Ischemic and hemorrhagic brain injury during venoarterial-extracorporeal membrane oxygenation

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

doi:10.1186/s13613-018-0475-6

Ischemic and hemorrhagic brain injury during venoarterial-extracorporeal membrane oxygenation

Ann Intensive Care. 2018 Dec 20;8(1):129. doi: 10.1186/s13613-018-0475-6.

Authors

Loïc Le Guennec¹, Clémentine Cholet², Florent Huang², Matthieu Schmidt^{2

3}, Nicolas Bréchot^{2

3}, Guillaume Hékimian², Sébastien Besset², Guillaume Lebreton^{3

4}, Ania Nieszkowska², Pascal Leprince^{3

4}, Alain Combes^{2

3}, Charles-Edouard Luyt^{2

3}

Affiliations

¹ Service de Réanimation, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47, boulevard de l'Hôpital, 75013, Paris, France. loic.leguennec@aphp.fr.
² Service de Réanimation, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47, boulevard de l'Hôpital, 75013, Paris, France.
³ UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Sorbonne Universités, UPMC Université Paris 06, INSERM, Paris, France.
⁴ Service de Chirurgie Thoracique et Cardiovasculaire, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.

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.

Keywords: Blood coagulation disorders; Brain hemorrhage; Carbon dioxide; Ischemic stroke; Refractory cardiogenic shock; Venoarterial-extracorporeal membrane oxygenation.