Focal Cerebral Injury in Pediatric Extracorporeal Life Support: Timing in Relation to Cannulation or Other Circuit Events in a Single-Center Retrospective Series, 2015-2023.

Abstract

Objectives: To review the timing of extracorporeal life support (ECLS)-related focal cerebral injury (FCI) in relation to circuit interruptions in children and young adults.

Design: Retrospective study from January 1, 2015, to December 31, 2023.

Setting: Single-center academic children's hospital.

Patients: Children and young adults younger than 21 years old who had neuroimaging during or after ECLS. Multiple ECLS runs in individual patients were analyzed as distinct runs.

Interventions: None.

Measurements and main results: FCI was radiographically defined as lateralized ischemia or hemorrhagic parenchymal brain injury greater than 1 cm3 or as subdural hemorrhage causing midline shift. Timing of clinical FCI documentation was abstracted from chart review and based on times of new-onset focal neurologic examination findings, focal electroencephalography findings, or incidental discovery on imaging. In instances of FCI, electroencephalography reports and inpatient progress notes were reviewed to identify electroencephalography-related timing of FCI. Institutional ECLS registry data were used to identify times of circuit events (i.e., cannulation, decannulation, and circuit interruptions). The probable time course of FCI after circuit events was evaluated in the ECLS runs with an imaging diagnosis of FCI, and summarized using cumulative distribution with 95% CI. In 101 ECLS runs in 94 patients with brain imaging, 20 had FCI: ischemic stroke in 12, intraparenchymal hemorrhage in six, and subdural hemorrhage with midline shift in two. Eighteen FCIs were documented within 48 hours of a circuit event. Among 13 FCIs with electroencephalography recording at the time of FCIs, eight had new-onset subclinical electroencephalography abnormality as the initial documented sign of FCI. The presence of FCI vs. not was associated with lower survival to decannulation (p = 0.007).

Conclusions: In this single-center retrospective series, 2015-2023, the majority of ECLS-related FCIs were evident within 48 hours of ECLS cannulation, decannulation, or circuit interruption. These events warrant increased surveillance for neurologic complications.