Incidence, Outcome, and Predictors of Intracranial Hemorrhage in Adult Patients on Extracorporeal Membrane Oxygenation: A Systematic and Narrative Review.

Alexander Fletcher-Sandersjöö,Eric Peter Thelin,Mikael Broman,Jiri Bartek,Bo-Michael Bellander,Adrian Elmi-Terander,Marko Sallisalmi

doi:10.3389/fneur.2018.00548

Abstract

Background: Intracranial hemorrhage (ICH) is a common complication in adults treated with extracorporeal membrane oxygenation (ECMO).Objectives: The aim of this study was to conduct a systematic review of the literature on the incidence, outcome and predictors of ECMO-associated ICH in adult patients, supplemented by a narrative review of its pathophysiology, management and future perspectives.Methods: MEDLINE, EMBASE, Cochrane Database of Systematic Reviews and www.clinicaltrials.gov were systematically searched. Studies that reported incidence, outcome or predictors of ECMO-associated ICH in adults (≥18 years) were eligible for inclusion.Results: Twenty five articles were included in the systematic review. The incidence of ECMO-associated ICH varied between 1.8 and 21 %. Mortality rates in ICH-cohorts varied between 32 and 100 %, with a relative risk of mortality of 1.27–4.43 compared to non-ICH cohorts. An increased risk of ICH was associated with ECMO-duration, antithrombotic therapy, altered intrinsic coagulation, renal failure, need of blood products, rapid hypercapnia at ECMO initiation, and even pre-ECMO morbidity.Conclusions: ICH is a common complication in adults treated with ECMO and associated with increased mortality. Treating an ICH during ECMO represents a balance between pro- and anticoagulatory demands. Neurosurgical treatment is associated with severe morbidity, but has been successful in selected cases. Future studies should aim at investigating the validity and feasibility of non-invasive monitoring in early detection of ECMO-associated ICH.

Highlights

Intracranial hemorrhage (ICH) is a common complication in adults treated with extracorporeal membrane oxygenation (ECMO)
Our results indicate that ICH in ECMO patients is generally associated with increased mortality, but that the mortality rates varied between studies
We have identified nine cases of surgical intervention in adult patients with ECMO-associated ICH [23, 55,56,57,58], with two survivors [23, 57]

Summary

Introduction

Intracranial hemorrhage (ICH) is a common complication in adults treated with extracorporeal membrane oxygenation (ECMO). Extracorporeal membrane oxygenation (ECMO) is being used more frequently in adults [1,2,3,4,5], and is recognized as an important part in the treatment of severe reversible refractory respiratory and/or circulatory failure [1,2,3]. The treatment itself is associated with significant morbidity and mortality [6], and intracranial hemorrhage (ICH) is one of the most frequent serious adverse events occurring during ECMO support [7,8,9]. During the H1N1 pandemic in Australia and New Zealand, ICH was the most common cause of death among ECMO treated patients [10]. There are no established guidelines on its detection, prevention or management [11]

Objectives

Methods

Results

Discussion

Conclusion