Epidemiology of ischemic stroke and hemorrhagic stroke in venoarterial extracorporeal membrane oxygenation

Patient Characteristics and Extracorporeal Membrane Oxygenation Outcomes at Nelson Mandela Children's Hospital: A South African Experience

This study aimed to describe patient characteristics, mortality, and morbidity outcomes in children at a South African extracorporeal membrane oxygenation (ECMO) center. Fifty-seven patients required ECMO from 2018 to 2023 at the Nelson Mandela Children's Hospital in Johannesburg; eight neonates (14%), 35 infants (61.4%) 29 days-1 year, 11 (19%) aged 1-5 years, and three (5%) over 5 years. Fifty patients received venoarterial (VA)-ECMO (88%), six (11%) received venovenous (VV)-ECMO, and one patient (2%) was converted from VV- to VA-ECMO. Nineteen (33%) required ECMO for an underlying congenital cardiac lesion; 34 (60%) for respiratory indications and four (7%) post-thoracic surgery. The overall mortality rate was 54.4% with no significant difference in survival between patients on VA-ECMO compared with VV-ECMO. Differences in patient age, sex, nutrition, and human immunodeficiency virus (HIV) status were not significantly associated with mortality. The median length of ECMO run was 14 days, with significantly longer runs in respiratory cases. The most common patient morbidities experienced on ECMO were fluid overload (92%) and infection (84%). Neurologic sequelae occurred in 40% of cases. Mechanical complications were rare. Our findings highlight that ECMO can be offered successfully despite challenges experienced in resource-limited settings. Future research should focus on specific prognostic factors of relevance to our populations.

Focal Cerebral Injury in Pediatric Extracorporeal Life Support: Timing in Relation to Cannulation or Other Circuit Events in a Single-Center Retrospective Series, 2015-2023

OBJECTIVES

To review the timing of extracorporeal life support (ECLS)-related focal cerebral injury (FCI) in relation to circuit interruptions in children and young adults.

DESIGN

Retrospective study from January 1, 2015, to December 31, 2023.

SETTING

Single-center academic children's hospital.

PATIENTS

Children and young adults younger than 21 years old who had neuroimaging during or after ECLS. Multiple ECLS runs in individual patients were analyzed as distinct runs.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

FCI was radiographically defined as lateralized ischemia or hemorrhagic parenchymal brain injury greater than 1 cm3 or as subdural hemorrhage causing midline shift. Timing of clinical FCI documentation was abstracted from chart review and based on times of new-onset focal neurologic examination findings, focal electroencephalography findings, or incidental discovery on imaging. In instances of FCI, electroencephalography reports and inpatient progress notes were reviewed to identify electroencephalography-related timing of FCI. Institutional ECLS registry data were used to identify times of circuit events (i.e., cannulation, decannulation, and circuit interruptions). The probable time course of FCI after circuit events was evaluated in the ECLS runs with an imaging diagnosis of FCI, and summarized using cumulative distribution with 95% CI. In 101 ECLS runs in 94 patients with brain imaging, 20 had FCI: ischemic stroke in 12, intraparenchymal hemorrhage in six, and subdural hemorrhage with midline shift in two. Eighteen FCIs were documented within 48 hours of a circuit event. Among 13 FCIs with electroencephalography recording at the time of FCIs, eight had new-onset subclinical electroencephalography abnormality as the initial documented sign of FCI. The presence of FCI vs. not was associated with lower survival to decannulation (p = 0.007).

CONCLUSIONS

In this single-center retrospective series, 2015-2023, the majority of ECLS-related FCIs were evident within 48 hours of ECLS cannulation, decannulation, or circuit interruption. These events warrant increased surveillance for neurologic complications.

Ultra-Low-Field Portable Brain Magnetic Resonance Imaging in Patients With Cardiac Devices: Current Evidence and Future Directions

The use of cardiac devices, including mechanical circulatory support (MCS), cardiac implantable electronic devices (CIEDs), and pacing wires, has increased and significantly improved survival in patients with severe cardiac failure. However, these devices are frequently associated with acute brain injuries (ABIs) including ischemic strokes, intracranial hemorrhages, seizures, and hypoxic-ischemic brain injury which contribute substantially to morbidity and mortality. Computed tomography (CT) and magnetic resonance imaging (MRI), the standard imaging modalities for ABI diagnosis, can pose significant challenges in this patient population due to the risks associated with patient transportation and the incompatibility of ferromagnetic components of certain cardiac devices with high magnetic field of the MRI. This review discusses the application of Ultralow-field portable MRI (ULF-pMRI), which operates at much lower magnetic field (0.064 T), with the potential to allow safe bedside imaging of critically ill patients. In this review, we detail the clinical studies and research findings defining the safety, feasibility, and diagnostic utility of ULF-pMRI in detecting ABI in the critically ill. We further discuss the potential broader applications of ULF-pMRI, as a standard diagnostic tool for neurocritical care in patients with cardiac devices. The integration of such technology into current practice promises to enhance diagnostic accuracy, improve patient outcomes, and optimize healthcare resources.

Exploring the potential of machine learning and magnetic resonance imaging in early stroke diagnosis: a bibliometric analysis (2004-2023)

Objective

To examine the focal areas of research in the early diagnosis of stroke through machine learning identification of magnetic resonance imaging characteristics from 2004 to 2023.

Methods

Data were gathered from the Science Citation Index-Expanded (SCI-E) within the Web of Science Core Collection (WoSCC). Utilizing CiteSpace 6.2.R6, a thorough analysis was conducted, encompassing publications, authors, cited authors, countries, institutions, cited journals, references, and keywords. This investigation covered the period from 2004 to 2023, with the data retrieval completed on December 1, 2023, in a single day.

Results

In total, 395 articles were incorporated into the analysis. Prior to 2015, the annual publication count was under 10, but a significant surge in publications was observed post-2015. Institutions and authors from the USA and China have established themselves as mature academic entities on a global scale, forging extensive collaborative networks with other institutions. High-impact journals in this field predominantly feature in top-tier publications, indicating a consensus in the medical community on the application of machine learning for early stroke diagnosis. "deep learning," "magnetic resonance imaging," and "stroke" emerged as the most attention-gathering keywords among researchers. The development in this field is marked by a coexisting pattern of interdisciplinary integration and refinement within major disciplinary branches.

Conclusion

The application of machine learning in the early prediction and personalized medical plans for stroke patients using neuroimaging characteristics offers significant value. The most notable research hotspots currently are the optimal selection of neural imaging markers and the most suitable machine learning algorithm models.

Incidence and risk factors associated with stroke when utilizing peripheral VA-ECMO

BACKGROUND

Mechanical circulatory support with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has brought forward a paradigm shift in the management of cardiogenic shock. Neurological complications associated with VA-ECMO represent a significant source of morbidity and mortality and serve as a limiting factor in its application and duration of use.

METHODS

We performed a single-center retrospective case-control study of patients who developed stroke while managed with peripheral VA-ECMO from January 2018 to September 2022 at a quaternary center. We included consecutive patients above the age of 18 who were admitted to the cardiac intensive care unit and were managed with peripheral VA-ECMO. All patients who developed a stroke while on VA-ECMO were included in the case cohort, and compared to those who did not suffer stroke. Multivariable logistic regression was performed to identify risk factors associated with stroke on VA-ECMO. In-hospital outcomes were assessed out to 30 days.

RESULTS

A total 244 patients were included in the final analysis, 36 (14.7 %) of whom developed stroke on VA-ECMO. Ischemic stroke was seen in 20 patients (55.6 %) whereas hemorrhagic stroke was seen in 16 patients (44.4 %). The use of P2Y12 antagonists (aOR 2.70, p = 0.019), limb ischemia (aOR 4.41, p = 0.002), and blood transfusion requirement (aOR 8.55, p = 0.041) were independently associated with development of stroke on VA-ECMO. Female sex trended towards statistical significance (aOR 2.19, p = 0.053) while age was not independently associated with development of stroke on VA-ECMO. There was no significant association between stroke development and outcomes of VA-ECMO duration, hospital length of stay, and all-cause mortality out to 30-days.

CONCLUSIONS

VA-ECMO carried a considerable risk of neurological complications. Mortality and duration of hemodynamic support was not associated with stroke risk. Awareness regarding stroke risk is imperative in facilitating early identification and management of ischemic and hemorrhagic stroke. Research involving clinical trials and multicenter studies are necessary to empower centers in mitigating this source of significant morbidity and mortality in patients on mechanical circulatory support.

Efficacy, safety, and effect on platelet activation of the timing of administration of tirofiban in patients with acute ischemic stroke

OBJECTIVE

To evaluate the efficacy, safety, and effects on platelet activation of tirofiban administered at different times in patients with acute ischemic stroke, with the goal of providing precise guidance for clinical treatment timing.

METHODS

A total of 262 patients with acute ischemic stroke admitted to No. 215 Hospital of Shaanxi Nuclear Industry between January 2021 and June 2023 were retrospectively analyzed. Patients were divided into an early treatment group (ETG, n = 124) and a late treatment group (LTG, n = 138) based on the timing of tirofiban administration. The ETG received tirofiban within 6 hours after thrombolysis, while the LTG received it 6 to 24 hours after thrombolysis. Clinical efficacy was evaluated post-treatment, and adverse reactions during treatment were recorded. Comparisons were made for pre- and post-treatment National Institutes of Health Stroke Scale (NIHSS) scores, Modified Rankin Scale (mRS) scores, neurological function markers, coagulation factors, inflammatory markers, and homocysteine (Hcy) levels. Correlations between efficacy and post-treatment indicators were analyzed, and logistic regression identified factors influencing outcome.

RESULTS

The ETG demonstrated significantly better overall efficacy than the LTG (P = 0.004). Post-treatment NIHSS and mRS scores, neuron-specific enolase (NSE), platelet-activating factor (PAF), high-sensitivity C-reactive protein (hs-CRP), Hcy, and interleukin-1β (IL-1β) levels were significantly lower in the ETG, while brain-derived neurotrophic factor (BDNF) levels were higher (all P < 0.001). Clinical efficacy correlated significantly with post-treatment mRS scores, PAF levels, and Hcy levels (all P < 0.001). The ETG also had significantly lower rates of re-occlusion (P = 0.001), cardiopulmonary complications (P = 0.004), and symptomatic cerebral hemorrhage (P = 0.035). Logistic regression showed that the LTG was associated with reduced efficacy (β = -4.469, P = 0.019), while higher post-treatment PAF (β = 2.437, P < 0.001) and Hcy levels (β = 1.782, P = 0.013) were linked to poorer outcome.

CONCLUSION

Early administration of tirofiban in acute ischemic stroke offers significant clinical benefits, including improved neurological function and enhanced daily living abilities, with reduced inflammatory response and complications.

Plasma brain-related biomarkers and potential therapeutic targets in pediatric ECMO

Extracorporeal membrane oxygenation (ECMO) is a technique used to support severe cardiopulmonary failure. Its potential life-saving benefits are tempered by the significant risk for acute brain injury (ABI), from both primary pathophysiologic factors and ECMO-related complications through central nervous system cellular injury, blood-brain barrier dysfunction (BBB), systemic inflammation and neuroinflammation, and coagulopathy. Plasma biomarkers are an emerging tool used to stratify risk for and diagnose ABI, and prognosticate neurofunctional outcomes. Components of the neurovascular unit have been rational targets for this inquiry in ECMO. Central nervous system (CNS) neuronal and astroglial cellular-derived neuron-specific enolase (NSE), tau, glial fibrillary acidic protein (GFAP) and S100β elevations have been detected in ABI and are associated with poorer outcomes. Evidence of BBB breakdown through peripheral blood detection of CNS cellular components NSE, GFAP, and S100β, as well as evidence of elevated BBB components vWF and PDGFRβ are associated with higher mortality and worse neurofunctional outcomes. Higher concentrations of pro-inflammatory cytokines (IL-1β, IL-6, IFN-γ, TNF-α) are associated with abnormal neuroimaging, and proteomic expression panels reveal different coagulation and inflammatory responses. Abnormal coagulation profiles are common in ECMO with ongoing studies attempting to describe specific abnormalities either being causal or associated with neurologic outcomes; vWF has shown some promise. Understanding these mechanisms of injury through biomarker analysis supports potential neuroprotective strategies such as individualized blood pressure targets, judicious hypercarbia and hypoxemia correction, and immunomodulation (inhaled hydrogen and N-acetylcysteine). Further research continues to elucidate the role of biomarkers as predictors, prognosticators, and therapeutic targets.

Impact of complications on survival outcomes in different temporary mechanical circulatory support techniques: A large retrospective cohort study of cardiac surgical and nonsurgical patients

BACKGROUND

Temporary mechanical circulatory support (tMCS) has become a standard treatment in cardiogenic shock but is associated with high complication rates. This study analyzes common complications associated with modern tMCS devices and their impact on mortality depending on the tMCS approach.

METHODS

We conducted a retrospective single-center analysis of patients with all-cause cardiogenic shock treated with veno-arterial extracorporeal life support, microaxial flow pump, and a combination of both (ECMELLA). The primary outcome was the impact of cumulative complications on mortality, evaluated separately for nonsurgical (non-PCCS) and cardiac surgical (PCCS) patients. Secondary outcomes included the impact of complications on mortality stratified by tMCS type and rates of bleeding, the need for renal replacement therapy (RRT), hemolysis, neurological complications, bloodstream infections, and ischemic limb complications.

RESULTS

We included 493 patients, totaling 4,881 days on tMCS support. Non-PCCS patients with 1 complication had a hazard ratio (HR) of 1.92 (95% confidence interval [CI]: 1.22, 3.00, p = 0.004) for mortality and 3.73 (95% CI: 2.48, 5.60, p < 0.001) for 2 or more complications compared to those without complications. In PCCS patients, 1 complication was associated with an HR of 2.22 (95% CI: 1.29, 3.81, p = 0.004) and 3.44 (95% CI: 2.04, 5.78, p < 0.001) for 2 or more complications. The most common complications in both non-PCCS and PCCS patients were bleeding (33% and 60%), need for RRT (31% and 43%), and severe hemolysis (26% and 35%).

CONCLUSION

Complications among tMCS-treated patients are common and clearly associated with an elevated mortality risk.

Neurological Monitoring and Management for Adult Extracorporeal Membrane Oxygenation Patients: Extracorporeal Life Support Organization Consensus Guidelines

BACKGROUND

Critical care of patients on extracorporeal membrane oxygenation (ECMO) with acute brain injury (ABI) is notable for a lack of high-quality clinical evidence. Here, we offer guidelines for neurological care (neurological monitoring and management) of adults during and after ECMO support.

METHODS

These guidelines are based on clinical practice consensus recommendations and scientific statements. We convened an international multidisciplinary consensus panel including 30 clinician-scientists with expertise in ECMO from all chapters of the Extracorporeal Life Support Organization (ELSO). We used a modified Delphi process with three rounds of voting and asked panelists to assess the recommendation levels.

RESULTS

We identified five key clinical areas needing guidance: (1) neurological monitoring, (2) post-cannulation early physiological targets and ABI, (3) neurological therapy including medical and surgical intervention, (4) neurological prognostication, and (5) neurological follow-up and outcomes. The consensus produced 30 statements and recommendations regarding key clinical areas. We identified several knowledge gaps to shape future research efforts.

CONCLUSIONS

The impact of ABI on morbidity and mortality in ECMO patients is significant. Particularly, early detection and timely intervention are crucial for improving outcomes. These consensus recommendations and scientific statements serve to guide the neurological monitoring and prevention of ABI, and management strategy of ECMO-associated ABI.

Spinal Cord Infarction During Extracorporeal Membrane Oxygenation：A Case Series and Review of the Literature

Background: Little is known about extracorporeal membrane oxygenation (ECMO)-related spinal cord infarction (SCI), and reports regarding this rare and catastrophic complication are rare. Here, we report two cases of ECMO-related SCI that occurred between April and December 2023. Data were collected from patients' medical records, with SCI as the endpoint. We reviewed previously published reports by searching PubMed and summarizing the findings. Case summary: One female patient presenting with multiple traumas required oxygenation support through veno-venous ECMO (VV ECMO) due to pulmonary hemorrhage, while one male patient required circulatory support via veno-arterial ECMO (VA ECMO) concurrently with an intra-aortic balloon pump due to cardiac arrest. Neither patient had preexisting neurological deficits; however, upon weaning from ECMO, they presented with severe neurological deficits of uncertain etiology, subsequently confirmed as SCI using magnetic resonance imaging. Conclusion: ECMO-related SCI remains elusive and intricate, and this is the first report of adult VV ECMO-related SCI.

Impact of Left Ventricular Venting on Acute Brain Injury in Patients with Cardiogenic Shock: An Extracorporeal Life Support Organization Registry Analysis

Background

While left ventricular (LV) venting reduces LV distension in cardiogenic shock patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO), it may also amplify risk of acute brain injury (ABI). We investigated the hypothesis that LV venting is associated with increased risk of ABI. We also compared ABI risk of the two most common LV venting strategies, percutaneous microaxial flow pump (mAFP) and intra-aortic balloon pump (IABP).

Methods

The Extracorporeal Life Support Organization registry was queried for patients on peripheral VA-ECMO for cardiogenic shock (2013-2024). ABI was defined as hypoxic-ischemic brain injury, ischemic stroke, or intracranial hemorrhage. Secondary outcome was hospital mortality. We compared no LV venting with 1) LV venting, 2) mAFP, and 3) IABP using multivariable logistic regression. To compare ABI risk of mAFP vs. IABP, propensity score matching was performed.

Results

Of 13,276 patients (median age=58.2, 69.9% male), 1,456 (11.0%) received LV venting (65.5% mAFP and 29.9% IABP), and 525 (4.0%) had ABI. After multivariable regression, LV-vented patients had increased odds of ABI (adjusted odds ratio (aOR)=1.76, 95% CI=1.29, 2.37, p<0.001) but no difference in mortality (aOR=1.08, 95% CI=0.91-1.28, p=0.39) compared to non-LV-vented patients. In the propensity- matched cohort of IABP (n=231) vs. mAFP (n=231) patients, there was no significant difference in odds of ABI (aOR=1.35, 95%CI=0.69-2.71, p=0.39) or mortality (aOR=0.88, 95%CI=0.58-1.31, p=0.52).

Conclusions

LV venting was associated with increased odds of ABI but not mortality in patients receiving peripheral VA-ECMO for cardiogenic shock. There was no difference in odds of ABI or mortality for IABP vs. mAFP patients.

Clinical Perspective

In patients receiving peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) for cardiogenic shock, left ventricular venting is associated with increased odds of acute brain injury (ABI) but not mortality. However, mode of venting-intra-aortic balloon pump (IABP) or percutaneous microaxial flow pump (mAFP)-does not appear to impact either odds of ABI or mortality. These findings highlight a link between venting strategies and neurological outcomes in this high-risk population. Clinicians must weigh the benefits of venting against ABI risk when managing neurocritically ill patients, though our findings provide reassurance clinicians that both IABP and mAFP may offer comparable neurologic safety profiles.

FLAIR vascular hyperintensity is associated with functional outcome in patients with ischemic stroke receiving endovascular treatment: a meta-analysis

Background

Fluid-attenuated inversion recovery (FLAIR) vascular hyperintensity (FVH) might be useful for predicting and functional outcome in ischemic stroke patients after endovascular thrombectomy (EVT), but its clinical benefit remains controversial. Thus, this study aimed to evaluate the association of FVH on prognosis in ischemic stroke patients who received EVT.

Methods

PubMed, Embase, Cochrane Library, Web of Science, and Wanfang databases were searched for potentially eligible studies published up to March 2024. Pooled standard mean difference (SMD), risk ratios (RR) with 95% confidence intervals (CI) were employed to assess the association of FVH on prognosis in ischemic stroke patients who received EVT. All statistical analyses were conducted using STATA 12.0 software.

Results

A total of 10 studies were included in our study. The results indicated that higher FVH score were associated with better prognosis (SMD: 0.80, 95% CI 0.63-0.97). Moreover, the presence of FVH was significant associated with better functional outcome in ischemic stroke patients who received EVT (RR: 0.68, 95% CI, 0.58-0.79).

Conclusion

The current meta-analysis suggests that FVH is related the prognosis of ischemic stroke patients after EVT.

Oltipraz attenuated cerebral ischemia-reperfusion injury through inhibiting the oxidative stress and ferroptosis in mice

Oltipraz (OPZ) is a synthetic dithiolethione and is considered a novel activator of nuclear factor E2-related factor 2 (Nrf2). Increasing evidence indicates that Nrf2 protects against cerebral ischemia/reperfusion (I/R) injury by antagonizing ferroptosis and lipid peroxidation. However, the protective effects of OPZ on cerebral I/R injury remain to be elucidated. We investigated the in vitro and in vivo neuroprotective effects of OPZ. Mice were subjected to middle cerebral artery occlusion/reperfusion (MCAO/R) to construct an in vivo model and PC12 cells were exposed to oxygen and glucose deprivation/reoxygenation (OGD/R) to establish an in vitro model. OPZ administration reduced the infarct volume and brain water content, and alleviated the neurological deficit of MCAO/R mice. Moreover, OPZ ameliorated MCAO/R-induced oxidative stress by decreasing the levels of 4-HNE and MDA and increasing the activities of SOD and GSH. We also found that OPZ ameliorated MCAO/R-induced ferroptosis by increasing SLC7A11 and GPX4 protein expression and downregulating ACSL4 protein expression. Similarly, the in vitro results revealed that OGD/R-induced oxidative stress and ferroptosis. Finally, mechanistic analysis revealed that OPZ significantly upregulated the Nrf2 expression and Nrf2 knockout (Nrf2 KO) abolished the OPZ-mediated protective effects. Taken together, these findings demonstrate that OPZ ameliorates cerebral I/R injury by suppressing the oxidative stress and ferroptosis.

Acute Ischemic Stroke during Extracorporeal Membrane Oxygenation (ECMO): A Narrative Review of the Literature

Ischemic stroke (IS) is a severe complication and leading cause of mortality in patients under extracorporeal membrane oxygenation (ECMO). The aim of our narrative review is to summarize the existing evidence and provide a deep examination of the diagnosis and treatment of acute ischemic stroke patients undergoing ECMO support. The incidence rate of ISs is estimated to be between 1 and 8%, while the mortality rate ranges from 44 to 76%, depending on several factors, including ECMO type, duration of support and patient characteristics. Several mechanisms leading to ISs during ECMO have been identified, with thromboembolic events and cerebral hypoperfusion being the most common causes. However, considering that most of the ECMO patients are severely ill or under sedation, stroke symptoms are often underdiagnosed. Multimodal monitoring and daily clinical assessment could be useful preventive techniques. Early recognition of neurological deficits is of paramount importance for prompt therapeutic interventions. All ECMO patients with suspected strokes should immediately receive brain computed tomography (CT) and CT angiography (CTA) for the identification of large vessel occlusion (LVO) and assessment of collateral blood flow. CT perfusion (CTP) can further assist in the detection of viable tissue (penumbra), especially in cases of strokes of unknown onset. Catheter angiography is required to confirm LVO detected on CTA. Intravenous thrombolytic therapy is usually contraindicated in ECMO as most patients are on active anticoagulation treatment. Therefore, mechanical thrombectomy is the preferred treatment option in cases where there is evidence of LVO. The choice of the arterial vascular access used to perform mechanical thrombectomy should be discussed between interventional radiologists and an ECMO team. Anticoagulation management during the acute phase of IS should be individualized after the thromboembolic risk has been carefully balanced against hemorrhagic risk. A multidisciplinary approach is essential for the optimal management of ISs in patients treated with ECMO.

Neurological monitoring and management for adult extracorporeal membrane oxygenation patients: Extracorporeal Life Support Organization consensus guidelines

BACKGROUND

Critical care of patients on extracorporeal membrane oxygenation (ECMO) with acute brain injury (ABI) is notable for a lack of high-quality clinical evidence. Here, we offer guidelines for neurological care (neurological monitoring and management) of adults during and after ECMO support.

METHODS

These guidelines are based on clinical practice consensus recommendations and scientific statements. We convened an international multidisciplinary consensus panel including 30 clinician-scientists with expertise in ECMO from all chapters of the Extracorporeal Life Support Organization (ELSO). We used a modified Delphi process with three rounds of voting and asked panelists to assess the recommendation levels.

RESULTS

We identified five key clinical areas needing guidance: (1) neurological monitoring, (2) post-cannulation early physiological targets and ABI, (3) neurological therapy including medical and surgical intervention, (4) neurological prognostication, and (5) neurological follow-up and outcomes. The consensus produced 30 statements and recommendations regarding key clinical areas. We identified several knowledge gaps to shape future research efforts.

CONCLUSIONS

The impact of ABI on morbidity and mortality in ECMO patients is significant. Particularly, early detection and timely intervention are crucial for improving outcomes. These consensus recommendations and scientific statements serve to guide the neurological monitoring and prevention of ABI, and management strategy of ECMO-associated ABI.

Short-Term Neurologic Complications in Patients Undergoing Extracorporeal Membrane Oxygenation Support: A Review on Pathophysiology, Incidence, Risk Factors, and Outcomes

Regardless of the type, extracorporeal membrane oxygenation (ECMO) requires the use of large intravascular cannulas and results in multiple abnormalities including non-physiologic blood flow, hemodynamic perturbation, rapid changes in blood oxygen and carbon dioxide levels, coagulation abnormalities, and a significant systemic inflammatory response. Among other sequelae, neurologic complications are an important source of mortality and long-term morbidity. The frequency of neurologic complications varies and is likely underreported due to the high mortality rate. Neurologic complications in patients supported by ECMO include ischemic and hemorrhagic stroke, hypoxic brain injury, intracranial hemorrhage, and brain death. In addition to the disease process that necessitates ECMO, cannulation strategies and physiologic disturbances influence neurologic outcomes in this high-risk population. For example, the overall documented rate of neurologic complications in the venovenous ECMO population is lower, but a higher rate of intracranial hemorrhage exists. Meanwhile, in the venoarterial ECMO population, ischemia and global hypoperfusion seem to compose a higher percentage of neurologic complications. In what follows, the literature is reviewed to discuss the pathophysiology, incidence, risk factors, and outcomes related to short-term neurologic complications in patients supported by ECMO.

Epidemiology of Seizures and Association With Mortality in Adult Patients Undergoing ECMO: A Systematic Review and Meta-analysis

BACKGROUND AND OBJECTIVES

Extracorporeal membrane oxygenation (ECMO) provides lifesaving support to patients with cardiopulmonary failure. Although seizures increase mortality risks among critically ill patients broadly, studies specific to adult ECMO patients have largely been limited to single-center studies. Thus, we aimed to perform a systematic review and meta-analyses of seizure prevalence, mortality, and their associations in adult ECMO patients.

METHODS

PubMed, EMBASE, Cochrane trial registry, Web of Science, and SCOPUS were searched on August 5, 2023. Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, we included studies of adults undergoing venovenous ECMO (VV-ECMO), venoarterial ECMO (VA-ECMO), or extracorporeal cardiopulmonary resuscitation (ECPR) that reported seizures during ECMO. The extracted data included study characteristics, patient demographics, ECMO support, EEG monitoring, and seizures, organized by ECMO types. Forest plot and meta-regression analyses were performed. Bias assessment was performed with the Egger test and Newcastle-Ottawa Scale.

RESULTS

Twenty-three studies (n = 40,420, mean age = 51.8 years, male = 62%) were included. Data were extracted by ECMO type as follows: VV-ECMO (n = 16,633), non-ECPR VA-ECMO (n = 11,082), ECPR (n = 3,369), combination of VA-ECMO and ECPR (n = 240), and combination of all types (n = 9,096). The pooled seizure prevalence for all ECMO types was 3.0%, not significantly different across ECMO types (VV-ECMO = 2.0% [95% CI 0.8-4.5]; VA-ECMO = 3.5% [95% CI 1.7-7.0]; ECPR = 4.9% [95% CI 1.3-17.2]). The pooled mortality was lower for VV-ECMO (46.2% [95% CI 39.3-53.2]) than VA-ECMO (63.4% [95% CI 56.6-69.6]) and ECPR (61.5% [95% CI 57.3-65.6]). Specifically, for VV-ECMO, the pooled mortality of patients with and without seizures was 55.1% and 36.7%, respectively (relative risk = 1.5 [95% CI 1.3-1.7]). Similarly, for VA-ECMO, the pooled mortality of patients with and without seizures was 74.4% and 56.1%, respectively (relative risk = 1.3 [95% CI 1.2-1.5]). Meta-regression analyses demonstrated that seizure prevalence was not associated with prior neurologic comorbidities, adjusted for ECMO type and study year.

DISCUSSION

Seizures are infrequent during ECMO support. However, they were associated with increased mortality when present. Multi-institutional, larger-scale studies using standardized EEG monitoring are necessary to further understand the risk factors of specific classes of seizures for individual ECMO types, and their effects on mortality. Limitations of our study include missing data for details on seizure types, sedating/antiseizure medications used during ECMO, other ECMO-related complications, and EEG recording protocols.

Effects of Dl-3-n-butylphthalide on neurological function, hemodynamics and Hcy concentration in cerebral hemorrhage: a systematic review and meta-analysis

Background

Dl-3-n-Butylphthalide (NBP) has emerged as a potential therapeutic agent for cerebral hemorrhage, despite not being included in current guideline recommendations. Investigating the underlying physiological and pathological mechanisms of Dl-3-n-Butylphthalide in cerebral hemorrhage treatment remains a critical area of research.

Objective

This review aims to evaluate the efficacy of Dl-3-n-Butylphthalide in cerebral hemorrhage treatment and elucidate its potential biological mechanisms, thereby providing evidence to support treatment optimization.

Methods

A comprehensive search of seven electronic databases (PubMed, Web of Science, Embase, Cochrane Library, China National Knowledge Infrastructure, VIP, and Wanfang Database) was conducted for studies published up to September 2023. Screening and data extraction were performed by a team of researchers. The Cochrane collaboration tool was utilized for risk bias assessment, and Revman 5.3 along with Stata 17.0 were employed for statistical analysis.

Outcomes

We searched 254 literature, and 19 were included in this meta-analysis. The results showed that Dl-3-n-Butylphthalide improved the clinical efficacy rate (RR = 1.25, 95% CI 1.19-1.31; p = 0.00), quality of life (MD = 13.93, 95% CI: 11.88-15.98; p = 0.000), increased cerebral blood flow and velocity, reduced cerebral edema volume, Hcy concentration, and did not have obvious adverse reactions (RR = 0.68, 95% CI: 0.39-1.18; p = 0.10).

Conclusion

This meta-analysis is the first to demonstrate the potential of Dl-3-n-Butylphthalide in treating cerebral hemorrhage. It suggests that Dl-3-n-Butylphthalide may alleviate clinical symptoms by modulating neurological function and improving hemodynamics. Our findings provide robust evidence for incorporating Dl-3-n-Butylphthalide into cerebral hemorrhage treatment strategies, potentially guiding future clinical practice and research. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/ display_record.php?RecordID=355114, Identifier CRD42022355114.

Association of Sepsis With Neurologic Outcomes of Adult Patients Treated With Venoarterial Extracorporeal Membrane Oxygnenation

OBJECTIVES

Neurologic outcomes of patients under venoarterial extracorporeal membrane oxygenation (VA-ECMO) may be worsened by secondary insults of systemic origin. We aimed to assess whether sepsis, commonly observed during ECMO support, is associated with brain injury and outcomes.

DESIGN

Single-center cohort study of the "exposed-non-exposed" type on consecutive adult patients treated by VA-ECMO.

SETTING

Medical ICU of a university hospital, France, 2013-2020.

PATIENTS

Patients with sepsis at the time of VA-ECMO cannulation ("sepsis" group) were compared with patients without sepsis ("no sepsis" group). The primary outcome measure was poor functional outcome at 90 days, defined by a score greater than or equal to 4 on the modified Rankin scale (mRS), indicating severe disability or death.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 196 patients were included ("sepsis," n = 128; "no sepsis," n = 68), of whom 87 (44.4%) had presented cardiac arrest before VA-ECMO cannulation. A poor functional outcome (mRS ≥ 4) was observed in 99 of 128 patients (77.3%) of the "sepsis" group and 46 of 68 patients (67.6%) of the "no sepsis" group (adjusted logistic regression odds ratio (OR) 1.21, 95% CI, 0.58-2.47; inverse probability of treatment weighting (IPTW) OR 1.24; 95% CI, 0.79-1.95). Subsequent analyses performed according to pre-ECMO cardiac arrest status suggested that sepsis was independently associated with poorer functional outcomes in the subgroup of patients who had experienced pre-ECMO cardiac arrest (adjusted logistic regression OR 3.44; 95% CI, 1.06-11.40; IPTW OR 3.52; 95% CI, 1.68-7.73), whereas no such association was observed in patients without pre-ECMO cardiac arrest (adjusted logistic regression OR 0.69; 95% CI, 0.27-1.69; IPTW OR 0.76; 95% CI, 0.42-1.35). Compared with the "no sepsis" group, "sepsis" patients presented a significant increase in S100 calcium-binding protein beta concentrations at day 1 (0.94 μg/L vs. 0.52 μg/L, p = 0.03), and more frequent EEG alterations (i.e., severe slowing, discontinuous background, and a lower prevalence of sleep patterns), suggesting brain injury.

CONCLUSION

We observed a detrimental role of sepsis on neurologic outcomes in the subgroup of patients who had experienced pre-ECMO cardiac arrest, but not in other patients.