Patterns of Head Computed Tomography Abnormalities During Pediatric Extracorporeal Membrane Oxygenation and Association With Outcomes

Publication date: Available online 18 May 2017
Source:Pediatric Neurology
Author(s): Kerri L. LaRovere, Frederick W. Vonberg, Sanjay P. Prabhu, Kush Kapur, Chellamani Harini, Rogelio Garcia-Jacques, Jessica H. Chao, Aliresa Akhondi-Asl, Ravi Thiagarajan, Robert C. Tasker
ObjectiveTo classify the type and distribution of acute infarction and hemorrhage detected on head computed tomography (CT) during pediatric extracorporeal membrane oxygenation (ECMO). We also sought to compare clinical factors, including the occurrence of seizures detected on electroencephalogram (EEG) and outcomes, between those with these CT abnormalities and those without CT abnormalities.DesignRetrospective observational study.SettingSingle center, pediatric intensive care units.PatientsMedical record review of 179 children who were treated with ECMO between the years 2009 and 2013.InterventionsNone.Measurements and Main Results46% (82/179 children) of the entire cohort underwent 113 portable CT scans. Of these, 60% (49/82) had acute pathology on CT. Cerebral infarction occurred in 55% (27/49) and intracranial hemorrhage in 41% (20/49). Infarction was arterial in distribution in 67% (18/27 cases) with preponderance for middle cerebral artery territory (17 cases). Infarction was bilateral in 41% (11/27) and not specific to side of cannulation in the rest. The sensitivity and specificity for head ultrasound in predicting infarction on head CT was 100% and 53%, respectively. A total of 36% (65/179) underwent continuous EEG monitoring, and 22% (14/65) of these had electrographic seizures. Electrographic seizures were detected more frequently in those with infarction compared to the rest of the cohort (odds ratio [OR], 6.81; 95% confidence interval [CI], 1.98 – 23.43). Survival was reduced in both infarction (OR, 0.22; 95% CI, 0.09 – 0.54) and hemorrhage (OR, 0.31; 95% CI, 0.13 – 0.72) compared to those who did not have these abnormalities. Children with acute CT abnormalities were also more likely to have unfavorable outcomes at hospital discharge compared to those without infarction or hemorrhage on CT (P=0.01).ConclusionsCerebral infarction and hemorrhage are of great concern during ECMO therapy in children. Head ultrasound is insufficient to rule out cerebral infarction. Cerebral infarction detected by CT is MCA predominant, and associated with increased risk for electrographic seizures. Cerebral infarction and hemorrhage during the course of ECMO are associated with reduced survival and unfavorable outcomes. Prospective studies are needed to clarify the epidemiology and circumstances of these acute cerebral insults, and ultimately develop practices that may prevent these complications and improve outcomes.



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