Neuromonitoring detects brain injury in patients receiving extracorporeal membrane oxygenation support

Ong, Chin Siang; Etchill, Eric; Dong, Jie; Shou, Benjamin L.; Shelley, Leah; Giuliano, Katherine; Al‐Kawaz, Mais; Ritzl, Eva K.; Geocadin, Romergryko G.; Kim, Bo Soo; Bush, Errol L.; Choi, Chun Woo; Whitman, Glenn; Cho, Sung Min

doi:10.1016/j.jtcvs.2021.09.063

Cited by 46 publications

(48 citation statements)

References 15 publications

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“…In ECMO patients where MRI at 1.5T is contraindicated and transportation for HCT can be dangerous and require signi cant human resources, POC MRI allows early ABI detection, which is critical in improving ECMO survival. 4 As demonstrated, POC MRI detected ischemic strokes, one of which was not visualized with HCT, suggesting POC MRI may be a good bedside diagnostic tool for cerebral ischemia. As demonstrated in patient #1, the detection of hemorrhagic conversion in ischemic stroke needs further experience and validation, especially, when hemorrhages are small.…”

Section: Discussionmentioning

confidence: 83%

“…2,3 Protocolized neuromonitoring improves the detection of ABI and may limit its sequelae with timely management. 4 However, early diagnosis of ABI is di cult due to an inability to safely transport patients and lack of available transport personnel. Even when possible, HCT (currently the only imaging modality used), has limited sensitivity for detecting ischemic ABI.…”

Section: Introductionmentioning

confidence: 99%

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Assessing the SAfety and FEasibility of Bedside Portable Low-Field Brain Magnetic Resonance Imaging in Patients on ECMO (SAFE-MRI ECMO study) – Study Protocol and First Case Series Experience

Cho

Wilcox

Keller

et al. 2022

Preprint

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BACKGROUND To assess the safety and feasibility of imaging of the brain with a point-of-care (POC) magnetic resonance imaging (MRI) system in patients on extracorporeal membrane oxygenation (ECMO). Early detection of acute brain injury (ABI) is critical in improving survival for patients with ECMO support. METHODS Patients from a single tertiary academic ECMO center who underwent head CT (HCT), followed by POC brain MRI exams within 24 hours following HCT while on ECMO. Primary outcomes were safety and feasibility, defined as completion of MRI exam without serious adverse events (SAEs). Secondary outcome was the quality of MR images in assessing ABIs. RESULTS We report 3 consecutive adult patients (median age: 47 years; 67% male) with veno-arterial (n = 1) and veno-venous ECMO (n = 2) (VA- and VV-ECMO) support. All patients were imaged successfully without SAEs. Times to complete POC brain MRI exams were 34, 40, and 43 minutes. Two patients had ECMO suction events, resolved with fluid and repositioning. Two patients were found to have an unsuspected acute stroke, well visualized with MRI. CONCLUSIONS Adult patients with VA- or VV-ECMO support can be safely imaged with low-field POC brain MRI in the intensive care unit, allowing for the assessment of presence and timing of ABI.

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Section: Discussionmentioning

confidence: 83%

Section: Introductionmentioning

confidence: 99%

Assessing the SAfety and FEasibility of Bedside Portable Low-Field Brain Magnetic Resonance Imaging in Patients on ECMO (SAFE-MRI ECMO study) – Study Protocol and First Case Series Experience

Cho

Wilcox

Keller

et al. 2022

Preprint

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“…The ELSO registry does not collect anticoagulation data, which is an important risk factor of ICH that could not be adjusted in our analysis. Further, as suggested by previous studies, the lack of adjudication of neurological diagnosis and standardized neuromonitoring protocol across contributing centers likely underestimates ABI frequency(34). As the study was retrospective, the association between hyperoxia and ABI is not causal in the absence of information regarding the timing of ABI.…”

Section: Discussionmentioning

confidence: 96%

Arterial Oxygen and Carbon Dioxide Tension and Acute Brain Injury in Extracorporeal Cardiopulmonary Resuscitation Patients: Analysis of the Extracorporeal Life Support Organization Registry

Shou

Ong

Premraj

et al. 2022

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Objective: Acute brain injury remains common after extracorporeal cardiopulmonary resuscitation. Using a large international multicenter cohort, we investigated the impact of peri-cannulation arterial oxygen (PaO2) and carbon dioxide (PaCO2) on ABI occurrence. Design: Retrospective cohort study. Setting: Data in the Extracorporeal Life Support Organization Registry from 2009 to 2020. Patients: Adult patients (≥18 years old) who underwent extracorporeal cardiopulmonary resuscitation. Interventions: None. Measurements and Main Results: Of 3,125 patients with extracorporeal cardiopulmonary resuscitation (median age=58, 69% male), 488 (16%) experienced at least one form of acute brain injury, which included ischemic stroke, intracranial hemorrhage, seizures, and brain death. 217 (7%) experienced ischemic stroke and 88 (3%) experienced intracranial hemorrhage. The registry collects two blood gas data pre- (6 hours before) and on- (24 hours after) extracorporeal membrane oxygenation (ECMO) cannulation. Blood gas parameters were classified as: hypoxia (<60mmHg), normoxia (60-119mmHg), and mild (120-199mmHg), moderate (200-299mmHg), and severe hyperoxia (≥300mmHg); hypocarbia (<35mmHg), normocarbia (35-44mmHg), mild (45-54mmHg) and severe hypercarbia (≥55mmHg). In multivariable logistic regression analysis, pre-ECMO hypoxia (aOR=1.46, 95%CI: 1.03-2.08, p=0.04) and on-ECMO severe hyperoxia (aOR=1.55, 95%CI: 1.02-2.36, p=0.04) were associated with composite ABI. Also, on-ECMO severe hyperoxia was associated with intracranial hemorrhage (aOR=1.88, 95%CI: 1.02-3.47, p=0.04) and in-hospital mortality (aOR=3.51, 95%CI: 1.98-6.22, p<0.001). Pre- and on-ECMO PaCO2 levels were not significantly associated with composite ABI or mortality, though mild hypercarbia pre- and on-ECMO were protective of ischemic stroke and intracranial hemorrhage, respectively. Conclusions: Early severe hyperoxia (≥300mmHg) on ECMO was a significant risk factor for acute brain injury and mortality for patients undergoing extracorporeal cardiopulmonary resuscitation. Careful consideration should be given in early oxygen delivery in ECPR patients who are at risk of reperfusion injury.

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“…HCT examinations were routinely performed on these patients as part of a standardized neuromonitoring protocol [ 4 ], with the addition of POC MRI within 24 h utilizing a 64mT Swoop® MR imaging system (Hyperfine, Inc., Guilford, CT). The MR system was positioned into the patient’s room with all ICU equipment outside the magnet’s 5G safety line (Additional file 1 : Figs.…”

Section: Methodsmentioning

confidence: 99%

“…Despite rapidly expanding use [ 1 ], the therapeutic potential of ECMO is limited by significant morbidity such as acute brain injury (ABI), a devastating complication [ 2 , 3 ]. Protocolized neuromonitoring improves the detection of ABI and may limit its sequelae with timely management [ 4 ]. However, early diagnosis of ABI is difficult due to an inability to safely transport patients and lack of available transport personnel.…”

Section: Introductionmentioning

confidence: 99%

Assessing the SAfety and FEasibility of bedside portable low-field brain Magnetic Resonance Imaging in patients on ECMO (SAFE-MRI ECMO study): study protocol and first case series experience

et al. 2022

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Background To assess the safety and feasibility of imaging of the brain with a point-of-care (POC) magnetic resonance imaging (MRI) system in patients on extracorporeal membrane oxygenation (ECMO). Early detection of acute brain injury (ABI) is critical in improving survival for patients with ECMO support. Methods Patients from a single tertiary academic ECMO center who underwent head CT (HCT), followed by POC brain MRI examinations within 24 h following HCT while on ECMO. Primary outcomes were safety and feasibility, defined as completion of MRI examination without serious adverse events (SAEs). Secondary outcome was the quality of MR images in assessing ABIs. Results We report 3 consecutive adult patients (median age 47 years; 67% male) with veno-arterial (n = 1) and veno-venous ECMO (n = 2) (VA- and VV-ECMO) support. All patients were imaged successfully without SAEs. Times to complete POC brain MRI examinations were 34, 40, and 43 min. Two patients had ECMO suction events, resolved with fluid and repositioning. Two patients were found to have an unsuspected acute stroke, well visualized with MRI. Conclusions Adult patients with VA- or VV-ECMO support can be safely imaged with low-field POC brain MRI in the intensive care unit, allowing for the assessment of presence and timing of ABI.

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Neuromonitoring detects brain injury in patients receiving extracorporeal membrane oxygenation support

Cited by 46 publications

References 15 publications

Assessing the SAfety and FEasibility of Bedside Portable Low-Field Brain Magnetic Resonance Imaging in Patients on ECMO (SAFE-MRI ECMO study) – Study Protocol and First Case Series Experience

Assessing the SAfety and FEasibility of Bedside Portable Low-Field Brain Magnetic Resonance Imaging in Patients on ECMO (SAFE-MRI ECMO study) – Study Protocol and First Case Series Experience

Arterial Oxygen and Carbon Dioxide Tension and Acute Brain Injury in Extracorporeal Cardiopulmonary Resuscitation Patients: Analysis of the Extracorporeal Life Support Organization Registry

Assessing the SAfety and FEasibility of bedside portable low-field brain Magnetic Resonance Imaging in patients on ECMO (SAFE-MRI ECMO study): study protocol and first case series experience

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