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Am J Perinatol 2021; 38(14): 1557-1564
DOI: 10.1055/s-0040-1714208
Original Article

Risk Factors for Brain Injury in Newborns Treated with Extracorporeal Membrane Oxygenation

Launice Melbourne
1   Division of Neonatology, Children's National Hospital, Washington, District of Columbia
2   Department of Pediatrics, The George Washington University School of Medicine, Washington, District of Columbia
,
Michael A. Wien
3   Division of Diagnostic Imaging and Radiology, Children's National Hospital, Washington, District of Columbia
,
Matthew T. Whitehead
2   Department of Pediatrics, The George Washington University School of Medicine, Washington, District of Columbia
3   Division of Diagnostic Imaging and Radiology, Children's National Hospital, Washington, District of Columbia
,
Michelande Ridore
1   Division of Neonatology, Children's National Hospital, Washington, District of Columbia
,
Yunfei Wang
4   Division of Biostatistics and Study Methodology, Children's National Research Institute, Washington, District of Columbia
,
Billie L. Short
1   Division of Neonatology, Children's National Hospital, Washington, District of Columbia
2   Department of Pediatrics, The George Washington University School of Medicine, Washington, District of Columbia
,
Dorothy Bulas
2   Department of Pediatrics, The George Washington University School of Medicine, Washington, District of Columbia
3   Division of Diagnostic Imaging and Radiology, Children's National Hospital, Washington, District of Columbia
,
An N. Massaro
1   Division of Neonatology, Children's National Hospital, Washington, District of Columbia
2   Department of Pediatrics, The George Washington University School of Medicine, Washington, District of Columbia
› Author Affiliations Funding This study received financial support from Extracorporeal Life Support Organization.
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Abstract

Objective This study aimed to assess the association of clinical risk factors with severity of magnetic resonance imaging (MRI) brain injury in neonatal extracorporeal membrane oxygenation (ECMO) patients.

Study Design This is a single-center retrospective study conducted at an outborn level IV neonatal intensive care unit in a free-standing academic children's hospital. Clinical and MRI data from neonates treated with ECMO between 2005 and 2015 were reviewed. MRI injury was graded by two radiologists according to a modified scoring system that assesses parenchymal injury, extra-axial hemorrhage, and cerebrospinal fluid spaces. MRI severity was classified as none (score = 0), mild/moderate (score = 1–13.5), and severe (score ≥ 14). The relationship between selected risk factors and MRI severity was assessed by Chi-square, analysis of variance, and Kruskal–Wallis tests where appropriate. Combinative predictive ability of significant risk factors was assessed by logistic regression analyses.

Results MRI data were assessed in 81 neonates treated with ECMO. Veno-arterial (VA) patients had more severe injury compared with veno-venous patients. There was a trend toward less severe injury over time. After controlling for covariates, duration of ECMO remained significantly associated with brain injury, and the risk for severe injury was significantly increased in patients on ECMO beyond 210 hours.

Conclusion Risk for brain injury is increased with VA ECMO and with longer duration of ECMO. Improvements in care may be leading to decreasing incidence of brain injury in neonatal ECMO patients.

Key Points

  • Veno-arterial ECMO is associated with more brain injury by MRI compared with veno-venous ECMO.

  • Longer duration of ECMO is significantly associated with severe brain injury by MRI.

  • Risk for neurologic injury may be decreasing over time with advances in neonatal ECMO.

Keywords

extracorporeal life support - neonate - magnetic resonance imaging - brain injury


Publication History

Received: 13 February 2020

Accepted: 09 June 2020

Article published online:
16 July 2020

© 2020. Thieme. All rights reserved.

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  • References

  • 1 Paden ML, Rycus PT, Thiagarajan RR, Registry E. ELSO Registry. Update and outcomes in extracorporeal life support. Semin Perinatol 2014; 38 (02) 65-70
    CrossrefPubMedGoogle Scholar
  • 2 Barbaro RP, Paden ML, Guner YS. et al; ELSO member centers. Pediatric extracorporeal life support organization registry international report 2016. ASAIO J 2017; 63 (04) 456-463
    CrossrefPubMedGoogle Scholar
  • 3 van Heijst AF, de Mol AC, Ijsselstijn H. ECMO in neonates: neuroimaging findings and outcome. Semin Perinatol 2014; 38 (02) 104-113
    CrossrefPubMedGoogle Scholar
  • 4 Bulas D, Glass P. Neonatal ECMO: neuroimaging and neurodevelopmental outcome. Semin Perinatol 2005; 29 (01) 58-65
    CrossrefPubMedGoogle Scholar
  • 5 Rollins MD, Yoder BA, Moore KR. et al. Utility of neuroradiographic imaging in predicting outcomes after neonatal extracorporeal membrane oxygenation. J Pediatr Surg 2012; 47 (01) 76-80
    CrossrefPubMedGoogle Scholar
  • 6 Bulas DI, Taylor GA, O'Donnell RM, Short BL, Fitz CR, Vezina G. Intracranial abnormalities in infants treated with extracorporeal membrane oxygenation: update on sonographic and CT findings. AJNR Am J Neuroradiol 1996; 17 (02) 287-294
    PubMedGoogle Scholar
  • 7 Taylor GA, Fitz CR, Miller MK, Garin DB, Catena LM, Short BL. Intracranial abnormalities in infants treated with extracorporeal membrane oxygenation: imaging with US and CT. Radiology 1987; 165 (03) 675-678
    CrossrefPubMedGoogle Scholar
  • 8 Benya EC, Bulas DI, Eichelberger MR, Sivit CJ. Splenic injury from blunt abdominal trauma in children: follow-up evaluation with CT. Radiology 1995; 195 (03) 685-688
    CrossrefPubMedGoogle Scholar
  • 9 Graziani LJ, Gringlas M, Baumgart S. Cerebrovascular complications and neurodevelopmental sequelae of neonatal ECMO. Clin Perinatol 1997; 24 (03) 655-675
    CrossrefPubMedGoogle Scholar
  • 10 Woodward LJ, Anderson PJ, Austin NC, Howard K, Inder TE. Neonatal MRI to predict neurodevelopmental outcomes in preterm infants. N Engl J Med 2006; 355 (07) 685-694
    CrossrefPubMedGoogle Scholar
  • 11 Woodward LJ, Clark CA, Bora S, Inder TE. Neonatal white matter abnormalities an important predictor of neurocognitive outcome for very preterm children. PLoS One 2012; 7 (12) e51879
    CrossrefPubMedGoogle Scholar
  • 12 Palanzo D, Qiu F, Baer L, Clark JB, Myers JL, Undar A. Evolution of the extracorporeal life support circuitry. Artif Organs 2010; 34 (11) 869-873
    CrossrefPubMedGoogle Scholar
  • 13 Maslach-Hubbard A, Bratton SL. Extracorporeal membrane oxygenation for pediatric respiratory failure: history, development and current status. World J Crit Care Med 2013; 2 (04) 29-39
    CrossrefPubMedGoogle Scholar
  • 14 Maul TM, Kuch BA, Wearden PD. Development of risk indices for neonatal respiratory extracorporeal membrane oxygenation. ASAIO J 2016; 62 (05) 584-590
    CrossrefPubMedGoogle Scholar
  • 15 Paden ML, Conrad SA, Rycus PT, Thiagarajan RR, Registry E. ELSO Registry. Extracorporeal life support organization registry report 2012. ASAIO J 2013; 59 (03) 202-210
    CrossrefPubMedGoogle Scholar
  • 16 Wien MA, Whitehead MT, Bulas D. et al. Patterns of brain injury in newborns treated with extracorporeal membrane oxygenation. AJNR Am J Neuroradiol 2017; 38 (04) 820-826
    CrossrefPubMedGoogle Scholar
  • 17 Bulas DI, Glass P, O'Donnell RM, Taylor GA, Short BL, Vezina GL. Neonates treated with ECMO: predictive value of early CT and US neuroimaging findings on short-term neurodevelopmental outcome. Radiology 1995; 195 (02) 407-412
    CrossrefPubMedGoogle Scholar
  • 18 Babcock DS, Han BK, Weiss RG, Ryckman FC. Brain abnormalities in infants on extracorporeal membrane oxygenation: sonographic and CT findings. AJR Am J Roentgenol 1989; 153 (03) 571-576
    CrossrefPubMedGoogle Scholar
  • 19 Lin N, Flibotte J, Licht DJ. Neuromonitoring in the neonatal ECMO patient. Semin Perinatol 2018; 42 (02) 111-121
    CrossrefPubMedGoogle Scholar
  • 20 Lazar EL, Abramson SJ, Weinstein S, Stolar CJ. Neuroimaging of brain injury in neonates treated with extracorporeal membrane oxygenation: lessons learned from serial examinations. J Pediatr Surg 1994; 29 (02) 186-190 , discussion 190–191
    CrossrefPubMedGoogle Scholar
  • 21 Wiznitzer M, Masaryk TJ, Lewin J, Walsh M, Stork EK. Parenchymal and vascular magnetic resonance imaging of the brain after extracorporeal membrane oxygenation. Am J Dis Child 1990; 144 (12) 1323-1326
    PubMedGoogle Scholar
  • 22 Raets MM, Dudink J, Ijsselstijn H. et al. Brain injury associated with neonatal extracorporeal membrane oxygenation in the Netherlands: a nationwide evaluation spanning two decades. Pediatr Crit Care Med 2013; 14 (09) 884-892
    CrossrefPubMedGoogle Scholar
  • 23 Gauger PG, Hirschl RB, Delosh TN, Dechert RE, Tracy T, Bartlett RH. A matched pairs analysis of venoarterial and venovenous extracorporeal life support in neonatal respiratory failure. ASAIO J 1995; 41 (03) M573-M579
    CrossrefPubMedGoogle Scholar
  • 24 Hardart GE, Fackler JC. Predictors of intracranial hemorrhage during neonatal extracorporeal membrane oxygenation. J Pediatr 1999; 134 (02) 156-159
    CrossrefPubMedGoogle Scholar
  • 25 Roy BJ, Rycus P, Conrad SA, Clark RH. The changing demographics of neonatal extracorporeal membrane oxygenation patients reported to the Extracorporeal Life Support Organization (ELSO) Registry. Pediatrics 2000; 106 (06) 1334-1338
    CrossrefPubMedGoogle Scholar
  • 26 Roberts J, Keene S, Heard M, McCracken C, Gauthier TW. Successful primary use of VVDL+V ECMO with cephalic drain in neonatal respiratory failure. J Perinatol 2016; 36 (02) 126-131
    CrossrefPubMedGoogle Scholar
  • 27 Skarsgard ED, Salt DR, Lee SK. Extracorporeal Life Support Organization Registry. Venovenous extracorporeal membrane oxygenation in neonatal respiratory failure: does routine, cephalad jugular drainage improve outcome?. J Pediatr Surg 2004; 39 (05) 672-676
    CrossrefPubMedGoogle Scholar
  • 28 Wilson JM, Bower LK, Thompson JE, Fauza DO, Fackler JC. ECMO in evolution: the impact of changing patient demographics and alternative therapies on ECMO. J Pediatr Surg 1996; 31 (08) 1116-1122 , discussion 1122–1123
    CrossrefPubMedGoogle Scholar
  • 29 Mahmood B, Newton D, Pallotto EK. Current trends in neonatal ECMO. Semin Perinatol 2018; 42 (02) 80-88
    CrossrefPubMedGoogle Scholar
  • 30 Prodhan P, Stroud M, El-Hassan N. et al. Prolonged extracorporeal membrane oxygenator support among neonates with acute respiratory failure: a review of the Extracorporeal Life Support Organization registry. ASAIO J 2014; 60 (01) 63-69
    CrossrefPubMedGoogle Scholar
  • 31 Short BL. The effect of extracorporeal life support on the brain: a focus on ECMO. Semin Perinatol 2005; 29 (01) 45-50
    CrossrefPubMedGoogle Scholar
  • 32 Melbourne L, Chang T, Murnick J, Zaniletti I, Glass P, Massaro AN. Clinical impact of term-equivalent magnetic resonance imaging in extremely low-birth-weight infants at a regional NICU. J Perinatol 2016; 36 (11) 985-989
    CrossrefPubMedGoogle Scholar
  • 33 O'Halloran CP, Thiagarajan RR, Yarlagadda VV. et al. Outcomes of infants supported with extracorporeal membrane oxygenation using centrifugal versus roller pumps: an analysis from the Extracorporeal Life Support Organization Registry. Pediatr Crit Care Med 2019; 20 (12) 1177-1184
    CrossrefPubMedGoogle Scholar
  • 34 Barrett CS, Jaggers JJ, Cook EF. et al. Outcomes of neonates undergoing extracorporeal membrane oxygenation support using centrifugal versus roller blood pumps. Ann Thorac Surg 2012; 94 (05) 1635-1641
    CrossrefPubMedGoogle Scholar