Neuroimaging of brain injury in neonates treated with extracorporeal membrane oxygenation: lessons learned from serial examinations

Abstract

The head ultrasound (US) is used extensively at most extracorporeal membrane oxygenation (ECMO) centers to screen for intracranial pathology in the ECMO candidate. Daily head US examinations are obtained in patients on ECMO to detect the emergence of intracranial hemorrhage (ICH). The authors asked whether these serial studies could be correlated with more definitive diagnostic studies, such as computed tomography (CT) and magnetic resonance imaging (MRI) scans, autopsy data, or the long-term neurodevelopmental status, to discern the predictive value of these daily examinations. Seventy-four consecutively treated neonates with reversible respiratory failure refractory to conventional support met institutional criteria for placement on ECMO. In addition to a pre-ECMO US, daily real-time portable head US images were evaluated for changes in echotexture, ventricular configuration, and extraaxial fluid. Follow-up CT and MRI scans were evaluated for the presence of hemorrhagic or ischemic lesions. Autopsy data were obtained from nonsurvivors. Survivors were examined by a neurodevelopmental specialist at regular intervals and classified as normal or delayed for chronological age. In this series of 74 patients, CT/MRI scanning and autopsy data demonstrated structural injury in 19 patients; there were 16 ischemic infarctions and three hemorrhages. The incidence of hemorrhage in this series was considerably lower than that previously reported. Ten of the 19 patients had serial head US findings demonstrating a progression from focal increases in echotexture to diffuse effacement of cerebral architecture. In the remaining nine, serial head US examinations did not show injury. An additional 10 children had a clear delay in neurological development despite no evidence of anatomic injury on serial head US examinations or CT/MRI scanning.(ABSTRACT TRUNCATED AT 250 WORDS)