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Published on: March 26, 2019
Routine Neuroimaging: Understanding Brain Injury in Pediatric Extracorporeal Membrane Oxygenation
Abdelaziz Farhat1, Xilong Li2, Beverley Huet2
1Pediatric Critical Care, Pediatrix Medical Group, Orem, UT.
Insights
Brain injuries are common in pediatric patients on extracorporeal membrane oxygenation (ECMO), but most survivors achieve good neurocognitive outcomes. Imaging is crucial for identifying injuries and guiding interventions.
Area of Science:
- Pediatric Neurology
- Neonatal Intensive Care
- Neuroimaging
Background:
- Extracorporeal membrane oxygenation (ECMO) is a life-support measure for critically ill neonates and children.
- Brain injuries are a known complication in this vulnerable population.
- Understanding the incidence and impact of these injuries is crucial for improving patient outcomes.
Purpose of the Study:
- To describe the prevalence and characteristics of brain injuries detected via routine neuroimaging in a large pediatric ECMO cohort.
- To investigate the association between these brain injuries and neurocognitive outcomes in survivors.
- To identify laboratory markers associated with neurological injury during ECMO.
Main Methods:
- Retrospective observational single-center cohort study.
- Analysis of neuroimaging (CT/MRI) in pediatric patients undergoing ECMO for noncardiac indications.
- Scoring of brain injuries and correlation with clinical and laboratory data.
- Assessment of neurocognitive outcomes using standardized scales (PCPC, POPC).
Main Results:
- 74% of 132 imaged patients showed radiological evidence of brain injury.
- Higher neuroimaging injury scores correlated with unfavorable neurocognitive outcomes (PCPC, POPC).
- Ischemic brain injury was linked to poorer neurodevelopmental outcomes.
- Specific laboratory findings (lactate, vasoactive-inotropic scores, elevated bilirubin/creatinine, thrombocytopenia) were associated with injury.
Conclusions:
- Brain injury is frequent in pediatric ECMO patients, yet most survivors exhibit favorable neurocognitive function.
- Head ultrasound and clinical suspicion are insensitive for detecting ECMO-related brain injuries.
- Routine post-ECMO MRI is recommended for injury identification and timely neurocognitive intervention planning.
Objectives:
This project aims to describe brain injuries on routine neuroimaging in a large single-center neonatal and pediatric cohort supported by extracorporeal membrane oxygenation. The study also aims to examine the association of these injuries with neurocognitive outcomes in survivors and identify laboratory findings associated with neurologic injury.
Design:
Retrospective observational single-center cohort study.
Setting:
Tertiary care PICU.
Patients:
Pediatric patients with noncardiac indications for extracorporeal membrane oxygenation supported by venoarterial or venovenous extracorporeal membrane oxygenation, with on-extracorporeal membrane oxygenation brain CT or postextracorporeal membrane oxygenation brain CT/MRI.
Interventions:
Extracorporeal membrane oxygenation support.
Measurements And Main Results:
Occurrence of brain injury on CT and MRI was reviewed; injuries were scored. Clinical and laboratory results associated with injury were identified. Survivor neurocognitive outcomes were obtained using the Pediatric Overall Performance Category scale and Pediatric Cerebral Performance Category scale. Of 132 imaged patients, 98 (74%) had radiological evidence of brain injury. Mean injury score was 6.5 (± 3.8). Head ultrasounds and clinician suspicion performed poorly in suspecting the presence of injury. Of 104 respondents to neurodevelopmental assessments, 61 (59%) had normal scores; 12.5%, 17%, and 11.5% had mild, moderate, or severe disability. A neuroimaging score greater than 10 was associated with an unfavorable outcome on the Pediatric Cerebral Performance Category (odds ratio, 3.4; p < 0.01) and Pediatric Overall Performance Category (odds ratio, 1.7; p < 0.05). Ischemic injury correlated with worse neurodevelopmental outcome. Preextracorporeal membrane oxygenation lactate, Vasoactive-Inotropic Scores, transaminitis, elevated bilirubin and creatinine levels, and thrombocytopenia were associated with injury occurrence.
Conclusions:
Brain injury is frequent in extracorporeal membrane oxygenation patients, although the majority of survivors have favorable neurocognitive outcomes. More research is needed in order to understand the etiology of such injuries. Head ultrasound and clinician suspicion are not sensitive in detecting extracorporeal membrane oxygenation-related brain injuries. Protocolizing postextracorporeal membrane oxygenation imaging with brain MRI allows the identification of injuries and provision of timely neurocognitive intervention.
