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

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.

Intracerebral hemorrhage in COVID-19 patients with pulmonary failure – a propensity score matched registry study

“…A systematic literature review suggested incidence of intracranial hemorrhage between 1.8-21% during veno-venous or veno-arterial ECMO. (21,22) ICU survival in our cohort (52.8%) is lower than reported by other data for severe ARDS (38%). (23) Our registry contains severely ill patients as suggested by the predicted mortality of 50.0% according to the SOFA score (24), which might explain these differences.…”

Hemostatic Management of Extracorporeal Circuits Including Cardiopulmonary Bypass and Extracorporeal Membrane Oxygenation

“…ICH is the most severe bleeding complication in patients on ECMO, with a mortality rate of 32 to 100%. 95,96 According to the 2019 ELSO registry data, incidence of ICH is 6 to 15% in pediatric patients compared with 2 to 4% in adults. The underlying mechanisms of hemorrhagic diathesis are still not completely understood due to the complexity of underlying disease-related factors and ECMO-related factors.…”

Hematologic concerns in extracorporeal membrane oxygenation

“…The circuit volume of an ECMO circuit is large volume relative to the total blood volume of neonates, giving the priming fluid in ECMO circuits a larger influence on the hematologic status of the patient 78,79 . Neonatal patients have increased rates of intracranial hemorrhage compared to adults, with rates up to 16%‐34% compared to 2%‐21% for adults 7,80‐84 . Neonatal ECMO survivors below 2 kg have been reported, although this population has an increased complication rate, including intracranial hemorrhage, and increased mortality 85 …”