Acute and Long-Term Outcomes after Intracranial Hemorrhage in Transplant Patients

Introduction: Data on management of patients who experience intracranial hemorrhage (ICH) following organ transplantation is sparse. We examine the incidence, presentation, and outcomes of ICH in transplant patients.

Methods: We retrospectively reviewed patients who underwent heart, liver, or lung transplant between April 2017 and June 2023. Patients who developed ICH within 3 months were included irrespective of whether neurosurgical intervention was pursued. Functional status, imaging, hospital course, and clinical outcomes were reviewed. Primary outcome was 90-day mortality. Secondary outcomes were post-ICH shift in modified Rankin score (mRS) and re-hemorrhage.

Results: Among 2223 patients managed for heart, liver, and lung transplants at Emory University Hospitals, 28 patients (1.3%) experienced ICH within 3 months. Of these, 39% were female and mean age was 56 years. Transplants were heart (54%), liver (39%), or lung (7%). Average time from transplant to ICH was 20 days. Primary hemorrhage was intraparenchymal (43%), subarachnoid (28.5%), or subdural (28.5%). ICH etiology was hemorrhagic stroke transformation (39%), traumatic (32%), hypertensive (14%), spontaneous (7%), or aneurysmal (7%). Median GCS at presentation was 10.5, and 25% had GCS < 8. Following hemorrhage, the average shift in mRS was 2.1 (p < 0.01). When adjusting for age and etiology, GCS ≤ 8 at presentation independently predicted worsening shift in mRS with coefficient of 3.4 (p < 0.001) on linear regression. Based on imaging criteria, 8 (29%) patients were deemed operative, and of those 50% underwent decompressive surgery and 87% died or went to hospice within 90 days. Re-hemorrhage occurred in 5 patients with median time of 14 days. Mortality rate at 90 days was 39.2%.

Conclusion : ICH remains a rare complication of organ transplantation, predominantly occurs secondary to hemorrhagic stroke transformation or trauma, and is associated with significant morbidity. Among patients with low GCS or large hematoma, neurosurgical prognosis remains dismal with or without decompressive surgery.