Understanding Characteristics of Acute Brain Injury in Adult Extracorporeal Membrane Oxygenation: An Autopsy Study*
Understanding Characteristics of Acute Brain Injury in Adult Extracorporeal Membrane Oxygenation: An Autopsy Study*
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DOI：
10.1097/ccm.0000000000004289
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发表时间：
2020-06-01
影响因子：
8.8
通讯作者：
Chen, Liam L.
中科院分区：
文献类型：
--
作者：
Cho, Sung-Min;Geocadin, Romergryko G.;Chen, Liam L.
目的：目前的研究缺乏体外膜氧合患者急性脑损伤特征的信息。我们试图描述体外膜氧合中急性脑损伤的类型、时间和危险因素。设计：回顾性分析。背景：我们回顾了 2009 年 1 月至 2018 年 12 月在单一三级中心接受脑部尸检并进行肉眼和显微镜检查的体外膜氧合患者。患者：25 名患者（中位年龄 53 岁）有死后脑部尸检。干预措施：神经病理学结果的描述和分析。测量和主要结果：25 例中，22 例接受了静脉-动脉体外膜氧合（88%）（9 例心脏骤停；13 例心源性休克），3 例接受了静脉-静脉体外膜氧合插管（12%）。中位体外膜氧合支持时间为 96 小时（四分位数范围，26-181 小时）。最常见的急性脑损伤是缺氧缺血性脑损伤（44%），其次是颅内出血（24%）和缺血性梗死（16%）。蛛网膜下腔出血（20%）是最常见的颅内出血类型，其次是脑内出血（8%）和硬膜下出血（4%）。只有八名患者（32%）在体外膜肺氧合后没有出现急性脑损伤。缺氧缺血性脑损伤最常见的累及部位是大脑皮质（82%）和小脑（55%）。缺血性梗塞的模式是大脑皮质区域性的。急性脑损伤的危险因素包括高血压病史（11 vs 1；p = 0.01）、体外膜氧合抗血小板药物使用（7 vs 0；p = 0.03）和第 1 天乳酸水平较高（10.0 vs 5.1；p = 0.02）。缺氧缺血性脑损伤患者的高血压程度较高（8 vs 4；p = 0.047），第 1 天乳酸水平较高（12.6 vs 5.8；p = 0.02），pH 水平较低（7.09 vs 7.24；p = 0.027）。体外膜氧合持续时间、插管方法、血红蛋白水平、昏迷、肾功能损害和肝功能损害与急性脑损伤无关。结论：在接受死后神经病理学评估的人群中，68%的体外膜氧合非幸存者发生急性脑损伤。缺氧缺血性脑损伤是最常见的损伤类型，表明患者因心源性休克和心脏骤停而遭受急性脑损伤。有必要进行系统性神经系统监测的进一步研究，以确定体外膜氧合患者发生急性脑损伤的时间。
Objectives:Current studies lack information on characteristics of acute brain injury in patients with extracorporeal membrane oxygenation. We sought to characterize the types, timing, and risk factors of acute brain injury in extracorporeal membrane oxygenation.Design:Retrospective analysis.Setting:We reviewed the extracorporeal membrane oxygenation patients who had undergone brain autopsy with gross and microscopic examinations from January 2009 to December 2018 from a single tertiary center.Patients:Twenty-five patients (median age 53 yr) had postmortem brain autopsy.Interventions:Description and analysis of neuropathologic findings.Measurement and Main Results:Of 25, 22 had venoarterial extracorporeal membrane oxygenation (88%) (nine cardiac arrest; 13 cardiogenic shock) and three had venovenous extracorporeal membrane oxygenation cannulation (12%). The median extracorporeal membrane oxygenation support time was 96 hours (interquartile range, 26-181 hr). The most common acute brain injury was hypoxic-ischemic brain injury (44%), followed by intracranial hemorrhage (24%), and ischemic infarct (16%). Subarachnoid hemorrhage (20%) was the most common type of intracranial hemorrhage, followed by intracerebral hemorrhage (8%), and subdural hemorrhage (4%). Only eight patients (32%) were without acute brain injury after extracorporeal membrane oxygenation. The most common involved location for hypoxic-ischemic brain injury was cerebral cortices (82%) and cerebellum (55%). The pattern of ischemic infarct was territorial in cerebral cortices. The risk factors for acute brain injury included hypertension history (11 vs 1; p = 0.01), preextracorporeal membrane oxygenation antiplatelet use (7 vs 0; p = 0.03), and a higher day 1 lactate level (10.0 vs 5.1; p = 0.02). Patients with hypoxic-ischemic brain injury had more hypertension (8 vs 4; p = 0.047), a higher day 1 lactate level (12.6 vs 5.8; p = 0.02), and a lower pH level (7.09 vs 7.24; p = 0.027). Extracorporeal membrane oxygenation duration, cannulation methods, hemoglobin level, coma, renal impairment, and hepatic impairment were not associated with acute brain injury.Conclusions:In the population who underwent postmortem neuropathologic evaluation, 68% of extracorporeal membrane oxygenation nonsurvivors developed acute brain injury. Hypoxic-ischemic brain injury was the most common type of injury suggesting that patients sustained acute brain injury as a consequence of cardiogenic shock and cardiac arrest. Further research with a systematic neurologic monitoring is necessary to define the timing of acute brain injury in patients with extracorporeal membrane oxygenation.