Craniectomy and Traumatic Brain Injury in Children on Extracorporeal Membrane Oxygenation Support

Abstract

Severe trauma may cause refractory life-threatening respiratory failure requiring extracorporeal membrane oxygenation (ECMO). Concurrent traumatic brain injury, however, complicates the use of ECMO because of the major risk of intracranial bleeding with systemic anticoagulation. Craniotomy and/or craniectomy for hematoma evacuation during ECMO are extremely high-risk procedures secondary to ongoing anticoagulation, and there are only a few such case reports in the literature. We present the case of a child with multiple thoracic injuries and life-threatening respiratory failure supported on ECMO. She developed an intracranial hemorrhage while systemically heparinized that required emergent decannulation and bedside craniectomy for hematoma extraction. She survived with an excellent neurologic outcome. We also review the relevant literature regarding the use of ECMO in patients with polytrauma and the occurrence of craniectomy on extracorporeal support, with a focus on pediatric publications. Patients with polytrauma with brain injury can be supported on ECMO, but extreme precaution must be taken regarding anticoagulation. The intracranial complications of ECMO in this population are not infrequent, but our case report and review of the literature suggest that neurosurgical intervention should be considered in life-threatening conditions when no other alternatives are available.

Extracorporeal Life Support in Hemorrhagic Conditions: A Systematic Review

“…Through the literature search, 614 articles were found in Pubmed, 488 in Medline, 869 in Embase, and 5 by searching the references in publications included in the analysis (Figure 1). The following subgroups were created based on the bleeding conditions: 1 patient with tracheal injury, 13 11 patients with postpartum or cesarean delivery hemorrhage, 14–19 7 patients with intracranial hemorrhage, 20–25 53 patients with pulmonary hemorrhage, 5,26–66 13 patients with postpulmonary endarterectomy bleeding, 67–72 and 96 patients with bleeding trauma 51,73–96 (Table 1; see Supplementary Tables 1–5, Supplemental Digital Content, http://links.lww.com/ASAIO/A515). Overall, 183 patients were identified in 86 included publications, namely, 74 case reports, 4 case series, 7 retrospective database observational studies, and 1 preliminary results of ongoing study.…”

“…During the use of heparin in the complete ECLS, activated clotting time (ACT) targets were reported in 35 patients, 13,17,27,31,37,42,45,47,54,55,58,59,61,62,66,73,79,82,89,90,92,93 and activated partial thromboplastin time (aPTT) targets were reported in 10 patients. 20,21,26,40,73,95 In the subgroup with different anticoagulation other than heparin, ACT targets were defined in four patients, 36,38,48,52 whereas no specific mention of anticoagulation assessment was available in the other studies. 25 For 96 patients, the targets or duration of anticoagulation management was missing.…”

“…67,74,76–82,84,85,87,89,90,92–94,96 One patient received a stent in the vena cava during fluoroscopy-guided intervention. 76 Furthermore, drugs were also used to minimize coagulopathy, such as factor VII, 15,55,75,84 prothrombin, 31,63,69–71,73 and aminocaproic acid 53,54,58,73,77 (Supplemental Tables 1–5, Supplemental Digital Content, http://links.lww.com/ASAIO/A515).…”

Extracorporeal life support in pediatric trauma: a systematic review

“…In the last decade this dogma has been challenged in adult studies and has in part been driven by newer technology with improved pumps and heparin-coated lines allowing for reductions in anticoagulation 13. Several case series have described ECMO use in adult trauma patients with TBI and in extreme cases post-traumatic craniectomies have been performed while on ECMO 14 15. There has also been increasing support for heparin-free and anticoagulation-free ECMO circuits 15 16.…”

Fixed, Dilated, and Cannulated - Medical Management of Elevated Intracranial Pressures due to a Large Intracranial Hemorrhage in a Patient on Veno-Venous Extracorporeal Membrane Oxygenation: Case Report

“…To date, there are only few reports describing intracranial pressure (ICP) management in the ECMO population. 2,7 We present a novel case of a patient on V-V ECMO who developed a clinical herniation syndrome due to a large ICH in the context of rapid PaCO 2 fluctuations, with marked diffuse sulcal effacement on computed tomography (CT). The patient's pupillary and motor exam substantially improved in response to hyperosmolar therapy.…”