Neurosurgical Procedures in Patients Requiring ECMO (NSPIRE)
Samantha Marie Helmy1, Ryan Lee2, Jeronimo Cardona1, David Zhao4, Raymond Rector3, Joseph Rabin3, Michael Mazzeffi5, Sung-Min Cho4, Nicholas Morris6, Imad Khan7
1University of Rochester School of Medicine and Dentistry, 2Critical Care, 3Surgery, University of Maryland School of Medicine, 4Johns Hopkins University School of Medicine, 5Anesthesiology, University of Virginia Medical Center, 6University of Maryland Medical Center, 7University of Rochester Medical Center
Objective:
The objective is to improve understanding of the indications, risks, benefits, and outcomes of adults who require neurosurgical interventions while undergoing extracorporeal membrane oxygenation (ECMO). 
Background:

ECMO is a lifesaving intervention often withheld in patients requiring acute neurosurgical intervention given associated risks. Outcomes for ECMO patients requiring neurosurgery are rarely reported.

Design/Methods:
A retrospective chart review of adult ECMO patients from 2015-2023 who underwent neurosurgery during or before ECMO therapy in the same hospitalization was performed independently at 4 institutions and combined for analysis. The primary outcome was survival to hospital discharge. The key secondary outcome was survival to discharge with good neurologic outcome (Cerebral Performance Category [CPC] 1-2).
Results:

In total, 24 patients were evaluated. Of the total, 88% were male with a mean age of 40.9 years. Neurosurgical intervention indications included traumatic brain injury (n=7), spinal injury (n=3), spontaneous intracranial hemorrhage (n=6) and acute ischemic stroke (n=5). Neurosurgical procedures performed included EVD/ICP monitor placement (n=10), craniectomy/craniotomy (n=5), endovascular thrombectomy (n=4) and spinal surgery (n=3). Neurosurgery was performed during ECMO in 11 (46%) patients while the remainder occurred prior to ECMO. ECMO indications included acute respiratory distress syndrome (ARDS) (n= 11), cardiac arrest (n=6) and refractory shock (n=6). Sequential organ failure assessment (SOFA) scores on cannulation day averaged 10.7. 

Fifteen (63%) patients survived discharge, 12 (80%) of whom with favorable neurologic outcome (CPC 1-2).
Survival to discharge was similar between those who had neurosurgical procedures performed while on ECMO (7/11, 63%) and prior to ECMO (8/13, 62%). ECMO related complications occurred in 17/24 (62.9%) patients while 3/24 (12.5%) experienced a complication related to neurosurgery. The cohort had similar survival to discharge as a comparison of Extracorporeal Life Support Organization registry patients from 2018-2022 of 53.3%.

Conclusions:
Carefully selected patients requiring neurosurgical intervention treated with ECMO have comparable survival outcomes.
10.1212/WNL.0000000000204459