Acute Brain Injury in Neonatal and Infant ECMO: An Autopsy Study (2413)

Objective: Characterization of types, timing, and risk factors of ABI in ECMO neonatal and infant patients. Background: Estimated prevalence of ABI in ECMO varies from 10% to 59% by neuroimaging and 46% to 63% at autopsy. Mechanism and timing of ABI are not well described, as it may occur due to hypoxia or hemodynamic instability prior to ECMO and/or due to adverse events during ECMO course. Design/Methods: This retrospective cohort study reviewed clinical and pathological records from neonatal and infant ECMO patients who had undergone brain autopsy from January 2009 through December 2018 at a single tertiary center. Results: Twenty-four venoarterial ECMO neonatal and infant patients had postmortem examination with brain autopsy. Median age at initiation of ECMO was 82 days (IQR, 11–263); median age at time of death was 20 weeks (IQR, 5–44); median ECMO support duration was 108 hours (IQR, 35–366). Most common ABI was hypoxic-ischemic brain injury (HIBI; 50%) followed by intracranial hemorrhage (29%). Of 19 patients with ABI, 14 (74%) had documented neurological injury prior to autopsy based on clinical (4, 29%) or radiological (10, 71%) findings. Median time from cannulation to diagnosis of brain injury was 3.7 days (IQR: 0.33–8), and 3 (21%) patients had ABI before cannulation. Most common types of intracranial hemorrhage were intracerebral (17%), subarachnoid (17%), and subdural (8%). Risk factors for ABI included low pre-ECMO oxygen saturation as well as elevated liver enzymes, bilirubin, and lactate on days 1 and 3 of ECMO. Gestational age, Apgar scores, birth weight, ECMO duration, cannulation method, antithrombotic therapy, renal and hepatic impairment were not associated with ABI. Conclusions: ABI was observed in 79% of neonatal and infant ECMO autopsy patients. HIBI was the most common type of injury and neurological complications arose several days after ECMO initiation, suggesting that ~50% of patients sustained ABI in the peri-cannulation period. Disclosure: Dr. Caturegli has nothing to disclose. Dr. Chen has nothing to disclose. Dr. Cho has nothing to disclose.