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Jin Y, Zhang Y, Liu J. Ischemic stroke and intracranial hemorrhage in extracorporeal membrane oxygenation for COVID-19: A systematic review and meta-analysis. Perfusion 2023; 38:1722-1733. [PMID: 36189498 PMCID: PMC9527229 DOI: 10.1177/02676591221130886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Extracorporeal membrane oxygenation (ECMO) is employed to support critically ill COVD-19 patients. The occurrence of ischemic stroke and intracranial hemorrhage (ICH), as well as the implementation of anticoagulation strategies under the dual influence of ECMO and COVID-19 remain unclear. We conducted a systematic review and meta-analysis to describe the ischemic stroke, ICH and overall in-hospital mortality in COVID-19 patients receiving ECMO and summarize the anticoagulation regimens. METHODS EMBASE, PubMed, Cochrane, and Scopus were searched for studies examining ischemic stroke, ICH, and mortality in COVID-19 patients supported with ECMO. The outcomes were incidences of ischemic stroke, ICH, overall in-hospital mortality and anticoagulation regimens. We calculated the pooled proportions and 95% confidence intervals (CIs) to summarize the results. RESULTS We analyzed 12 peer-reviewed studies involving 6039 COVID-19 patients. The incidence of ischemic stroke had a pooled estimate of 2.2% (95% CI: 1.2%-3.2%). The pooled prevalence of ICH was 8.0% (95% CI: 6.3%-9.6%). The pooled estimate of overall in-hospital mortality was 40.3% (95% CI: 33.1%-47.5%). The occurrence of ICH was significantly higher in COVID-19 patients supported with ECMO than in other respiratory ECMO [relative risk=1.75 (95% CI: 1.00-3.07)]. Unfractionated heparin was the most commonly used anticoagulant, and anticoagulation monitoring practice varied among centers. CONCLUSIONS Ischemic stroke and ICH were common under the double "hit" of COVID-19 and ECMO. The prevalence of ICH was significantly higher in COVID-19 patients supported with ECMO than non-COVID-19 patients requiring ECMO. Individualized anticoagulation regimens may be a good choice to balance thrombosis and bleeding. More detailed research and further exploration are needed to clarify the underlying mechanism and clinical management decisions.
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Affiliation(s)
- Yu Jin
- Department of Cardiopulmonary Bypass, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yang Zhang
- Department of Laboratory Medicine, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jinping Liu
- Department of Cardiopulmonary Bypass, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Lannon M, Duda T, Greer A, Hewitt M, Sharma A, Martyniuk A, Owen J, Amin F, Sharma S. Intracranial hemorrhage in patients treated for SARS-CoV-2 with extracorporeal membrane oxygenation: A systematic review and meta-analysis. J Crit Care 2023; 77:154319. [PMID: 37178492 PMCID: PMC10173703 DOI: 10.1016/j.jcrc.2023.154319] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 12/21/2022] [Accepted: 04/24/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is routinely used in patients with severe respiratory failure and has been increasingly needed during the COVID-19 pandemic. In patients treated with ECMO, significant intracranial hemorrhage (ICH) risk exists due to circuit characteristics, anticoagulation, and disease characteristics. ICH risk may be substantially higher in COVID-19 patients than patients treated with ECMO for other indications. METHODS We systematically reviewed current literature regarding ICH during ECMO treatment of COVID-19. We utilized Embase, MEDLINE, and Cochrane Library databases. Meta-analysis was performed for included comparative studies. Quality assessment was performed using MINORS criteria. RESULTS A total of 54 studies with 4000 ECMO patients were included, all retrospective. Risk of bias was increased via MINORS score primarily due to retrospective designs. ICH was more likely in COVID-19 patients (RR 1.72, 95% CI 1.23, 2.42). Mortality among COVID patients on ECMO with ICH was 64.0%, compared with 41% in patients without ICH (RR1.9, 95% 1.44, 2.51). CONCLUSION This study suggests increased hemorrhage rates in COVID-19 patients on ECMO compared to similar controls. Hemorrhage reduction strategies may include atypical anticoagulants, conservative anticoagulation strategies, or biotechnology advances in circuit design and surface coatings.
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Affiliation(s)
- Melissa Lannon
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada.
| | - Taylor Duda
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada.
| | - Alisha Greer
- Division of Emergency Medicine, Department of Medicine, Division of Critical Care, McMaster University, Hamilton, Ontario, Canada.
| | - Mark Hewitt
- Division of Emergency Medicine, Department of Medicine, Division of Critical Care, McMaster University, Hamilton, Ontario, Canada.
| | - Arjun Sharma
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, Ontario, Canada.
| | - Amanda Martyniuk
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada.
| | - Julian Owen
- Division of Emergency Medicine, Department of Medicine, Division of Critical Care, McMaster University, Hamilton, Ontario, Canada.
| | - Faizan Amin
- Department of Medicine, Divisions of Critical Care and Cardiology, McMaster University, Hamilton, Ontario, Canada.
| | - Sunjay Sharma
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada.
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Hingorani KS, Bhadola S, Cervantes-Arslanian AM. COVID-19 and the Brain. Trends Cardiovasc Med 2022; 32:323-330. [PMID: 35461991 PMCID: PMC9022395 DOI: 10.1016/j.tcm.2022.04.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 04/19/2022] [Accepted: 04/19/2022] [Indexed: 12/11/2022]
Abstract
Entering the third year into the pandemic, overwhelming evidence demonstrates that Coronavirus disease 2019 (COVID-19) infection is a systemic illness, often with involvement of the central nervous system. Multiple mechanisms may underlie the development of neurologic manifestations of illness, including hypoxia, systemic illness, hypercoagulability, endothelial dysfunction, general critical illness, inflammatory response, and neurotropism of the severe acute respiratory syndrome coronavirus 2 (SARS-Co-V2) virus. COVID-19 infection is associated with neurologic involvement in all stages; acute infection, subacute/post-infection, and growing evidence also suggests during a chronic phase, the post-acute sequalae of COVID-19 (PASC). With over 20,000 published articles on COVID and the brain at the time of writing, it is virtually impossible to present an unbiased comprehensive review of how SARS-Co-V2 impacts the nervous system. In this review, we will present an overview of common neurologic manifestations, in particular focusing on the cerebrovascular complications, and proposed pathophysiology.
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von Stillfried S, Bülow RD, Röhrig R, Meybohm P, Boor P, Böcker J, Schmidt J, Tholen P, Majeed R, Wienströer J, Weis J, Bremer J, Knüchel R, Breitbach A, Cacchi C, Freeborn B, Wucherpfennig S, Spring O, Braun G, Römmele C, Märkl B, Claus R, Dhillon C, Schaller T, Sipos E, Hirschbühl K, Wittmann M, Kling E, Kröncke T, Heppner FL, Meinhardt J, Radbruch H, Streit S, Horst D, Elezkurtaj S, Quaas A, Göbel H, Hansen T, Titze U, Lorenzen J, Reuter T, Woloszyn J, Baretton G, Hilsenbeck J, Meinhardt M, Pablik J, Sommer L, Holotiuk O, Meinel M, Mahlke N, Esposito I, Crudele G, Seidl M, Amann KU, Coras R, Hartmann A, Eichhorn P, Haller F, Lange F, Schmid KW, Ingenwerth M, Rawitzer J, Theegarten D, Birngruber CG, Wild P, Gradhand E, Smith K, Werner M, Schilling O, Acker T, Gattenlöhner S, Stadelmann C, Metz I, Franz J, Stork L, Thomas C, Zechel S, Ströbel P, Wickenhauser C, Fathke C, Harder A, Ondruschka B, Dietz E, Edler C, Fitzek A, Fröb D, Heinemann A, Heinrich F, Klein A, Kniep I, Lohner L, Möbius D, Püschel K, Schädler J, Schröder AS, Sperhake JP, Aepfelbacher M, Fischer N, Lütgehetmann M, Pfefferle S, Glatzel M, Krasemann S, Matschke J, Jonigk D, Werlein C, Schirmacher P, Domke LM, Hartmann L, Klein IM, Schwab C, Röcken C, Friemann J, Langer D, Roth W, Strobl S, Rudelius M, Stock KF, Weichert W, Delbridge C, Kasajima A, Kuhn PH, Slotta-Huspenina J, Weirich G, Barth P, Wardelmann E, Schnepper A, Evert K, Büttner A, Manhart J, Nigbur S, Bittmann I, Fend F, Bösmüller H, Granai M, Klingel K, Warm V, Steinestel K, Umathum VG, Rosenwald A, Kurz F, Vogt N. Intracranial hemorrhage in COVID-19 patients during extracorporeal membrane oxygenation for acute respiratory failure: a nationwide register study report. Crit Care 2022; 26:83. [PMID: 35346314 PMCID: PMC8958804 DOI: 10.1186/s13054-022-03945-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 03/04/2022] [Indexed: 12/22/2022] Open
Abstract
Background In severe cases, SARS-CoV-2 infection leads to acute respiratory distress syndrome (ARDS), often treated by extracorporeal membrane oxygenation (ECMO). During ECMO therapy, anticoagulation is crucial to prevent device-associated thrombosis and device failure, however, it is associated with bleeding complications. In COVID-19, additional pathologies, such as endotheliitis, may further increase the risk of bleeding complications. To assess the frequency of bleeding events, we analyzed data from the German COVID-19 autopsy registry (DeRegCOVID). Methods The electronic registry uses a web-based electronic case report form. In November 2021, the registry included N = 1129 confirmed COVID-19 autopsy cases, with data on 63 ECMO autopsy cases and 1066 non-ECMO autopsy cases, contributed from 29 German sites. Findings The registry data showed that ECMO was used in younger male patients and bleeding events occurred much more frequently in ECMO cases compared to non-ECMO cases (56% and 9%, respectively). Similarly, intracranial bleeding (ICB) was documented in 21% of ECMO cases and 3% of non-ECMO cases and was classified as the immediate or underlying cause of death in 78% of ECMO cases and 37% of non-ECMO cases. In ECMO cases, the three most common immediate causes of death were multi-organ failure, ARDS and ICB, and in non-ECMO cases ARDS, multi-organ failure and pulmonary bacterial ± fungal superinfection, ordered by descending frequency. Interpretation Our study suggests the potential value of autopsies and a joint interdisciplinary multicenter (national) approach in addressing fatal complications in COVID-19. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03945-x.
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