Variation in electroencephalography and neuroimaging for children receiving extracorporeal membrane oxygenation
Joseph G Kohne1,2, Graeme MacLaren3, Renée A Shellhaas4
1Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, USA. jkohne@med.umich.edu.
Insights
Neurologic monitoring in children on extracorporeal membrane oxygenation (ECMO) varies significantly between hospitals. Despite differing approaches to electroencephalography (EEG) and neuroimaging, seizure and stroke diagnoses remained consistent, suggesting a need for standardized best practices.
Area of Science:
- Pediatric Neurology
- Critical Care Medicine
- Neurocritical Care
Background:
- Children on extracorporeal membrane oxygenation (ECMO) face high risks of neurologic complications like seizures and strokes.
- Current methods for monitoring and detecting neurologic injury during ECMO lack established best practices.
- This study aimed to characterize current clinical approaches to electroencephalography (EEG) and neuroimaging in pediatric ECMO patients.
Purpose of the Study:
- To investigate the utilization patterns of EEG and various neuroimaging modalities in children receiving ECMO support.
- To identify variations in diagnostic and monitoring strategies across different hospital settings.
- To correlate monitoring practices with the incidence of key neurologic diagnoses.
Main Methods:
- A retrospective observational cohort study was conducted using data from the US Pediatric Health Information System (PHIS) between 2016 and 2021.
- Hospitalizations involving ECMO support were analyzed, stratified by patient population (pediatric, neonatal, cardiac/non-cardiac surgery).
- Frequencies of EEG, cranial ultrasound, CT, MRI, and transcranial Doppler (TCD) were assessed, alongside diagnoses of stroke and seizures, and antiseizure medication use.
Main Results:
- Over 8700 ECMO hospitalizations were analyzed, with significant variation observed in EEG and neuroimaging utilization across hospitals.
- EEG use increased from 52% to 72% during the study period, yet hospital rates varied widely.
- Despite monitoring variations, seizure and stroke diagnoses, as well as antiseizure medication use, were consistent across hospitals with differing EEG and MRI utilization rates.
Conclusions:
- Significant heterogeneity exists in the neurodiagnostic and neuroimaging approaches for children on ECMO.
- The observed variations in monitoring did not appear to influence the rates of diagnosed seizures or strokes.
- Further research is needed to establish optimal screening and monitoring strategies for this high-risk pediatric population, balancing efficacy with resource utilization.
Background:
Seizures, strokes, and intracranial hemorrhage are common and feared complications in children receiving extracorporeal membrane oxygenation (ECMO) support. Researchers and clinicians have proposed and deployed methods for monitoring and detecting neurologic injury, but best practices are unknown. We sought to characterize clinicians' approach to electroencephalography (EEG) and brain imaging modalities in children supported by ECMO.
Methods:
We performed a retrospective observational cohort study among US Children's Hospitals participating in the Pediatric Health Information System (PHIS) from 2016 to 2021. We identified hospitalizations containing ECMO support. We stratified these admissions by pediatric, neonatal, cardiac surgery, and non-cardiac surgery. We characterized the frequency of EEG, cranial ultrasound, brain computed tomography (CT), magnetic resonance imaging (MRI), and transcranial Doppler during ECMO hospitalizations. We reported key diagnoses (stroke and seizures) and the prescription of antiseizure medication. To assess hospital variation, we created multilevel logistic regression models.
Results:
We identified 8746 ECMO hospitalizations. Nearly all children under 1 year of age (5389/5582) received a cranial ultrasound. Sixty-two percent of the cohort received an EEG, and use increased from 2016 to 2021 (52-72% of hospitalizations). There was marked variation between hospitals in rates of EEG use. Rates of antiseizure medication use (37% of hospitalizations) and seizure diagnoses (20% of hospitalizations) were similar across hospitals, including high and low EEG utilization hospitals. Overall, 37% of the cohort received a CT and 36% received an MRI (46% of neonatal patients). Stroke diagnoses (16% of hospitalizations) were similar between high- and low-MRI utilization hospitals (15% vs 17%, respectively). Transcranial Doppler (TCD) was performed in just 8% of hospitalizations, and 77% of the patients who received a TCD were cared for at one of five centers.
Conclusions:
In this cohort of children at high risk of neurologic injury, there was significant variation in the approach to EEG and neuroimaging in children on ECMO. Despite the variation in monitoring and imaging, diagnoses of seizures and strokes were similar across hospitals. Future work needs to identify a management strategy that appropriately screens and monitors this high-risk population without overuse of resource-intensive modalities.
