Cerebral Outcome in Adult Patients Treated With Extracorporeal Membrane Oxygenation

Department of Thoracic and Cardiovascular Surgery, Rikshospitalet University Hospital, Oslo, Norway.
The Annals of thoracic surgery (Impact Factor: 3.85). 05/2006; 81(4):1401-6. DOI: 10.1016/j.athoracsur.2005.10.008
Source: PubMed


Extracorporeal membrane oxygenation (ECMO) carries a high risk of brain injury. The aim of this study was to determine the cerebral status in 28 adult survivors on average 5.0 (range, 0.5 to 12) years after ECMO treatment for severe cardiorespiratory failure.
All 28 patients were investigated at our institution. A comprehensive assessment protocol included a medical history, physical examination, neuropsychological assessment, electroencephalography, and neuroradiologic assessment.
All patients were ambulant unaided, and 43% were without any clinical findings. Impaired neuropsychological performance was found in 41%, neuroradiologic findings in 52%, and a pathologic electroencephalogram in 41% of the patients. There was a significant correlation between the cognitive outcome and neuroradiologic findings. The incidence of neuroradiologic findings (cerebral infarction, microemboli or hemorrhage) was significantly higher in the venoarterial group compared with the venovenous group (75% versus 17%). There was no correlation between the type of ECMO and neuropsychological impairment. Electroencephalography findings did not correlate with neuropsychological performance, nor with the neuroradiologic findings.
Late cerebral sequelae were frequently seen in patients treated on venoarterial ECMO. A significant correlation was found between cognitive impairment and neuroradiologic findings.

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Available from: Kjetil Sundet
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    • "In 2009, the national Extracorporeal Life Support Organization (ELSO) registry reported that 21% of 295 adults treated with ECPR experienced brain death. Additionally, approximately one-half of the survival patients showed evidence of cerebral injury [8]. CBF reduction (inadequate perfusion) and non-pulsate blood flow during VA ECMO might play a role in the pathogenesis of this complication [8,9]. "
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    ABSTRACT: The addition of an intra-aortic balloon pump (IABP) during peripheral venoarterial extracorporeal membrane oxygenation (VA ECMO) support has been shown to improve coronary bypass graft flows and cardiac function in refractory cardiogenic shock after cardiac surgery. The purpose of this study was to evaluate the impact of additional IABP support on the cerebral blood flow (CBF) in patients with peripheral VA ECMO following cardiac procedures. Twelve patients (mean age 60.40 +/- 9.80 years) received VA ECMO combined with IABP support for postcardiotomy cardiogenic shock after coronary artery bypass grafting. The mean CBF in the bilateral middle cerebral arteries was measured with and without IABP counterpulsation by transcranial Doppler. The patients provided their control values. The mean CBF data were divided into two groups (pulsatile pressure greater than 10 mmHg, P group; pulsatile pressure less than 10 mmHg, N group) based on whether the patients experienced cardiac stun. The mean cerebral blood flow in VA ECMO (IABP turned off) alone and VA ECMO with IABP support were compared using the paired t test. All of the patients were successfully weaned from VA ECMO, and eight patients survived to discharge. The addition of IABP to VA ECMO did not change the mean CBF (251.47 +/- 79.28 ml/min vs. 251.30 +/- 79.47 ml/min, P = 0.963). The mean CBF was higher in VA ECMO alone than in VA ECMO combined with IABP support in the N group (257.68 +/- 97.21 ml/min vs. 239.47 +/- 95.60, P = 0.00). The addition of IABP to VA ECMO support increased the mean CBF values significantly compared with VA ECMO alone (261.68 +/- 82.45 ml/min vs. 244.43 +/- 45.85 ml/min, P = 0.00) in the P group. These results demonstrate that an IABP significantly changes the CBF during peripheral VA ECMO, depending on the antegrade blood flow by spontaneous cardiac function. The addition of an IABP to VA ECMO support decreased the CBF during cardiac stun, and it increased CBF without cardiac stun.
    Full-text · Article · Apr 2014 · Journal of Translational Medicine
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    • "Our case confirms that ECMO patients are at risk for a wider spectrum of neurologic complications then previously considered [1] [6]. The pathophysiology of the ECMO/brain interaction is still poorly understood, although clotting, bleeding, and hypoperfusion apparently account for the majority of neurologic events [1] [3] [6]. The herein reported case, to our knowledge, represents the first evidence of PRES, and brain-related arterial vasospasm, during an ECMO run, but also indicates that favorable outcome may still be achieved in these complex conditions. "

    Full-text · Article · Jan 2014 · International journal of cardiology
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    • "The main reasons include: first, in the study, the VV-ECMO bypass method was used rather than the venoarterial (V-A) ECMO method. Current studies believe the injuries were observed mainly in patients treated with VA-ECMO [10,11,37]. This is because in the VA-ECMO model rather than in the VV-ECMO model [11,37], the carotid artery needs to be ligated and nonpulsatile flow generated in the brain, which results in loss of autoregulation, hypoxia and ischemia in the brain. "
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    ABSTRACT: Extra-Corporeal Membrane Oxygenation (ECMO) therapy is associated with high risk of neurologic injury. But the mechanism of neurologic injury during and/or after ECMO therapy is still unclear. Recent animal experiments confirmed that ECMO treatment increases the immune inflammatory response. The aim of this study is to investigate the effect of VV- ECMO on immune inflammatory response of cerebral tissues and neurological impairment. 18 porcine were randomly divided into control, sham and ECMO group (n = 6/group). ECMO was run 24h in the ECMO group, and serum collected at 0, 2, 6, 12 and 24h during ECMO treatment for the analysis of cytokine(IL-1beta, IL-6, IL-10, TNF-a) and cerebral injury specific biomarker S100B and NSE. After 24h ECMO treatment, all animals were euthanized and cerebral tissues (hypothalamus, hippocampus and cortex) were collected for measure of mRNA and protein levels of cytokine (IL-1beta, IL-6, IL-10, TNF-a). The results during ECMO treatment showed that all the pro-inflammation cytokines were increased significantly after 2h, and anti-inflammation IL-10 showed transient hoist in the first 2h in serum. After 24h ECMO therapy, the mRNA levels of pro-inflammation cytokines and anti-inflammation IL-10 were simultaneously up-regulated in cerebral tissues (hypothalamus, hippocampus and cortex). And protein concentrations also showed different increasing levels in cerebral tissues. However, during the ECMO treatment, S100B and NSE protein in serum did not change significantly. These findings suggest VV-ECMO treatment can not only lead to immune inflammatory response in blood, but can also produce immune and inflammatory response in cerebral tissues. However the extent of immune inflammation was not sufficient to cause significant neurological impairment in this study. But the correlation between cerebral inflammatory response and cerebral impairment need to further explore.
    Full-text · Article · Aug 2013 · Journal of Cardiothoracic Surgery
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