Challenges of acute phase neuroimaging in VA-ECMO, pitfalls and alternative imaging options

Nour, Hassan Aboul; Poyiadji, Neo; Mohamed, Ghada A; Alsrouji, Owais; Ramadan, Ahmad Riad; Griffith, Brent; Marin, Horia; Chebl, Alex

doi:10.1177/1591019920962881

Cited by 6 publications

(11 citation statements)

References 16 publications

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“…The 2017 ELSO guidelines recommend sedation for at least the first 12–24 h of ECMO initiation to prevent air embolism from spontaneous respirations as well as for patient comfort [ 17 ]. Thus, the sensitivity of the neurologic exam in patients on ECMO is often compromised due to the use of sedatives, analgesics and sometimes paralytics [ 18 , 19 ]. The combined central nervous system (CNS) depression due to sedatives and analgesics reduces the level of consciousness and precludes the assessment of higher cortical function.…”

Section: Methodsmentioning

confidence: 99%

“…Obtaining neuroimaging to investigate suspected neurological disturbances in ECMO patients poses a challenge. From a technical perspective, contrast-based imaging modalities can be particularly misleading due to ECMO [ 19 , 20 ]. Logistically, the severity of the critical illness and the degree of mechanical support in patients supported by ECMO poses a challenge for safe transport to radiological testing areas [ 18 ].…”

Section: Methodsmentioning

confidence: 99%

“…Limited studies identify challenges facing contrast-based neuroimaging in ECMO patients including computed tomography angiography (CTA) of the head and neck, CT perfusion (CTP) and conventional cerebral angiograms (CCA) [ 19 , 20 ]. This can become an issue with distinct sites of V-AECMO cannulation including outflow cannulas placed in the common iliac or axillary arteries.…”

Section: Ct Angiography Ct Perfusion and Conventional Cerebral Angiog...mentioning

confidence: 99%

“…In our experience cannulation through the axillary artery presents an issue of high-pressure non-opacified blood flow competing with the systemic contrast-opacified blood causing unilateral non-opacification of the extracranial and intracranial vessels. The CTA and CTP resulted in false positives mimicking LVO with irreversibly infarcted tissue, respectively [ 19 ]. CCA can demonstrate the reversal of flow in the brachiocephalic and subclavian arteries in patients with right axillary cannulation [ 19 ].…”

Section: Ct Angiography Ct Perfusion and Conventional Cerebral Angiog...mentioning

confidence: 99%

“…The CTA and CTP resulted in false positives mimicking LVO with irreversibly infarcted tissue, respectively [ 19 ]. CCA can demonstrate the reversal of flow in the brachiocephalic and subclavian arteries in patients with right axillary cannulation [ 19 ]. Another group has shown similar disturbances of hemodynamics from V-A ECMO where the outflow cannula is in the common iliac artery.…”

Section: Ct Angiography Ct Perfusion and Conventional Cerebral Angiog...mentioning

confidence: 99%

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Neurological monitoring in ECMO patients: current state of practice, challenges and lessons

et al. 2023

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Background Extracorporeal membrane oxygenation (ECMO) in critically ill patients serves as a management option for end-stage cardiorespiratory failure in medical and surgical conditions. Patients on ECMO are at a high risk of neurologic adverse events including intracranial hemorrhage (ICH), acute ischemic stroke (AIS), seizures, diffuse cerebral edema, and hypoxic brain injury. Standard approaches to neurological monitoring for patients receiving ECMO support can be challenging for multiple reasons, including the severity of critical illness, deep sedation, and/or paralysis. This narrative literature review provides an overview of the current landscape for neurological monitoring in this population. Methods A literature search using PubMed was used to aid the understanding of the landscape of published literature in the area of neurological monitoring in ECMO patients. Results Review articles, cohort studies, case series, and individual reports were identified. A total of 73 varied manuscripts were summarized and included in this review which presents the challenges and strategies for performing neurological monitoring in this population. Conclusion Neurological monitoring in ECMO is an area of interest to many clinicians, however, the literature is limited, heterogenous, and lacks consensus on the best monitoring practices. The evidence for optimal neurological monitoring that could impact clinical decisions and functional outcomes is lacking. Additional studies are needed to identify effective measures of neurological monitoring while on ECMO. Supplementary Information The online version contains supplementary material available at 10.1007/s13760-023-02193-2.

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Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Ct Angiography Ct Perfusion and Conventional Cerebral Angiog...mentioning

confidence: 99%

Section: Ct Angiography Ct Perfusion and Conventional Cerebral Angiog...mentioning

confidence: 99%

Section: Ct Angiography Ct Perfusion and Conventional Cerebral Angiog...mentioning

confidence: 99%

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Neurological monitoring in ECMO patients: current state of practice, challenges and lessons

et al. 2023

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Neuromonitoring During ECMO Support in Children

Felling

Kamerkar²,

Friedman³

et al. 2023

Neurocrit Care

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Cerebral pseudoinfarction due to venoarterial extracorporeal membrane oxygenation: A case report

Xu,

Yan,

Jin

et al. 2024

World J Clin Cases

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BACKGROUND Neurological complications are common in the management of venoarterial extracorporeal membrane oxygenation (VA-ECMO), with most patients requiring sedation and intubation, limiting the assessment of neurological function. There-fore, we must rely on advanced neuroimaging techniques, such as computed tomography angiography (CTA) and computed tomography perfusion (CTP). Because ECMO changes the normal blood flow pattern, it may interfere with the contrast medium in some special cases, leading to artifacts and ultimately mis-leading clinical decisions. CASE SUMMARY A 61-year-old man presented to a local hospital with chest tightness and pain 1 d prior to presentation. The patient was treated with VA-ECMO after sudden car-diac and respiratory arrest at a local hospital. For further treatment, the patient was transferred to our hospital. The initial consciousness assessment was not clear, and routine CTP was performed to understand the intracranial changes, which suggested a large area of cerebral infarction on the right side; however, the cerebral oxygen was not consistent with the CTP results, and the reexamination of CTA still suggested a right cerebral infarction. To identify this difference, bedside transcranial Doppler was performed, and the blood flow on both sides was different. By reducing the ECMO flow, CTP reexamination showed that the results were normal and consistent with the clinical results. On day 3, the patient was alert and showed good limb movements. CONCLUSION In patients with peripheral VA-ECMO, cerebral perfusion confirmed by CTP and CTA may lead to false cerebral infarction.

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Challenges of acute phase neuroimaging in VA-ECMO, pitfalls and alternative imaging options

Cited by 6 publications

References 16 publications

Neurological monitoring in ECMO patients: current state of practice, challenges and lessons

Neurological monitoring in ECMO patients: current state of practice, challenges and lessons

Neuromonitoring During ECMO Support in Children

Cerebral pseudoinfarction due to venoarterial extracorporeal membrane oxygenation: A case report

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