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Meta-Analysis
. 2023 Nov;38(8):1722-1733.
doi: 10.1177/02676591221130886. Epub 2022 Oct 1.

Ischemic stroke and intracranial hemorrhage in extracorporeal membrane oxygenation for COVID-19: A systematic review and meta-analysis

Yu Jin  1 , Yang Zhang  2 , Jinping Liu  1
Affiliations
Meta-Analysis

Ischemic stroke and intracranial hemorrhage in extracorporeal membrane oxygenation for COVID-19: A systematic review and meta-analysis

Yu Jin et al. Perfusion. 2023 Nov.

Abstract

Purpose: Extracorporeal membrane oxygenation (ECMO) is employed to support critically ill COVD-19 patients. The occurrence of ischemic stroke and intracranial hemorrhage (ICH), as well as the implementation of anticoagulation strategies under the dual influence of ECMO and COVID-19 remain unclear. We conducted a systematic review and meta-analysis to describe the ischemic stroke, ICH and overall in-hospital mortality in COVID-19 patients receiving ECMO and summarize the anticoagulation regimens.

Methods: EMBASE, PubMed, Cochrane, and Scopus were searched for studies examining ischemic stroke, ICH, and mortality in COVID-19 patients supported with ECMO. The outcomes were incidences of ischemic stroke, ICH, overall in-hospital mortality and anticoagulation regimens. We calculated the pooled proportions and 95% confidence intervals (CIs) to summarize the results.

Results: We analyzed 12 peer-reviewed studies involving 6039 COVID-19 patients. The incidence of ischemic stroke had a pooled estimate of 2.2% (95% CI: 1.2%-3.2%). The pooled prevalence of ICH was 8.0% (95% CI: 6.3%-9.6%). The pooled estimate of overall in-hospital mortality was 40.3% (95% CI: 33.1%-47.5%). The occurrence of ICH was significantly higher in COVID-19 patients supported with ECMO than in other respiratory ECMO [relative risk=1.75 (95% CI: 1.00-3.07)]. Unfractionated heparin was the most commonly used anticoagulant, and anticoagulation monitoring practice varied among centers.

Conclusions: Ischemic stroke and ICH were common under the double "hit" of COVID-19 and ECMO. The prevalence of ICH was significantly higher in COVID-19 patients supported with ECMO than non-COVID-19 patients requiring ECMO. Individualized anticoagulation regimens may be a good choice to balance thrombosis and bleeding. More detailed research and further exploration are needed to clarify the underlying mechanism and clinical management decisions.

Keywords: COVID-19; anticoagulation; extracorporeal membrane oxygenation; intracranial hemorrhage; ischemic stroke; overall in-hospital mortality.

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Conflict of interest statement

Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Figures

Figure 1.
Figure 1.
Preferred Reporting Items for Systematic reviews and Meta-Analyses flowchart.
Figure 2.
Figure 2.
Forest plot of incidence of ischemic stroke in COVID-19-related ECMO.
Figure 3.
Figure 3.
Forest plot of incidence of intracranial hemorrhage in COVID-19-related ECMO.
Figure 4.
Figure 4.
Forest plot of overall in-hospital mortality in COVID-19-related ECMO.
Figure 5.
Figure 5.
Comparison of the incidence of ischemic stroke and intracranial hemorrhage in the COVID-19 patients requiring ECMO with non-COVID-19 patients supported with ECMO.
See this image and copyright information in PMC

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