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Extracorporeal membrane oxygenation (ECMO), a life-saving technique for patients with severe respiratory and cardiac diseases, is being increasingly utilized worldwide, particularly during the coronavirus disease 2019(COVID-19) pandemic, and there has been a sharp increase in the implementation of ECMO. However, due to the presence of various complications, the survival rate of patients undergoing ECMO remains low. Among the complications, the neurologic morbidity significantly associated with venoarterial and venovenous ECMO has received increasing attention. Generally, failure to recognize neurologic injury in time is reportedly associated with poor outcomes in patients on ECMO. Currently, multimodal monitoring is increasingly utilized in patients with devastating neurologic injuries and has been advocated as an important approach for early diagnosis. Here, we highlight the prevalence and outcomes, risk factors, current monitoring technologies, prevention, and treatment of neurologic complications in adult patients on ECMO. We believe that an improved understanding of neurologic complications presumably offers promising therapeutic solutions to prevent and treat neurologic morbidity.

Purpose of Review: Mechanical circulatory support (MCS) devices have demonstrated improved survival outcomes in otherwise refractory cardiopulmonary failure but are associated with significant neurologic morbidity and mortality. This review aims to characterize MCS-associated brain injury and discuss the neurocritical care of this population. Recent Findings: We found no practice guidelines or specific management strategies for the neurocritical care of patients with MCS devices. Acute brain injury was commonly observed in short-term and durable MCS devices. There is emerging evidence that a standardized neurological monitoring and management algorithm for MCS device–associated brain injury is feasible and potentially improves neurological outcomes. Summary: While MCS devices are associated with significant neurologic morbidity and mortality, there is scant evidence regarding optimal neuromonitoring and neurocritical care. With the increase in use of MCS devices for both short-term and durable applications, improved outcomes will depend on early identification and intervention of neurologic complications and further research into their pathophysiology. [ABSTRACT FROM AUTHOR]

Children supported by extracorporeal membrane oxygenation present a high risk of neurological complications. Although carotid cannulation is known to be associated with neurologic injury, conflicting data exist with regard to the predominance of right- or left-sided lesions. We describe here two infants requiring veno-arterial extracorporeal membrane oxygenation for septic shock who encountered right watershed infarction ipsilateral to carotid artery cannulation. Hemodynamic failure seems to be the most probable underlying mechanism. The asymmetry of transcranial Doppler metrics in one case and the low right regional cerebral oxygen saturation value observed soon after right cannulation in both cases suggest an insufficient cerebral collateral flow compensation. The risk of ipsilateral watershed injury should be considered before cervical cannulation, notably in the context of sepsis and an evaluation of the cerebral collateral blood flow before and just after cannulation may be interesting in order to identify infants with higher risk of ipsilateral ischemic lesions. [ABSTRACT FROM AUTHOR]

Objectives: To review the neurocritical care aspects of patients supported by extracorporeal membrane oxygenation, including cerebral physiology, neurologic monitoring, use of sedatives and anti-seizure medications, and prevalence and management of extracorporeal membrane oxygenation associated brain injury.Data Sources: PubMed database search using relevant search terms related to neurologic complications, neurocritical care management, and brain injury management in patients with extracorporeal membrane oxygenation.Study Selection: Articles included original investigations, review articles, consensus statements and guidelines.Data Extraction: A detailed review of publications performed and relevant publications were summarized.Data Synthesis: We found no practice guidelines or management strategies for the neurocritical care of extracorporeal membrane oxygenation patients. Such patients are at high risk for hypoxic-ischemic brain injury, intracranial hemorrhage, cerebral edema, and brain death. Improving clinical outcomes will depend on better defining the neurologic complications and underlying pathophysiology that are specific to extracorporeal membrane oxygenation. Currently, insufficient understanding of the pathophysiology of neurologic complications prevents us from addressing their etiologies with specific, targeted monitoring techniques and interventions.Conclusions: A large knowledge gap exists in our understanding and treatment of extracorporeal membrane oxygenation-related neurologic complications. A systematic and multidisciplinary approach is needed to reduce the prevalence of these complications and to better manage the neurologic sequelae of extracorporeal membrane oxygenation in a way that will improve patient outcomes. [ABSTRACT FROM AUTHOR]

Abstract: Cerebral injury occurs with moderate frequency in patients with congenital heart disease. Physiology, measurement techniques, and targets for intervention in the perioperative period will be reviewed. The pathophysiology of neurologic injury is multi-factorial, but hypoxic–ischemic mechanisms are significant. Measures of oxygen supply, demand, and balance, and of cerebral function, can help identify conditions of risk and become targets for intervention. Measure of cerebral oxygen status with near-infrared spectroscopy is a practical component of comprehensive perioperative strategy that aims to avoid hypoxic–ischemic injury, and has validation in experimental and clinical literature related to pathophysiology, detection, treatment, and outcome. [ABSTRACT FROM AUTHOR]

Abstract: Operative mortality after repair of even the most complex congenital heart lesions has become rare. As such, the gaze of the surgical team has been diverted beyond that of early survival to focus on decreasing early and late morbidity. Important and concerning information is accumulating delineating the vulnerability of the neonatal brain to injury as the result of congenital heart disease and/or the techniques employed to correct the lesions. For many years the prevention of neurologic injury associated with congenital heart surgery has concentrated on “unraveling” the mysteries of the deleterious effects of intentional brain ischemia (in the form of deep hypothermic circulatory arrest) and developing methods to interrupt the pathway of irreversible injury. In the late 1990s, alternative perfusion techniques were developed to minimize or theoretically avoid the use of deep hypothermic circulatory arrest [1] where it was once thought to be mandatory. Simultaneously, the rather routine use of noninvasive, real-time, neurologic monitoring has provided surgical teams the opportunity to intervene and prevent brain injury [2–4], thus eliminating the historic reliance on postoperative surrogate markers to define the presence of brain injury. It is yet undetermined whether these strategies will translate into improved short- and long-term neurologic outcome. Common to all surgical disciplines is a trend that as mortality decreases for a particular disease process, focus is adjusted, and refinements in treatment protocols are designed to minimize morbidity of the disease and its treatment. This natural refining process of a discipline’s maturation is increasingly present in the field of congenital heart surgery. [Copyright &y& Elsevier]

Objective: to determine the methods of perfusion and cerebral protection currently used in France during aortic arch surgery in adults. Methods: national survey using a questionnaire mailed to every center (43 public and 25 private) performing cardiopulmonary bypass in adults. Gathereddata were analyzed by centers. Results: a 77.9% return rate has been obtained (n=53). 479 operations have been performed during the year 2000 in 49 centers (9.61±7.15 by center; range from 1 to 33). Almost half of the center used a single method to protect the brain (49.1%). Deep hypothermic circulatory arrest (<20°C) was still employed in more thanhalf of the centers (50.9%). However, 66% of the surgical groups modified their practice during the last few years toward less hypothermia (54% of the changing centers) and more cerebral perfusion (69% of the changing centers); 24.5% have planned modifications in the next future. The systemic arterial perfusion has been mostly achieved using femoral cannulae (91% of thecenters) but the axillary route has emerged yet (21% of the centers). Neuromonitoring is heterogeneous and often missing (71.7% of the centers). Aprotinin is used by 81.1% of the surgical groups to prevent postoperative blood loss. Conclusion: Despite the confidence that is still attributed to deep hypothermic circulatory arrest, the methods of perfusion and cerebral protection currently applied during aortic arch surgery are widely changing. [Copyright &y& Elsevier]