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Research ArticlePediatric Neuroimaging

Patterns of Brain Injury in Newborns Treated with Extracorporeal Membrane Oxygenation

M.A. Wien, M.T. Whitehead, D. Bulas, M. Ridore, L. Melbourne, G. Oldenburg, B.L. Short and A.N. Massaro
American Journal of Neuroradiology April 2017, 38 (4) 820-826; DOI: https://doi.org/10.3174/ajnr.A5092
M.A. Wien
aFrom the Divisions of Diagnostic Imaging and Radiology (M.A.W., M.T.W., D.B.)
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M.T. Whitehead
aFrom the Divisions of Diagnostic Imaging and Radiology (M.A.W., M.T.W., D.B.)
dThe George Washington University School of Medicine (M.T.W., D.B., L.M., A.N.M.), Washington, DC.
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D. Bulas
aFrom the Divisions of Diagnostic Imaging and Radiology (M.A.W., M.T.W., D.B.)
bNeonatology (D.B., M.R., L.M., B.L.S., A.N.M.)
dThe George Washington University School of Medicine (M.T.W., D.B., L.M., A.N.M.), Washington, DC.
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M. Ridore
bNeonatology (D.B., M.R., L.M., B.L.S., A.N.M.)
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L. Melbourne
bNeonatology (D.B., M.R., L.M., B.L.S., A.N.M.)
dThe George Washington University School of Medicine (M.T.W., D.B., L.M., A.N.M.), Washington, DC.
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G. Oldenburg
cthe ECMO Program (G.O.), Children's National Health System, Washington, DC
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B.L. Short
bNeonatology (D.B., M.R., L.M., B.L.S., A.N.M.)
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A.N. Massaro
bNeonatology (D.B., M.R., L.M., B.L.S., A.N.M.)
dThe George Washington University School of Medicine (M.T.W., D.B., L.M., A.N.M.), Washington, DC.
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  • Fig 1.
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    Fig 1.

    Types of intracranial injury associated with ECMO. Acute infarct within the right thalamus on DWI (arrow, A) and ADC (arrow, B) is classified as minor. Subacute infarct within the left MCA territory on T1 (arrows, C) and T2 (arrows, D) is classified as major. Punctate hemorrhage within the right frontal subcortical white matter on T2*-weighted angiography (arrow, E) is classified as minor. Hemorrhage within the cerebellum on T1 (arrow, F) and T2*-weighted angiography (arrow, G) is classified as major. Enlarged subarachnoid spaces are visible on axial T2 (H) and coronal T2 (I) views. Narrowing of the right ICA is visible on TOF MRA (arrows, J).

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    Fig 2.

    Location and frequency of brain injury. Heat maps demonstrate frequency of parenchymal injury on MR imaging (A) and sonography (B) in addition to comparison between VA (C) and VV (D) ECMO based on MR imaging lesions. MR imaging region key: 1, frontal cortex (left); 2, frontal cortex (right); 3, temporoparietal cortex (left); 4, temporoparietal cortex (right); 5, occipital cortex (left); 6, occipital cortex (right); 7, frontal white matter (left); 8, frontal white matter (right); 9, temporoparietal white matter (left); 10, temporoparietal white matter (right); 11, occipital white matter (left); 12, occipital white matter (right); 13, caudate (left); 14, caudate (right); 15, putamen (left); 16, putamen (right); 17, globus pallidus (left); 18, globus pallidus (right); 19, thalamus (left); 20, thalamus (right); 21, cerebellum (left); 22, cerebellum (right); and 23, brain stem. Sonography region key: 1, frontal (left); 2, frontal (right); 3, temporoparietal (left); 4, temporoparietal (right); 5, occipital (left); 6, occipital (right); 7, basal ganglia (left); 8, basal ganglia (right); 9, thalamus (left); 10, thalamus (right); and 11, posterior fossa.

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    Table 1:

    Clinical characteristics of patient populationa

    CharacteristicsTotal (n = 81)VA ECMO (n = 67)VV ECMO (n = 14)P Valueb
    Gestational age (wk)38.12 ± 3.1237.98 ± 2.8238.79 ± 4.35.382
    Birth weight (kg)3.16 ± 0.763.12 ± 0.723.35 ± 0.94.303
    Male, no. (%)48 (59)39 (81)9 (19).674
    Race, no. (%)
        White16 (20)13 (81)3 (19).804
        Black41 (50)35 (85)6 (15)
        Other24 (30)19 (79)5 (21)
    Apgar scorec
        1 mind5 (5)5 (4)4 (5).699
        5 mind7 (3)7.5 (2)7 (3).691
    Diagnosis, no. (%)
        MAS34 (42)25 (37)9 (64).033
        CDH17 (21)17 (25)0 (0)
        PPHN13 (16)12 (18)1 (7)
        Sepsis11 (14)7 (10)4 (29)
        Other6 (7)6 (9)0 (0)
    Age on ECMO (d)c,e2 (2)2 (3)1.5 (1.5).645
    ECMO hoursc168 (127)190 (128)103 (98).006
    Age at MRI (d)c26 (24)32 (24)16 (10).560
    Time from decannulation to MRI (d)c12 (16)13 (19)8 (4).034
    • Note:—CDH indicates congenital diaphragmatic hernia; MAS, meconium aspiration syndrome; PPHN, persistent pulmonary hypertension of the newborn.

    • ↵a Data presented as mean ± SD or proportions except where noted.

    • ↵b Comparison between VA and VV.

    • ↵c Data presented as median (interquartile range).

    • ↵d Data available for 79/81 patients.

    • ↵e Data available for 67/81 patients.

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    Table 2:

    Distribution of hemorrhagic and ischemic brain injuries by MRIa

    Description of InjuryHemorrhagic Injury (n = 19)Ischemic Injury (n = 18)
    Focality
        Unifocal (total)4 (21)4 (22)
            Unilateral right3 (16)3 (17)
            Unilateral left1 (5)1 (6)
        Multifocal (total)15 (79)14 (78)
            Unilateral right1 (5)1 (6)
            Unilateral left2 (10)4 (22)
            Bilateral12 (63)9 (50)
        Supratentorial16 (84)16 (89)
        Infratentorial6 (32)1 (6)
    Anatomic location
        Cortex and white matter2 (10)12 (67)
        White matter only10 (52)5 (28)
        Deep gray nuclei2 (10)7 (39)
        Brain stem3 (16)1 (6)
        Cerebellum5 (26)0 (0)
    Vascular territory
        ACANA4 (22)
        MCANA4 (22)
        PCANA1 (6)
    Extra-axial
        Minor (no mass effect)7 (37)NA
        Major (mass effect)1 (5)NA
    • Note:—ACA indicates anterior cerebral artery; NA, not applicable; PCA, posterior cerebral artery.

    • ↵a Data presented as no. of patients (%).

    • View popup
    Table 3:

    Comparison of intracranial injuries seen on MRI by type of ECMOa

    MRI FindingsTotal (n = 81)VA ECMO (n = 67)VV ECMO (n = 14)P Valueb
    Any injury (hemorrhage, infarction, volume loss, increased subarachnoid spaces)37 (46)33 (49)4 (29).157
    Any hemorrhage19 (23)15 (22)4 (26).247
    Major hemorrhage3 (4)3 (4)0 (0).420
    Minor hemorrhage16 (20)12 (18)4 (29).362
    Any infarction18 (22)16 (24)2 (14).432
    Major infarction (total including arterial,c venous infarcts, and others)8 (10)8 (12)0 (0).173
    Arterial: ACA territory4 (5)4 (6)0 (0).879
    Arterial: MCA territory4 (5)4 (6)0 (0).879
    Arterial: PCA territory1 (1)1 (1)0 (0).646
    Minor infarctions (total)10 (13)8 (12)2 (14).808
    Cerebellar injury5 (6)5 (7)0 (0).291
    Volume loss
        Any28 (35)25 (37)3 (21).256
        Cortical5 (6)5 (7)0 (0).291
        White matter27 (33)24 (36)3 (21).299
        Deep gray nuclei3 (4)3 (4)0 (0).420
        Cerebellum3 (4)3 (4)0 (0).420
        Brain stem3 (4)3 (4)0 (0).420
    Ventricular size
        Normal60 (74)49 (73)11 (79).673
        Slit2 (3)2 (3)0 (0).513
        Mild ventriculomegaly14 (17)11 (16)3 (21).652
        Moderate ventriculomegaly4 (5)4 (6)0 (0).879
        Severe ventriculomegaly1 (1)1 (1)0 (0).646
        Increased subarachnoid spaces36 (44)34 (51)2 (14).012
    • ↵a Data presented as no. of patients (%).

    • ↵b Comparison between VA and VV.

    • ↵c There was overlap among arterial territories on some studies.

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American Journal of Neuroradiology: 38 (4)
American Journal of Neuroradiology
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1 Apr 2017
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M.A. Wien, M.T. Whitehead, D. Bulas, M. Ridore, L. Melbourne, G. Oldenburg, B.L. Short, A.N. Massaro
Patterns of Brain Injury in Newborns Treated with Extracorporeal Membrane Oxygenation
American Journal of Neuroradiology Apr 2017, 38 (4) 820-826; DOI: 10.3174/ajnr.A5092

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Patterns of Brain Injury in Newborns Treated with Extracorporeal Membrane Oxygenation
M.A. Wien, M.T. Whitehead, D. Bulas, M. Ridore, L. Melbourne, G. Oldenburg, B.L. Short, A.N. Massaro
American Journal of Neuroradiology Apr 2017, 38 (4) 820-826; DOI: 10.3174/ajnr.A5092
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