J Neurocrit Care.  2021 Dec;14(2):63-77. 10.18700/jnc.210016.

Brain injury in extracorporeal cardiopulmonary resuscitation: translational to clinical research

Affiliations
  • 1Department of Neurosciences, Mercy Hospital of Buffalo, Buffalo, NY, USA
  • 2Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
  • 3Division of Neuroscience Critical Care, Departments of Neurology, Neurosurgery, Anesthesiology, and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA

Abstract

The addition of extracorporeal membrane oxygenation (ECMO) to conventional cardiopulmonary resuscitation (CPR), termed extracorporeal cardiopulmonary resuscitation (ECPR), has significantly improved survival in selected patient populations. Despite this advancement, significant neurological impairment persists in approximately half of survivors. ECPR represents a potential advancement for patients who experience refractory cardiac arrest (CA) due to a reversible etiology and do not regain spontaneous circulation. Important risk factors for acute brain injury (ABI) in ECPR include lack of perfusion, reperfusion, and altered cerebral autoregulation. The initial hypoxic-ischemic injury caused by no-flow and low-flow states after CA and during CPR is compounded by reperfusion, hyperoxia during ECMO support, and nonpulsatile blood flow. Additionally, ECPR patients are at risk for Harlequin syndrome with peripheral cannulation, which can lead to preferential perfusion of cerebral vessels with deoxygenated blood. Lastly, the oxygenator membrane is prothrombotic and requires systemic anticoagulation. The two competing phenomena result in thrombus formation, hemolysis, and thrombocytopenia, increasing the risk of ischemic and hemorrhagic ABI. In addition to clinical studies, we assessed available ECPR animal models to identify the mechanisms underlying ABI at the cellular level. Standardized multimodal neurological monitoring may facilitate early detection of and intervention for ABI. With the increasing use of ECPR, it is critical to understand the pathophysiology of ABI, its prevention, and the management strategies for improving the outcomes of ECPR. Translational and clinical research focusing on acute ABI immediately after ECMO cannulation and its short- and long-term neurological outcomes are warranted.

Keyword

Extracorporeal membrane oxygenation; Acute brain injuries; Extracorporeal cardiopulmonary resuscitation

Figure

  • Fig. 1. Extracorporeal cardiopulmonary resuscitation (ECPR) model with associated risk factors for brain injury. This figure represents the model for the proposed timing for ECPR. ECPR should be considered if return of spontaneous circulation (ROSC) is not obtained within 10–15 minutes or after 3 shocks for ventricular tachycardia (VT)/ventricular fibrillation (VF). The cannulation goal is <60 minutes. Perfusion is restored after cannulation; however, ROSC may not be achieved until the underlying cause is addressed. The left column shows proposals of brain injury mechanisms during different stages of resuscitation. Flow time refers to duration in minutes. Bystander cardiopulmonary resuscitation (CPR) refers to life support measures initiated by on-scene persons before the arrival of emergency medical services (EMS) or health care agents before the arrival of the code team. ECMO, extracorporeal membrane oxygenation.

  • Fig. 2. Components of neurologic complications, monitoring, and prognostication in extracorporeal cardiopulmonary resuscitation (ECPR). NIRS, near-infrared spectroscopy; TCD, transcranial Doppler; CT, computed tomography; NSE, neuron-specific enolase; GFAP, glial fibrillary acidic protein; S100B, calcium-binding protein B; ICAM-5, intercellular adhesion molecule 5; MCP-1/CCL2, monocyte chemoattractant protein 1/chemokine (C-C motif) ligand-2; BDNF, brain-derived neurotrophic factor; SSEP, somatosensory evoked potential; ECMO, extracorporeal membrane oxygenation; EEG, electroencephalography.


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