Incidence and Impact of Intracranial Complications in Patients Undergoing Extracorporeal Membrane Oxygenation Treatment

Introduction Extracorporeal membrane oxygenation (ECMO) is a life-saving intervention for respiratory and/or cardiac failure but is associated with high morbidity and mortality, particularly due to intracranial complications. Research Question What is the incidence, type, and impact of intracranial complications in patients undergoing ECMO treatment? Material and Methods This retrospective single-center study included ECMO patients treated at a tertiary care center between 2013 and 2023. Patients with documented intracranial hemorrhage, cerebral ischemic stroke, or diffuse hypoxic cerebral edema were included. Demographic, clinical, radiological, and outcome data were analyzed. Results Among 775 ECMO patients, 141 (18%) developed intracranial complications, including intracerebral hemorrhage (36%), subarachnoid hemorrhage (22%), diffuse hypoxic cerebral edema (25%), ischemic stroke (14%), and subdural hematoma (4%). Secondary deterioration (p=0.009), midline shift (p=0.005), and pupillary abnormalities (p<0.001), were associated with in-hospital mortality, though only pupillary abnormalities remained significant in multivariate analysis (p=0.006). Patients with diffuse hypoxic cerebral edema were younger (p<0.001), had lower multimorbidity (p=0.019, p<0.001) and disease burden (p=0.02, p=0.011), and showed less secondary deterioration (p<0.001) than those with bleeding or ischemic stroke. In-hospital mortality was higher in patients with intracranial complications (77%) compared to those without (59%, p<0.001). Most survivors revealed severe disability, with a median modified Rankin Scale score of 5 at discharge. Discussion and Conclusion Acute intracranial complications in patients undergoing ECMO are frequent, heterogeneous in presentation, and associated with poor outcomes. Pupillary abnormalities emerged as the strongest predictor of mortality. Early identification of high-risk patients may facilitate targeted monitoring and timely interventions to improve outcomes.