Prognostic Factors Associated With Intracranial Hemorrhage and Ischemic Stroke During Venovenous Extracorporeal Membrane Oxygenation: A Systematic Review

Sonny Thiara; Alexander J Willms; Alexandre Tran; Anish R Mitra; Mypinder Sekhon; Ryan Hoiland; Donald Griesdale

doi:10.1097/CCM.0000000000006520

Prognostic Factors Associated With Intracranial Hemorrhage and Ischemic Stroke During Venovenous Extracorporeal Membrane Oxygenation: A Systematic Review

Crit Care Med. 2024 Dec 11. doi: 10.1097/CCM.0000000000006520. Online ahead of print.

Authors

Sonny Thiara¹, Alexander J Willms², Alexandre Tran^{3

4

5}, Anish R Mitra⁶, Mypinder Sekhon¹, Ryan Hoiland^{1

7

8

9}, Donald Griesdale¹⁰

Affiliations

¹ Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada.
² Department of Medicine, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada.
³ Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.
⁴ Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
⁵ Department of Surgery, University of Ottawa, Ottawa, ON, Canada.
⁶ Department of Critical Care, Faculty of Medicine, Surrey Memorial Hospital, Surrey, BC, Canada.
⁷ Collaborative Entity for REsearching BRain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada.
⁸ Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada.
⁹ Division of Neurosurgery, Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.
¹⁰ Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada.

PMID: 39660976
DOI: 10.1097/CCM.0000000000006520

Abstract

Objectives: Venovenous extracorporeal membrane oxygenation (ECMO) is a life-preserving intervention for patients with respiratory failure refractory to conventional mechanical ventilation. Intracranial hemorrhage (ICH) and ischemic stroke are life-threatening complications associated with venovenous ECMO. Despite this, little is known regarding the prognostic factors associated with these adverse neurologic events. We conducted a systematic review that characterizes these predictors of ICH and ischemic stroke during venovenous ECMO.

Data sources: We conducted a comprehensive search of MEDLINE and Embase via the Ovid interface.

Study selection: We developed and performed a literature search to identify articles that evaluated ICH and ischemic stroke in adult patients undergoing venovenous ECMO. We excluded studies based on design, target population, and outcomes.

Data extraction: Data were extracted manually by one reviewer. Risk of bias assessment was completed using the Quality in Prognostic Studies approach for each included study. Prognostic factors associated with ICH and ischemic stroke that were identified in two or more included studies were evaluated through the Grading of Recommendations, Assessment, Development, and Evaluation approach.

Data synthesis: Three hundred thirty-three studies met criteria for screening. Seventeen studies met final inclusion criteria. Seventeen studies addressed predictors of ICH. Five studies demonstrated an increased risk of ICH with lower pH before venovenous ECMO (moderate certainty). Five studies demonstrated an increased risk of ICH with greater decreases in Paco2 pre- to post-venovenous ECMO cannulation (moderate certainty). Four studies addressed predictors of ischemic stroke; however, there were no predictors of ischemic stroke identified in two or more of the included studies.

Conclusions: This systematic review demonstrates that abnormalities and changes in blood gas parameters from pre- to post-venovenous ECMO cannulation are probably associated with increased risk of ICH. Additional high-quality studies dedicated to probable predictors of these adverse neurologic events are crucial to understanding the pathophysiology of ICH and ischemic stroke in this population and informing clinical practice to mitigate the risk of these life-threatening events.