Routine Neuroimaging: Understanding Brain Injury in Pediatric Extracorporeal Membrane Oxygenation*

Abstract

This project aims to describe brain injuries on routine neuroimaging in a large single-center neonatal and pediatric cohort supported by extracorporeal membrane oxygenation. The study also aims to examine the association of these injuries with neurocognitive outcomes in survivors and identify laboratory findings associated with neurologic injury. DESIGN:Retrospective observational single-center cohort study. SETTING: Tertiary care PICU. PATIENTS: Pediatric patients with noncardiac indications for extracorporeal membrane oxygenation supported by venoarterial or venovenous extracorporeal membrane oxygenation, with on-extracorporeal membrane oxygenation brain CT or postextracorporeal membrane oxygenation brain CT/MRI. INTERVENTIONS: Extracorporeal membrane oxygenation support. MEASUREMENTS AND MAIN RESULTS:Occurrence of brain injury on CT and MRI was reviewed; injuries were scored. Clinical and laboratory results associated with injury were identified. Survivor neurocognitive outcomes were obtained using the Pediatric Overall Performance Category scale and Pediatric Cerebral Performance Category scale. Of 132 imaged patients, 98 (74%) had radiological evidence of brain injury. Mean injury score was 6.5 (± 3.8). Head ultrasounds and clinician suspicion performed poorly in suspecting the presence of injury. Of 104 respondents to neurodevelopmental assessments, 61 (59%) had normal scores; 12.5%, 17%, and 11.5% had mild, moderate, or severe disability. A neuroimaging score greater than 10 was associated with an unfavorable outcome on the Pediatric Cerebral Performance Category (odds ratio, 3.4; p < 0.01) and Pediatric Overall Performance Category (odds ratio, 1.7; p < 0.05). Ischemic injury correlated with worse neurodevelopmental outcome. Preextracorporeal membrane oxygenation lactate, Vasoactive-Inotropic Scores, transaminitis, elevated bilirubin and creatinine levels, and thrombocytopenia were associated with injury occurrence. CONCLUSIONS:Brain injury is frequent in extracorporeal membrane oxygenation patients, although the majority of survivors have favorable neurocognitive outcomes. More research is needed in order to understand the etiology of such injuries. Head ultrasound and clinician suspicion are not sensitive in detecting extracorporeal membrane oxygenation-related brain injuries. Protocolizing postextracorporeal membrane oxygenation imaging with brain MRI allows the identification of injuries and provision of timely neurocognitive intervention.

Association Between Disrupted Cerebral Autoregulation and Radiographic Neurologic Injury for Children on Extracorporeal Membrane Oxygenation: A Prospective Pilot Study

“…High NIS (10 or more) has been associated with poor developmental outcomes among children who require ECMO. 4 To augment the clinical implications of our analysis, patients were stratified into high NIS group (10 or more) or low NIS group (<10). The Median DCSx scores for each group were determined and Wilcoxon rank-sum test was used to test for difference in DCSx between these groups.…”

“…Despite possible differences in severity of illness before ECMO, intra-ECMO blood flow, and patient populations exposed to VA or VV ECMO, both forms of ECMO support are associated with risk for severe neurologic injuries. 4…”

“…3 In studies with standardized post-ECMO neuroimaging, moderate (38%) or severe (30%) neurologic injury occurred in the majority of survivors. 4 Long-term neurocognitive deficits have been estimated to occur in 50% of pediatric ECMO survivors. 5 While ECMO use is increasing, the incidence of serious neurologic complications has not declined.…”

Why Clinicians Should Adopt Routine Neuroimaging After Extracorporeal Membrane Oxygenation*

“…In the current study by Farhat et al (6), the investigators use a different lens. They tackle questions often expressed by a front clinician while in the ICU setting: “how frequent are brain abnormalities on routine neuroimaging after ECMO,” “what is the value of routine neuroimaging after ECMO if my patient is otherwise ‘doing fine,’ ‘what does it mean for the patient?’, and ‘which patient is most at risk of having these abnormalities?’.”…”

“…However, reports that evaluate factors related to survivorship beyond the index hospitalization in noncardiac patients exposed to ECMO are only recently emerging (5). The study by Farhat et al (6), published in this issue of Critical Care Medicine , fills this gap. In addition, the value of this investigation is that it uses information obtainable by most frontline busy clinicians.…”