Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
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.

PubMed Disclaimer

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

References

    1. Barbaro RP, MacLaren G, Boonstra PS, et al. Extracorporeal membrane oxygenation support in COVID-19: an international cohort study of the Extracorporeal Life Support Organization registry. Lancet 2020; 396: 1071–1078. - PMC - PubMed
    1. Barbaro RP, MacLaren G, Boonstra PS, et al. Extracorporeal membrane oxygenation for COVID-19: evolving outcomes from the international Extracorporeal Life Support Organization Registry. Lancet 2021; 398: 1230–1238. - PMC - PubMed
    1. Nunez JI, Gosling AF, O'Gara B, et al. Bleeding and thrombotic events in adults supported with venovenous extracorporeal membrane oxygenation: an ELSO registry analysis. Intensive Care Med 2022; 48(2): 213–224. - PMC - PubMed
    1. Reporting COVID-19 Cases into the ELSO Registry. Available from:https://www.elso.org/COVID19.aspx
    1. Doyle AJ, Hunt BJ. Current Understanding of How Extracorporeal Membrane Oxygenators Activate Haemostasis and Other Blood Components. Front Med (Lausanne) 2018; 5: 352. - PMC - PubMed

MeSH terms