Rationale and Objectives
To evaluate the clinical utility of cranial computed tomography (CT) in pediatric and adult patients during ongoing extracorporeal membrane oxygenation (ECMO) treatment from acute respiratory failure and to assess the frequency of intracranial hemorrhage (ICH) and infarction during the treatment.
Materials and Methods
The medical records of 123 consecutive patients, 54 children (ages 3 months–17 years) and 69 adults (ages 18–62 years), treated with ECMO over a 10-year period were searched for cranial CT performed during ECMO. Indications for CT, CT findings, impact on clinical management, and patient outcome were noted. In addition, all CT scans were reviewed for the frequency of ICH or infarction.
Results
Seventy-eight patients had cranial CT while on ECMO. ICH or cerebral infarction were detected in 45 (37%) of the 123 patients. Eighteen patients (15%) had focal hemorrhage, 11 (9%) focal infarction, and 16 (13%) general brain edema. In 16 of the 45 patients, the CT findings were decisive to withdraw the ECMO treatment. Five patients were weaned from ECMO, and in four patients the findings motivated cranial surgery during ECMO. In the remaining 20 patients with less extended intracranial pathology, the ECMO treatment was continued with high survival.
Conclusion
Cranial CT has an important role during ECMO treatment to reveal or exclude severe intracranial complications where ECMO treatment should be discontinued. Less severe complications have a favorable prognosis with continued treatment. Our study suggests an underreporting of intracranial complications in adults and pediatric patients on ECMO because of low utilization of neuroimaging.
Extracorporeal membrane oxygenation (ECMO) is a commonly used therapy for neonates, children, and adults with acute, extremely severe respiratory failure unresponsive to conventional medical management and intensive care ( ). In randomized studies, ECMO has proved to be a life-saving technique in neonates with a number of pulmonary disorders ( ), and several nonrandomized investigations have shown promising results in children ( ) and adults ( ). By January 2006, more than 30,000 patients have been reported to the Extracorporeal Life Support Organization (ELSO) from approximately 100 ECMO centers ( ).
A significant cause of morbidity and mortality among patients on ECMO therapy are related to intracranial complications, mainly intracranial hemorrhage (ICH) and cerebral infarction ( ). This can be attributed to both pre-ECMO asphyxia or hypotension and to the ECMO procedure itself, including the altered blood flow after ligation of the internal jugular vein and common carotid artery and the increased risk for thromboembolism and hemorrhage from extracorporeal circulation, coagulopathy, and systemic heparinization.
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Materials and methods
Patients and Study Design
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Table 1
Descriptive Data for Pediatric and Adult Patients Treated With ECMO During the Study Period
Number ( n ) Age (Years) Mean (Range) Gender Diagnosis Cannulation Type Days on ECMO Mean (Range) Survival ( n ) Children 54 5.6 (0.25–17)
12.4 (0.5–49) 30 (56%) Adults 69 38 (18–62)
14.7 (0.1–59) 41 (59%) All 123 23.8 (0.25–62)
13.7 (0.1–59) 71 (58%)
ECMO: extracorporeal membrane oxygenation; F: female; M: male; ARDS: acute respiratory distress syndrome; ARF: acute respiratory failure; VA: veno-arterial; VV: veno-venous.
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ECMO Technique and Transports
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CT Examinations
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Statistical Analysis
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Ethics
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Results
CT Findings
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Table 2
Intracranial Pathology in 45 Patients Diagnosed With Computed Tomography During Extracorporeal Membrane Oxygenation Treatment
Type of Intracranial Pathology_n_ Focal hemorrhage18 Supratentorial 11 Cerebellar 5 Extraaxial 2 Focal nonhemorrhagic infarction11 Supratentorial 10 Infratentorial 1 General edema/infarction16 Total45
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Effect on Treatment
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Statistics
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Table 3
Intracranial Pathology vs. Patient Characteristics Using the Chi-Square Test for Categorical and Student’s t -Test for Numerical Values
Patient Characteristics_P_ Value Age .43 Gender .78 Cannulation type .54 Days on extracorporeal membrane oxygenation .61 Diagnosis .06 Sepsis ⁎⁎ .004 ⁎ Survival .002 ⁎
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Discussion
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Frequency and Type of Intracranial Pathology
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Risk Factors for Intracranial Pathology
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Impact on Treatment
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Conclusion
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