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Open Access 01-12-2018 | Research

Ischemic and hemorrhagic brain injury during venoarterial-extracorporeal membrane oxygenation

Authors: Loïc Le Guennec, Clémentine Cholet, Florent Huang, Matthieu Schmidt, Nicolas Bréchot, Guillaume Hékimian, Sébastien Besset, Guillaume Lebreton, Ania Nieszkowska, Pascal Leprince, Alain Combes, Charles-Edouard Luyt

Published in: Annals of Intensive Care | Issue 1/2018

Abstract

Background

Structural neurological complications (ischemic stroke and intracranial bleeding) and their risk factors in patients receiving venoarterial-extracorporeal membrane oxygenation (VA-ECMO) are poorly described. Our objective was to describe frequencies, outcomes and risk factors for neurological complications (ischemic stroke and intracranial bleeding) in patients receiving VA-ECMO.

Methods

Retrospective observational study conducted, from 2006 to 2014, in a tertiary referral center on patients who developed a neurological complication(s) on VA-ECMO.

Results

Among 878 VA-ECMO-treated patients, 65 (7.4%) developed an ECMO-related brain injury: 42 (5.3%) ischemic strokes and 20 (2.8%) intracranial bleeding, occurring after a median [25th;75th percentile] of 11 [6;18] and 5 [2;9] days of support, respectively. Intracranial bleeding but not ischemic stroke was associated with higher mortality. Multivariable analysis retained only platelet level > 350 giga/L as being associated with ischemic stroke. Female sex, central VA-ECMO and platelets < 100 giga/L at ECMO start were independently associated with intracranial bleeding with respective odds ratios [95% CI] of 2.9 [1.1–7.5], 3.8 [1.1–10.2] and 3.7 [1.4–9.7]. In a nested case–control study, rapid CO₂-level change from before-to-after ECMO start also seemed to be associated with intracranial bleeding.

Conclusions

Neurological events are frequent in VA-ECMO-treated patients. Ischemic stroke is the most frequent, occurs after 1 week on ECMO support, has no specific risk factor and is not associated with higher mortality. Intracranial bleeding occurs earlier and is associated with female sex, central VA-ECMO, low platelet count and rapid CO₂ change at ECMO start, and high mortality.

Level of evidence

This study provides Class IV evidence that central VA-ECMO, low platelet count and rapid CO₂ change at ECMO start are associated with intracranial bleeding and high mortality.

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Davies A, Jones D, Bailey M, Beca J, Bellomo R, Blackwell N, Forrest P, Gattas D, Granger E, Herkes R, et al. Extracorporeal membrane oxygenation for 2009 influenza A(H1N1) acute respiratory distress syndrome. JAMA. 2009;302(17):1888–95.CrossRef

Muller G, Flecher E, Lebreton G, Luyt CE, Trouillet JL, Brechot N, Schmidt M, Mastroianni C, Chastre J, Leprince P, et al. The ENCOURAGE mortality risk score and analysis of long-term outcomes after VA-ECMO for acute myocardial infarction with cardiogenic shock. Intensive Care Med. 2016;42(3):370–8. https://doi.org/10.1007/s00134-00016-04223-00139.CrossRefPubMed

Abrams D, Combes A, Brodie D. What’s new in extracorporeal membrane oxygenation for cardiac failure and cardiac arrest in adults? Intensive Care Med. 2014;40(4):609–12. https://doi.org/10.1007/s00134-00014-03212-00130.CrossRefPubMed

Mateen FJ, Muralidharan R, Shinohara RT, Parisi JE, Schears GJ, Wijdicks EF. Neurological injury in adults treated with extracorporeal membrane oxygenation. Arch Neurol. 2011;68(12):1543–9.CrossRef

Nasr DM, Rabinstein AA. Neurologic complications of extracorporeal membrane oxygenation. J Clin Neurol. 2015;11(4):383–9. https://doi.org/10.3988/jcn.2015.3911.3984.3383.CrossRefPubMedPubMedCentral

Zangrillo A, Landoni G, Biondi-Zoccai G, Greco M, Greco T, Frati G, Patroniti N, Antonelli M, Pesenti A, Pappalardo F. A meta-analysis of complications and mortality of extracorporeal membrane oxygenation. Crit Care Resusc. 2013;15(3):172–8.PubMed

Lorusso R, Barili F, Mauro MD, Gelsomino S, Parise O, Rycus PT, Maessen J, Mueller T, Muellenbach R, Belohlavek J, et al. In-hospital neurologic complications in adult patients undergoing venoarterial extracorporeal membrane oxygenation: results from the extracorporeal life support organization registry. Crit Care Med. 2016;44(10):e964–72. https://doi.org/10.1097/CCM.0000000000001865.CrossRefPubMed

Schmidt M, Brechot N, Hariri S, Guiguet M, Luyt CE, Makri R, Leprince P, Trouillet JL, Pavie A, Chastre J, et al. Nosocomial infections in adult cardiogenic shock patients supported by venoarterial extracorporeal membrane oxygenation. Clin Infect Dis. 2012;55(12):1633–41. https://doi.org/10.1093/cid/cis1783.CrossRefPubMedPubMedCentral

Sutter R, Tisljar K, Marsch S. Acute neurologic complications during extracorporeal membrane oxygenation: a systematic review. Crit Care Med. 2018;46(9):1506–13. https://doi.org/10.1097/CCM.0000000000003223.CrossRefPubMed

10.

Xie A, Lo P, Yan TD, Forrest P. Neurologic complications of extracorporeal membrane oxygenation: a review. J Cardiothorac Vasc Anesth. 2017;31(5):1836–46. https://doi.org/10.1053/j.jvca.2017.1803.1001.CrossRefPubMed

11.

Luyt CE, Brechot N, Demondion P, Jovanovic T, Hekimian G, Lebreton G, Nieszkowska A, Schmidt M, Trouillet JL, Leprince P, et al. Brain injury during venovenous extracorporeal membrane oxygenation. Intensive Care Med. 2016;23:23.

12.

Le Guennec L, Bertrand A, Laurent C, Roze H, Chastre J, Combes A, Luyt CE. Diffuse cerebral microbleeds after extracorporeal membrane oxygenation support. Am J Respir Crit Care Med. 2015;191(5):594–6.CrossRef

13.

Dangers L, Brechot N, Schmidt M, Lebreton G, Hekimian G, Nieszkowska A, Besset S, Trouillet JL, Chastre J, Leprince P, et al. Extracorporeal membrane oxygenation for acute decompensated heart failure. Crit Care Med. 2017;45(8):1359–66. https://doi.org/10.1097/CCM.0000000000002485.CrossRefPubMed

14.

de Chambrun MP, Brechot N, Lebreton G, Schmidt M, Hekimian G, Demondion P, Trouillet JL, Leprince P, Chastre J, Combes A, et al. Venoarterial extracorporeal membrane oxygenation for refractory cardiogenic shock post-cardiac arrest. Intensive Care Med. 2016;42(12):1999–2007. https://doi.org/10.1007/s00134-00016-04541-y.CrossRef

15.

Lorusso R, Gelsomino S, Parise O, Di Mauro M, Barili F, Geskes G, Vizzardi E, Rycus PT, Muellenbach R, Mueller T, et al. Neurologic injury in adults supported with veno-venous extracorporeal membrane oxygenation for respiratory failure: findings from the extracorporeal life support organization database. Crit Care Med. 2017;45(8):1389–97. https://doi.org/10.1097/CCM.0000000000002502.CrossRefPubMed

16.

Gray BW, Haft JW, Hirsch JC, Annich GM, Hirschl RB, Bartlett RH. Extracorporeal life support: experience with 2000 patients. ASAIO J. 2015;61(1):2–7. https://doi.org/10.1097/MAT.0000000000000150.CrossRefPubMedPubMedCentral

17.

Rastan AJ, Lachmann N, Walther T, Doll N, Gradistanac T, Gommert JF, Lehmann S, Wittekind C, Mohr FW. Autopsy findings in patients on postcardiotomy extracorporeal membrane oxygenation (ECMO). Int J Artif Organs. 2006;29(12):1121–31.CrossRef

18.

Omar HR, Mirsaeidi M, Shumac J, Enten G, Mangar D, Camporesi EM. Incidence and predictors of ischemic cerebrovascular stroke among patients on extracorporeal membrane oxygenation support. J Crit Care. 2016;32:48–51. https://doi.org/10.1016/j.jcrc.2015.1011.1009.CrossRefPubMed

19.

Marinoni M, Migliaccio ML, Trapani S, Bonizzoli M, Gucci L, Cianchi G, Gallerini A, Tadini Buoninsegni L, Cramaro A, Valente S, et al. Cerebral microemboli detected by transcranial doppler in patients treated with extracorporeal membrane oxygenation. Acta Anaesthesiol Scand. 2016;60(7):934–44. https://doi.org/10.1111/aas.12736.CrossRefPubMed

20.

Kasirajan V, Smedira NG, McCarthy JF, Casselman F, Boparai N, McCarthy PM. Risk factors for intracranial hemorrhage in adults on extracorporeal membrane oxygenation. Eur J Cardiothorac Surg. 1999;15(4):508–14.CrossRef

21.

Fletcher Sandersjoo A, Bartek J Jr, Thelin EP, Eriksson A, Elmi-Terander A, Broman M, Bellander BM. Predictors of intracranial hemorrhage in adult patients on extracorporeal membrane oxygenation: an observational cohort study. J Intensive Care. 2017;5:27. https://doi.org/10.1186/s40560-40017-40223-40562.CrossRefPubMedPubMedCentral

22.

Lockie CJA, Gillon SA, Barrett NA, Taylor D, Mazumder A, Paramesh K, Rowland K, Daly K, Camporota L, Meadows CIS, et al. Severe respiratory failure, extracorporeal membrane oxygenation, and intracranial hemorrhage. Crit Care Med. 2017;45(10):1642–9. https://doi.org/10.1097/CCM.0000000000002579.CrossRefPubMed

23.

Heilmann C, Geisen U, Beyersdorf F, Nakamura L, Benk C, Trummer G, Berchtold-Herz M, Schlensak C, Zieger B. Acquired von Willebrand syndrome in patients with extracorporeal life support (ECLS). Intensive Care Med. 2012;38(1):62–8. https://doi.org/10.1007/s00134-00011-02370-00136.CrossRefPubMed

Title: Ischemic and hemorrhagic brain injury during venoarterial-extracorporeal membrane oxygenation
Authors: Loïc Le Guennec
Clémentine Cholet
Florent Huang
Matthieu Schmidt
Nicolas Bréchot
Guillaume Hékimian
Sébastien Besset
Guillaume Lebreton
Ania Nieszkowska
Pascal Leprince
Alain Combes
Charles-Edouard Luyt
Publication date: 01-12-2018
Publisher: Springer International Publishing
Published in: Annals of Intensive Care / Issue 1/2018
Electronic ISSN: 2110-5820
DOI: https://doi.org/10.1186/s13613-018-0475-6

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Ischemic and hemorrhagic brain injury during venoarterial-extracorporeal membrane oxygenation

Abstract

Background

Methods

Results

Conclusions

Level of evidence

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

Level of evidence

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