Fig. 2.1
Shown are several LAAC devices. (a) Percutaneous left atrial appendage transcatheter occlusion device (PLAATO). This was the first device available for percutaneous appendage closure and is no longer in use. (b) i) and ii) Amplatzer Cardiac Plug (ACP) which is in widespread use, to possibly be superseded by the next generation of device called the Amplatzer Amulet (St. Jude Medical, Inc., Plymouth, MN). (c) Amplatzer amulet LAA occluder device. This was developed for easier delivery and better coverage than the ACP and ss designed with a longer lobe and waist. (d) i) and ii) The Watchman device (Boston Scientific Corp., Natick, MA). The device comes in 5 different sizes: 21, 24, 27, 30, and 33 mm. (e) The wavecrest device (Coherex Medical, Inc., Salt Lake City, UT). This is composed of a nitinol frame covered by a non-thrombogenic expanded polytetrafluoroethylene membrane and is available in 3 sizes: 22, 27 or 32 mm
Case Study
A 73 year old man was transferred as an emergency in November 2014 to the neurosurgical team for left burr-hole evacuation of left subacute subdural haematoma on a background of warfarin anticoagulation for non-valvular AF (Fig. 2.2a). Presenting symptoms were right-sided weakness and reduced Glasgow Coma Scale (GCS 13 – Eye opening 3 Verbal response 4 Motor response 6). Past medical history included AF and ischaemic stroke, hypertension, and non-insulin-dependent diabetes mellitus. CHA2DS2-VASc risk score was calculated as 5, but rising to 6 in 2 years’ time (Table 2.1).
Fig. 2.2
A series of computed tomographic scans of the patent’s head. (a) Large left subacute subdural haematoma (red arrow) with mass effect and midline shift. (b) Following surgical evacuation of the haematoma there is marked improvement in mass effect. There remains bilateral convexity with subdural fluid collections, larger on the left. There is minor distortion of the midline but no significant midline shift. Scattered locules of postoperative pneumocephalus are present. No hydrocephalus. There is also an old right frontal and insular middle cerebral artery territory infarct, and advanced small vessel ischaemia. (c) Large right chronic subdural haematoma (blue arrow). There is a mixed density but mainly intermediate density collection overlying the right cerebral hemisphere causing mass effect and midline shift toward the left, with partial effacement of the left lateral ventricle. Strands of high density are present within this extraaxial collection, suggesting that there is some organisation within the haematoma and that it is not acute. (d) Following surgical evacuation of the right-sided haematoma there is marked improvement in mass effect. There is less midline shift and less effacement of the convexity sulci. No significant interval change to the subdural overlying the left frontal convexity
Table 2.1
CHA2DS2-VASc risk score
Condition | Points | |
|---|---|---|
C | Congestive heart failure (or Left ventricular systolic dysfunction) | 1 |
H | Hypertension: blood pressure consistently above 140/90 mmHg (or treated hypertension on medication) | 1 |
A 2 | Age ≥75 years | 2 |
D | Diabetes Mellitus | 1 |
S2 | Prior Stroke or TIA or thromboembolism | 2 |
V | Vascular disease (e.g., peripheral artery disease, myocardial infarction, aortic plaque) | 1 |
A | Age 65–74 years | 1 |
Sc | Sex category (i.e., female sex) | 1 |
Post-operatively, the cardiology team were consulted by the neurosurgeons. Due to the high risk of recurrent ischaemic stroke in association with satisfactory resolution of the left subdural haematoma, re-initiation of warfarin after 6 weeks was advised with simultaneous referral for placement of a LAAC device. The patient was discharged with GCS 15 and a Falls Assessment indicating that he remained at risk of falls.
At outpatient neurosurgical review in February 2015 he complained of a deterioration in balance, gait, and memory for the preceding few weeks. The international normalised ratio (INR) was therapeutic at 2.8. Urgent head computed tomography (CT) demonstrated that he had now developed a chronic subdural haematoma on the right side which was drained the next day. The patient again made a good recovery and was discharged 3 days following this second burr-hole operation. Warfarin was now permanently discontinued.
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