A Meta-Analysis on the Neurovascular Complications Of Extracorporeal Membrane Oxygenation In Critically Ill COVID-19 Patients
Cathy Meng Fei Li1, Daisy Deng2, Yu Fei Ma7, Carol Li3, Emily Dawson8, Lynn Huong4, Dong Yao Wang5, Teneille Gofton9, Atul Dave Nagpal6, Marat Slessarev5
1Department of Clinical Neurological Sciences, 2Schulich School of Medicine, 3Faculty of Health Sciences, 4Department of Physiology and Pharmacology, 5Department of Medicine, 6Department of Surgery, Western University, 7Division of Neurology, Department of Medicine, Queen's Univeristy, 8Department of Epidemiology and Biostatistics, Schulich School of Medicine, 9London Health Sciences Centre
Objective:
To determine the incidence and type of neurovascular complications in adult COVID-19 patients requiring veno-venous extracorporeal membrane oxygenation (VV-ECMO).
Background:
ECMO is a high-stakes intervention for patients with acute respiratory failure from severe COVID-19 infections. Introduction of extracorporeal circuit, COVID-19 associated endothelial injury and anticoagulation can predispose these patients to neurovascular complications, but the incidence of these adverse events in COVID-19 patients remains unknown.
Design/Methods:
We performed a systematic review and meta-analysis using MEDLINE, Embase, PsycINFO, and Cochrane databases to identify studies that reported neurological complications in adult COVID-19 patients receiving ECMO for respiratory failure. Among 840 identified studies, 28 studies (n = 3147) were included in the systematic review. Studies that had ≥95% of patients on VV-ECMO were pooled for meta-analyses.
Results:
The incidence of intracranial hemorrhages was 11% [95% CI, 8–15%], and the incidence of ischemic strokes was 2% [9%% CI, 1–3%] in patients with COVID-19 requiring VV-ECMO. Intraparenchymal and subarachnoid hemorrhages accounted for 73% and 8% of all intracranial hemorrhages, respectively. Higher anticoagulation targets did not influence the incidence of intracranial hemorrhages (p = 0.22). One study reported the occurrence of cerebral venous sinus thrombosis.
Conclusions:
Patients with COVID-19 requiring ECMO have a higher incidence of intracranial hemorrhage compared to historical data in non-COVID-19 patients (11% vs. 8%), while the incidence of ischemic stroke is similar (2%) in both cohorts. Intraparenchymal hemorrhage occurred most frequently. Despite earlier observations of higher thrombotic rates in COVID-19 patients, cerebral venous sinus thrombosis was rarely reported in COVID-19 patients requiring ECMO. Healthcare providers should be aware of these increased risks and maintain a high index of suspicion for intracranial hemorrhage in this patient population.