these patients following medical and/or surgical management and to evaluate antithrombotic reversal and resumption strategies after hemorrhage. Results: 17 studies reporting on 3869 LVAD patients and 545 intracranial hemorrhages spanning investigative periods from 1996 to 2019 were included. The rate of ICH in LVAD patients was 10.6% (411/3869) with 58.6% (231/394) being intraparenchymal hemorrhage (IPH), 23.6% (93/394) sub- arachnoid hemorrhage (SAH), and 15.5% (61/394) subdural hemorrhage (SDH). Total mortality rates for surgical management 65.6% (40/61) differed from medical management at 45.2% (109/241). There was an increased relative risk of mortality (RR=1.45, 95% CI: 1.101.91, p = 0.01) for ICH patients undergoing surgical interven- tion. The hemorrhage subtype most frequently managed with anticoagulation rever- sal was IPH 81.8% (63/77), followed by SDH 52.2% (12/23), and SAH 39.1% (18/46). Mean number of days until antithrombotic resumption ranged from 6 to 10.5 days. Conclusion: Outcomes remain poor, specifically for those undergoing surgery. As experience with this population increases, prospective studies are warranted to con- tribute to management and prognostication . From the *Georgetown University School of Medicine, Washington, D.C., USA; †Georgetown University School of Medicine, Washington, D.C., USA; ‡Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, D.C., USA; §Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School at Brown University, Providence, R.I., USA; {Georgetown University School of Medicine, Washing- ton, D.C., USA; # Department of Critical Care Medicine, MedStar Washington Hospital Center, Washington D.C., USA; kDepartment of Neurosur- gery, MedStar Washington Hospital Center, Washington, D.C., USA; and **Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, D.C., USA. Received September 30, 2020; revision received November 12, 2020; accepted November 21, 2020. Previous Presentation or Submissions: None. We confirm that this manuscript has not been previously published in whole or in part, nor has it been submitted elsewhere for review. Prospero registration ID: CRD42020181283 Ethical Statement: Financial Disclosure: No sources of funding were used for this study. Conflict of Interest: On behalf of all authors, the corresponding author states that there is no conflict of interest. Ethical approval: This study obtained waiver for approval by the institutional review board of our institution given that no patient health infor- mation was used. Informed consent: Informed consent was not applicable for this study. Address correspondence to Ehsan Dowlati, MD, Department of Neurosurgery, MedStar Georgetown University Hospital, 3800 Reservoir Rd NW, PHC 7, Washington, D.C., USA. E-mail: edowlati@gmail.com. 1052-3057/$ - see front matter © 2020 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jstrokecerebrovasdis.2020.105501 Journal of Stroke and Cerebrovascular Diseases, Vol. 30, No. 2 (February), 2021: 105501 1