Use of extracorporeal membrane oxygenation during a decompressive hemicraniectomy for severe traumatic brain injury: illustrative case

Abstract

Background: Decompressive hemicraniectomy (DHC) can be a life-saving treatment for patients with severe traumatic brain injury (TBI) with a focal mass lesion who develop refractory elevated intracranial pressure (ICP). Nonetheless, successful completion of this procedure requires maintaining hemodynamic and respiratory stability. Extracorporeal membrane oxygenation (ECMO) use in patients with respiratory or cardiac failure is well described in the literature and has become routinely used in patients with refractory hypoxia unresponsive to traditional mechanical ventilation strategies, but few cases of its use have been reported in the neurosurgical literature.

Observations: Herein, the authors describe a unique case in which a man presented after an unwitnessed fall that caused severe TBI without a focal mass lesion. The patient subsequently developed medically refractory elevated ICP secondary to traumatic cerebral edema. He required DHC, but the procedure could only be completed safely with the utilization of intraoperative ECMO.

Lessons: As more is learned about the techniques and pitfalls of ECMO, its indications are rapidly expanding. The case presented describes the safe use of ECMO during a major neurosurgical procedure, showing that the technique can be completed safely and offering a therapeutic option for effectively addressing refractory hypoxia and hypercarbia in patients with severe TBI who require urgent or emergency neurosurgical procedures. https://thejns.org/doi/10.3171/CASE24264.

Keywords: case report; decompressive hemicraniectomy; extracorporeal membrane oxygenation; traumatic brain injury.

FIG. 1.

Axial cuts of the initial preoperative CT of the head, showing a left occipital skull fracture with extension to the skull base, SAH in the anterior interhemispheric fissure, and evidence of diffuse brain edema.

FIG. 2.

Chest radiograph at the time of the initial DHC attempt, showing significant interval increase in bilateral pulmonary opacities, with the right side greater than the left.

FIG. 3.

Postoperative axial CT revealing appropriate decompression with stable multicompartmental intracranial hemorrhages with no new intracranial bleeding or increase in midline shift.

FIG. 4.

Postoperative coronal CT revealing decompression down to the floor of the middle fossa.