Neurologic complications in venoarterial versus venovenous extracorporeal membrane oxygenation: A propensity score-matched retrospective cohort study

BACKGROUND: Neurologic complications are among the most devastating events associated with extracorporeal membrane oxygenation (ECMO), yet propensity-balanced comparisons of mode-specific neurologic risk between venoarterial (VA) and venovenous (VV) configurations remain limited. OBJECTIVES: To compare the 30-day incidence of five discrete neurologic outcomes: ischemic stroke, hemorrhagic stroke, seizures, hypoxic-ischemic encephalopathy (HIE), and brain death, between adult VA and VV ECMO patients. METHODS: In this retrospective cohort study using the TriNetX federated network, adults undergoing VA or VV ECMO (2015-2024) were identified by ICD-10-PCS codes and 1:1 propensity score matched on demographics, comorbidities, and antithrombotic exposures. Odds ratios (OR), risk ratios, and hazard ratios (HR) with 95% confidence intervals (CI) were estimated within 30 days; multivariable Cox regression was performed for each outcome. RESULTS: After matching (6944 per cohort), VA ECMO was associated with higher 30-day rates of cerebral infarction (7.04%vs 5.13%; OR 1.40, 95% CI 1.22-1.61), seizures (OR 1.15, 1.002-1.324), HIE (OR 2.17, 1.82-2.58), and brain death (OR 2.63, 1.67-4.14). Hemorrhagic stroke did not differ (OR 0.83, 0.66-1.04). Cox models concordantly showed higher hazard for all outcomes except hemorrhagic stroke (brain death adjusted HR 2.37, 1.58-3.57); heparin exposure was associated with lower hazard of cerebral infarction and HIE. CONCLUSION: VA ECMO was associated with higher 30-day ischemic and hypoxic-ischemic neurologic risk than VV ECMO, while hemorrhagic risk did not differ. The hypoxic-ischemic endpoints are not separable from the indication for VA support and reflect burden rather than modality effect. These findings motivate prospective evaluation of mode-specific neurologic surveillance.