Intracranial hemorrhage during the use of venovenous ecmo in COVID 19: A case series

Document Type

Conference Proceeding

Publication Date


Publication Title

Crit Care Med


INTRODUCTION/HYPOTHESIS: The COVID-19 outbreak was declared a pandemic by the World Health Organization on March 11, 2020. Severe infections can lead to multiorgan failure targeting respiratory and cardiac systems. Treatments have been evolving, with mechanical ventilation as the mainstay for cardiopulmonary support, however, there are instances where ventilatory support is inadequate. In these situations, observational reports have shown promise when using veno-venous extracorporeal membrane oxygenation (VVECMO). Despite ECMO being a valid option there have been reported complications possibly due to viral pathophysiology posing unique perturbations not seen in other cases of acute respiratory distress syndrome (ARDS). These complications include ischemic and hemorrhagic strokes that may result from prolonged hypoxia and microinfarcts in areas of the brain most susceptible to hypoxic injury. We present a case series that reviews a single center's intracranial hemorrhage (ICH) complications at a rate that exceeds previous reports seen in VVECMO for ARDS. METHODS: A case series of 12 COVID-19 patients from single urban academic institution in Detroit, Michigan requiring VVECMO. Patients' demographics and clinical characteristics were reviewed. RESULTS: Twelve patients were supported on VV ECMO for ARDS for a mean duration of 11.75 days. Six of 12 patients had ICH, amongst this group, 5/6 received therapeutic anticoagulation pre-ECMO. Mortality was 100% amongst those with ICH and those without ICH had 100% survival to discharge. CONCLUSIONS: We report a single center experience of increased rates of ICH when using VVECMO for COVID patients with severe ARDS. While we recognize this is a small cohort of patients, it is important for clinicians to be aware of this potential complication given the significant morbidity and mortality associated. Potential etiologies include prior ischemic injuries due to episodes of hypoxia, rapid normalization of PaCO2 levels, and therapeutic parenteral anticoagulation prior to ECMO. Deliberation of risks, benefits, and neurologic assessments prior to initiation of VVECMO in patients with COVID-19 ARDS needs to be taken. Additionally, prospective studies are needed to determine safe ECMO management practices in this complicated patient population.

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