EEG features of brain injury during extracorporeal membrane oxygenation in children
Arnold J Sansevere1, Melissa L DiBacco2, Alireza Akhondi-Asl2
1From the Division of Epilepsy and Neurophysiology (A.J.S., M.L.D., T.L. , P.L.P., M.H.L.), Department of Anesthesiology, Critical Care and Pain Medicine (A.A.-A., R.C.T.), Department of Neurology (K.L., T.L., M.J.R., P.L.P., M.H.L., R.C.T.), Department of Psychiatry and Radiology (M.J.R.), and Department of Cardiology, Division of Cardiovascular Critical Care (R.R.T.), Boston Children's Hospital, MA. arnold.sansevere@childrens.harvard.edu.
Insights
Electroencephalography (EEG) monitoring in pediatric patients on extracorporeal membrane oxygenation (ECMO) can predict outcomes. Abnormal EEG background activity and electrographic seizures (ES) are linked to mortality and brain injury, with cannulation type influencing lesion location.
Area of Science:
- Pediatric Neurology
- Neurocritical Care
- Extracorporeal Membrane Oxygenation
Background:
- Continuous electroencephalography (cEEG) monitoring is crucial for assessing neurological status in critically ill children.
- Understanding the electrophysiological changes during extracorporeal membrane oxygenation (ECMO) is vital for predicting patient outcomes.
- Major pathophysiology in children undergoing ECMO requires detailed examination through EEG.
Purpose of the Study:
- To investigate the relationship between EEG features and major pathophysiology in pediatric patients on ECMO.
- To determine the prognostic value of cEEG background activity and electrographic seizures (ES) in this population.
- To explore correlations between ECMO parameters, brain injury, and EEG findings.
Main Methods:
- A retrospective analysis of 201 pediatric patients undergoing ECMO.
- Utilized the first 24 hours of cEEG monitoring to assess background activity and ES.
- Correlated EEG data with neuroimaging, ECMO type, and patient outcomes.
Main Results:
- Severely abnormal cEEG background occurred in 12% of patients and was associated with death (specificity 0.97).
- Electrographic seizures (ES) occurred in 16% of patients and higher ES burden correlated with mortality.
- Arterial ECMO cannulation type (carotid vs. aortic) was associated with the side of focal cerebral injury, with ES present in about one-third of cases with abnormal imaging.
Conclusions:
- cEEG background activity after ECMO initiation can inform prognosis.
- The type of arterial ECMO cannulation correlates with the location of focal cerebral injury.
- The study hypothesizes that abnormal flow dynamics or embolic injury contribute to the observed patterns of brain injury and ES.
Objective:
To examine EEG features of major pathophysiology in children undergoing extracorporeal membrane oxygenation (ECMO).
Methods:
This was a single-center, retrospective study of 201 pediatric patients on ECMO, using the first 24 hours of continuous EEG (cEEG) monitoring, collating background activity and electrographic seizures (ES) with imaging, ECMO type, and outcome.
Results:
Severely abnormal cEEG background occurred in 12% (25/201), and was associated with death (sensitivity 0.23, specificity 0.97). ES occurred in 16% (33/201) within 3.2 (0.6-20.3) hours (median [interquartile range]) of cEEG commencement, and higher ES burden was associated with death. ES was always associated with ipsilateral injury (p = 0.006), but occurred in only one-third of cases with abnormal imaging. In 28 patients with isolated hemisphere lesion, type of arterial ECMO cannulation was associated with side of injury: right carotid cannulation was associated with right hemisphere lesions, and ascending aorta cannulation with left hemisphere lesions (odds ratio, 0.29 [95% confidence interval, 0.08-0.98], p = 0.03).
Conclusions:
After starting ECMO, cEEG background activity has the potential to inform prognosis. Type of arterial (carotid vs aortic) ECMO correlates with side of focal cerebral injury, which in ≈33% is associated with presence of ES. We hypothesize that the differential distribution reflects abnormal flow dynamics or embolic injury.
