# Cerebrovascular Strokes During Venoarterial Extracorporeal Membrane Oxygenation

## TL;DR

This study finds that cerebrovascular strokes are common during VA-ECMO and are linked to worse outcomes, especially for hemorrhagic strokes.

## Contribution

The study identifies novel predictors of ischemic and hemorrhagic strokes in VA-ECMO patients, including lactate levels and thrombocytopenia.

## Key findings

- 35 out of 173 VA-ECMO patients (20.2%) developed acute cerebrovascular strokes.
- Intracranial hemorrhage was associated with higher hospital mortality compared to ischemic stroke.
- Higher initial lactate levels and poor lactate clearance were linked to ischemic stroke risk.

## Abstract

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a life-saving mechanical support in patients with cardiogenic shock. There are great variations in the reported rates of neurological complications and associated mortality. Our aim was to analyze our cohort of adult patients supported with VA-ECMO to identify the incidence, outcomes, and predictors of acute ischemic and hemorrhagic strokes.

A total of 195 patients between January 2016 and January 2023 were reviewed, 22 (11.3%) ECPR patients were excluded, and 173 (88.7%) patients were analyzed. We divided the patients into stroke and nonstroke groups according to the presence of radiologically confirmed acute ischemic and hemorrhagic strokes.

Thirty-five (20.2%) patients had acute cerebrovascular strokes. 13 (7.5%) patients had intracranial hemorrhage (ICH) while 22 (12.7%) patients had ischemic stroke. The median age was 48 years (IQR: 31, 56), 98 (56.6%) patients were males, and 152 (87.9%) patients had cardiac surgeries. The patients who developed cerebrovascular stroke had higher blood lactate at ECMO initiation (8.9 [5.5, 11.2] versus 5.7 [4.6, 11.9] mmol/L, p = 0.02) and 12 h later (8.7 [4.7, 14.5] versus 5.8 [4.6, 15] mmol/L, p = 0.024) with lesser lactate clearance (LC) at 12 h (6.35 [−51.5, 40.6] versus 14.65% [−43.55, 38.3], p < 001) compared to the patients in the nonstroke group. The stroke group had longer ICU stay (21 vs. 15.5 days, p = 0.03), higher frequency of new hemodialysis (62.9% vs. 46.4%, p = 0.026), and on-ECMO mortality (54.3% vs. 44.9%, p = 0.041) compared with the nonstroke group. The ICH was associated with higher hospital mortality (p = 0.021) compared to the ischemic stroke. Logistic multivariate regression revealed that the initial lactate level (OR: 1.6, 95% CI: 1.2–8.92, p = 0.031), cardiopulmonary bypass time (OR:1.8, 95% CI: 1.32–6.42, p = 0.02), and LC at 12 h (OR: 2.4, 95% CI: 1.91–17.4, p = 0.042) were associated with ischemic stroke. Thrombocytopenia (OR: 3.22, 95% CI: 1.82–7.83, p = 0.001) and low body mass index (OR: 2.1, 95% CI: 1.31–4.6, p = 0.02) were associated with ICH.

Ischemic and hemorrhagic strokes are frequent with VA-ECMO support and associated with worse outcomes, especially the hemorrhagic type. Awareness of the incidence and the factors associated with strokes is crucial in early identification and management.