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Neurological Injury in Adults Treated With Extracorporeal Membrane Oxygenation

Farrah J. Mateen, MD; Rajanandini Muralidharan, MD; Russell T. Shinohara, MSc; Joseph E. Parisi, MD; Gregory J. Schears, MD; Eelco F. M. Wijdicks, MD, PhD
Arch Neurol. 2011;68(12):1543-1549. doi:10.1001/archneurol.2011.209.
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Background Extracorporeal membrane oxygenation (ECMO) may be urgently used as a last resort form of life support when all other treatment options for potentially reversible cardiopulmonary injury have failed.

Objective To examine the range and frequency of neurological injury in ECMO-treated adults.

Design Retrospective clinicopathological cohort study.

Setting Mayo Clinic, Rochester, Minnesota.

Patients A prospectively collected registry of all patients 15 years or older treated with ECMO for 12 or more hours from January 2002 to April 2010.

Intervention Patients were analyzed for potential risk factors for neurological events and death using logistic regression and Cox proportional hazards models.

Main Outcome Measures Neurological diagnosis and/or death.

Results A total of 87 adults were treated (35 female [40%]; median age, 54 years [interquartile range, 31]; mean duration of ECMO, 91 hours [interquartile range, 100]; overall survival >7 days after ECMO, 52%). Neurological events occurred in 42 patients who received ECMO (50%; 95% confidence interval [CI], 39%-61%). Diagnoses included subarachnoid hemorrhage, ischemic watershed infarctions, hypoxic-ischemic encephalopathy, unexplained coma, and brain death. Death in patients who received ECMO who did not require antecedent cardiopulmonary resuscitation was associated with increased age (odds ratio, 1.24 per decade; 95% CI, 1.03-1.50; P = .02) and lower minimum arterial oxygen pressure (odds ratio, 0.79; 95% CI, 0.68-0.92; P = .03). Although stroke was rarely diagnosed clinically, 9 of 10 brains studied at autopsy demonstrated hypoxic-ischemic and hemorrhagic lesions of vascular origin.

Conclusion Severe neurological sequelae occur frequently in adult ECMO-treated patients with otherwise reversible cardiopulmonary injury (conservative estimate, 50%) and include a range of potentially fatal neurological diagnoses that may be due to the precipitating event and/or ECMO treatment.

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Figure 1. Flow diagram of adult patients treated with extracorporeal membrane oxygenation (ECMO) (n = 87).

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Figure 2. Plot of Kaplan-Meier curve of time from extracorporeal membrane oxygenation (ECMO) initiation to death for all adult patients treated with ECMO by reason for ECMO treatment: after thoracic surgery (A; n = 73) and after CPR (B; n = 14).

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Figure 3. Bar graph of patient survival times among nonsurvivors by reason for extracorporeal membrane oxygenation treatment (n = 62).

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Figure 4. Diagnostic results of adult patients who received extracorporeal membrane oxygenation. The figure shows parafalcine subarachnoid hemorrhage and hydrocephalus on axial-view head computed tomography (A), diffuse subarachnoid hemorrhage on T1-weighted magnetic resonance imaging (B), and septic cerebral emboli on axial-view magnetic resonance imaging (C), which enhances with gadolinium-contrast; acute ischemic cell changes (“red dead neurons”) (D) and microscopic subacute ischemic thalamic infarction on histopathological sectioning (E); and diffuse petechial hemorrhages (F), subarachnoid hemorrhage (G), and massive intraventricular hemorrhage on gross pathological examination (H).




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