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Electroencephalographic, neuroradiologic, and neurodevelopmental studies in infants with subclavian steal during ECMO
L J Graziani1, L J Streletz, D G Mitchell
1Department of Pediatrics, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania 19107.
Insights
Subclavian steal, a condition affecting blood flow during extracorporeal membrane oxygenation (ECMO), did not impact infant mortality or neurological outcomes. Compensatory blood flow in the left vertebral artery maintained adequate cerebral circulation.
Area of Science:
- Pediatric Cardiology
- Neonatal Neurology
- Medical Imaging
Background:
- Extracorporeal membrane oxygenation (ECMO) is a life-support measure for critically ill neonates.
- Subclavian steal, characterized by retrograde flow in the vertebral artery, can occur during ECMO.
- The impact of subclavian steal on neonatal outcomes during ECMO requires further investigation.
Purpose of the Study:
- To investigate the incidence and implications of subclavian steal in infants undergoing ECMO.
- To compare neurological outcomes, mortality, and blood flow patterns in infants with and without subclavian steal during ECMO.
Main Methods:
- Color Doppler imaging was used to detect subclavian steal in 54 infants during ECMO.
- Infants were monitored for mortality, neurological assessments (EEG, cranial ultrasound, CT), and blood flow velocities.
- Comparison between infants with and without subclavian steal was performed.
Main Results:
- Subclavian steal was identified in 31% of infants during ECMO.
- No significant differences in mortality, neurological assessments, or early development were observed between groups.
- Cerebral blood flow patterns in the circle of Willis and major arteries were similar, with slightly lower right middle cerebral artery velocity.
Conclusions:
- Subclavian steal during ECMO does not appear to adversely affect mortality or neurological outcomes in neonates.
- Adequate compensation for cerebral circulation is likely maintained by increased left vertebral artery flow.
- The underlying causes of common EEG abnormalities and neurodevelopmental deficits in ECMO survivors remain unclear.
Abstract:
Color Doppler imaging revealed a subclavian steal--retrograde flow in the right vertebral artery which shunted blood from the brain's posterior circulation to the right arm via the subclavian artery--in 17 of 54 infants (31%) during extracorporeal membrane oxygenation (ECMO); right vertebral artery flow returned to antegrade after ECMO and removal of the right common carotid arterial cannula. When subjects with and without a subclavian steal were compared, there were no statistically significant differences in mortality; in the results of neonatal electroencephalograms, cranial ultrasound studies, or computed tomography studies; or in early neurological development. Blood flow patterns and peak systolic velocities in the circle of Willis, middle cerebral arteries, internal carotid arteries, and basilar artery were similar in both groups during ECMO; blood flow velocity in the middle cerebral arteries was slightly but significantly lower on the right than the left in both groups. Our results indicate that increased flow in the left vertebral artery adequately compensated for the effect of a subclavian steal on the basilar and cerebral circulation. The moderate to marked neonatal electroencephalographic abnormalities commonly occurring during ECMO and the approximately 20% incidence of neurodevelopmental deficits among ECMO survivors remain largely unexplained.