The Impact of Venoarterial and Venovenous Extracorporeal Membrane Oxygenation on Cerebral Metabolism in the Newborn Brain

Abstract

BackgroundExtracorporeal membrane oxygenation (ECMO) is an effective therapy for supporting infants with reversible cardiopulmonary failure. Still, survivors are at risk for long-term neurodevelopmental impairments, the cause of which is not fully understood.ObjectiveTo elucidate the effects of ECMO on the newborn brain. We hypothesized that the cerebral metabolic profile of neonates who received ECMO would differ from neonates who did not receive ECMO. To address this, we used magnetic resonance spectroscopy (1H-MRS) to investigate the effects of venoarterial and venovenous ECMO on cerebral metabolism.Methods41 neonates treated with ECMO were contrasted to 38 age-matched neonates.ResultsAll 1H-MRS data were acquired from standardized grey matter and white matter regions of interest using a short-echo (TE = 35 milliseconds), point-resolved spectroscopy sequence (PRESS) and quantitated using LCModel. Metabolite concentrations (mmol/kg) were compared across groups using multivariate analysis of covariance. Elevated creatine (p = 0.002) and choline (p = 0.005) concentrations were observed in the grey matter among neonates treated with ECMO relative to the reference group. Likewise, choline concentrations were elevated in the white matter (p = 0.003) while glutamate was reduced (p = 0.03). Contrasts between ECMO groups revealed lower osmolite concentrations (e.g. myoinositol) among the venovenous ECMO group.ConclusionNeonates who underwent ECMO were found to have an abnormal cerebral metabolic profile, with the pattern of abnormalities suggestive of an underlying inflammatory process. Additionally, neonates who underwent venovenous ECMO had low cerebral osmolite concentrations as seen in vasogenic edema.

What is new in pediatric ECMO? 2016, a year in review

“…A retrospective review of 41 neonates after VA‐ or VV‐ECMO, who were evaluated with MRI, identified an abnormal cerebral metabolic profile suggestive of an inflammatory process and/or vasogenic edema . The authors hypothesize that these subtle differences in the brains of ECMO survivors might play a role in later neurodevelopmental impairments.…”

ECMO in neonates: The association between cerebral hemodynamics with neurological function

“…In neonates, brain metabology studies have suggested a decrease in N-acetyl-aspartate and an increase in lactic acid, which were associated with adverse neurodevelopmental outcomes. However, there was no difference in the levels of N-acetyl-aspartate and lactic acid in the bilateral basal ganglia by 1H-MRS examination after ligation ( 44 , 45 ).…”

The Disconnect Between Extracorporeal Circulation and the Microcirculation: A Review

“…36 Increased counts of B and T cells during ECMO indicate upregulation of the adaptive immune system, 42 which persist post-ECMO, as reflected in elevated choline levels, although whether microglia are upregulated remains unknown, making the neurologic relevance questionable. 41 Increased inflammation has also been associated with decreased autoregulation of cerebral flow, 42 further increasing the risk of hypoperfusion and ischemic stroke.…”

“…39 Furthermore, poor circulation leads to spikes in proinflammatory responses and metabolic shifts. 40 Elevated creatinine levels from low clearance of metabolic byproducts, 41 along with increased lactate and localized oxygen desaturation indicate the onset of cerebral hypoxia. 36 Increased counts of B and T cells during ECMO indicate upregulation of the adaptive immune system, 42 which persist post-ECMO, as reflected in elevated choline levels, although whether microglia are upregulated remains unknown, making the neurologic relevance questionable.…”