The Use of Extracorporeal Membrane Oxygenation in Traumatic Brain Injury and Neurosurgical Patients: A Single-Center Analysis and Systematic Review

BACKGROUND: This study evaluates the outcomes and management considerations associated with using extracorporeal membrane oxygenation (ECMO) in patients with traumatic brain injury (TBI), including those requiring neurosurgical intervention. It examines the feasibility of managing patients with TBI and neurosurgical patients on ECMO by synthesizing institutional data with the existing literature, emphasizing observed clinical contexts, anticoagulation strategies, and peri-procedural factors relevant to safe ECMO use. Our aim is to elucidate the potential for ECMO to be safely applied in patients with TBI needing intensive cardiopulmonary support, and for neurosurgical intervention to remain an option when indicated. METHODS: We retrospectively reviewed the medical records of seven patients with TBI who received ECMO therapy at our institution. The peri-ECMO period was defined as 7 days before ECMO cannulation to 7 days after decannulation. A systematic review of the literature was conducted to compare outcomes, complications, and management strategies. RESULTS: Most patients in our cohort were managed without systemic anticoagulation during ECMO treatment. Five patients underwent neurosurgical procedures in the peri-ECMO period with overall positive outcomes. In the systematic review, outcomes for patients with TBI receiving ECMO varied; while some demonstrated neurological improvement, others succumbed to complications such as septic shock and multiorgan failure. A subset of patients with TBI developed intracranial hemorrhage (ICH) while on ECMO, a concern that often discourages its use. They, along with other non-TBI patients who developed ICH while on ECMO, were subsequently treated with neurosurgical interventions with the majority showing functional improvement. Key factors affecting prognosis included ICH size, timing of neurosurgical intervention, and careful adjustment of anticoagulation therapy. CONCLUSIONS: This study highlights that ECMO can be safely utilized in patients with TBI requiring intensive cardiopulmonary support, including those undergoing neurosurgical procedures for ECMO-related complications. In this high-risk population, maintaining ECMO circuits without systemic anticoagulation or with conservative anticoagulation should be considered. Our findings suggest that TBI should not be an absolute contraindication for ECMO therapy, and neurosurgical interventions can be safely performed in these patients, especially when ICH occurs.