Transcranial Doppler microemboli and acute brain injury in extracorporeal membrane oxygenation: A prospective observational study

Abstract

Objective: Extracorporeal membrane oxygenation (ECMO) carries a high morbidity of acute brain injury (ABI) with resultant mortality increase. Transcranial Doppler (TCD) allows real-time characterization of regional cerebral hemodynamics, but limited data exist on the interpretation of microembolic signals (MES) in ECMO.

Methods: This prospective cohort study was conducted at a single tertiary care center, November 2017 through February 2022, and included all adult patients receiving venoarterial (VA) and venovenous (VV) ECMO undergoing TCD examinations, which all included MES monitoring.

Results: Of 145 patients on ECMO who underwent at least 1 TCD examination, 100 (68.9%) patients on VA-ECMO received 187 examinations whereas 45 (31.1%) patients on VV-ECMO received 65 examinations (P = .81). MES were observed in 35 (35.0%) patients on VA-ECMO and 2 (4.7%) patients on VV-ECMO (P < .001), corresponding to 46 (24.6%) and 2 (3.1%) TCD examinations, respectively. MES were present in 29.4% of patients on VA-ECMO without additional cardiac support, compared with 38.1% with intra-aortic balloon pump and 57.1% with left ventricular assist device, but these differences were not statistically significant (P = .39; P = .20, respectively). Presence or number of MES was not associated with VA-ECMO cannulation mode (23.4% MES presence in peripheral cannulation vs 25.8% in central cannulation, P = .80). In both VA- and VV-ECMO, MES presence or number was not associated with presence of clot or fibrin in the ECMO circuit or with any studied hemodynamic, laboratory, or ECMO parameters at the time of TCD. ABI occurred in 38% and 31.1% of patients on VA- and VV-ECMO, respectively. In multivariable logistic regression analyses, neither ABI nor a composite outcome of arterial thromboembolic events was associated with presence or number of MES in VA- ECMO.

Conclusions: TCD analysis in a large cohort of patients on ECMO demonstrates a significant number of MES, especially in patients on VA-ECMO with intra-aortic balloon pump, and/or left ventricular assist device. However, clinical associations and significance of TCD MES remain unresolved and warrant further correlation with systematic imaging and long-term neurologic follow-up.

Keywords: ABI, acute brain injury; ACA, anterior cerebral artery; BA, basilar artery; ECMO; ECMO, extracorporeal membrane oxygenation; HIBI, hypoxic ischemic brain injury; ICA, internal carotid artery; MCA, middle cerebral artery; MES; MES, microembolic signal; TCD; TCD, transcranial Doppler; VA, venoarterial; VV, venovenous; VrA, vertebral artery; aPTT, activated partial thromboplastin time; brain injury; emboli; extracorporeal membrane oxygenation; stroke; transcranial Doppler.

High microembolic signals in the left middle cerebral artery in VA-ECMO patient.

Figure 1

Study design and participant selection. Patients receiving at least 1 transcranial Doppler (TCD) examination were selected from a prospective cohort of venoarterial (VA) and venovenous (VV) extracorporeal membrane oxygenation (ECMO) at a single tertiary care center.

Figure 2

Number and timing of transcranial Doppler (TCD) examinations with respect to cannulation among included patients on venoarterial (VA)- and venovenous (VV)-extracorporeal membrane oxygenation (ECMO).

Figure 3

Examples of transcranial Doppler (TCD) waveforms exhibiting high microembolic signals in the left middle cerebral artery in patients receiving (A) venoarterial (VA) and (B) venovenous (VV) extracorporeal membrane oxygenation (ECMO). MCA, Middle cerebral artery.