Themas Konstantinos, Zisis Marios, Kourek Christos, Konstantinou Giorgos, D'Anna Lucio, Papanagiotou Panagiotis, Ntaios George, Dimopoulos Stavros, Korompoki Eleni
Medical School, National and Kapodistrian University of Athens, 157 72 Athens, Greece.
Department of Cardiology, 417 Army Share Fund Hospital of Athens (NIMTS), 115 21 Athens, Greece.
J Clin Med. 2024 Oct 9;13(19):6014. doi: 10.3390/jcm13196014.
Ischemic stroke (IS) is a severe complication and leading cause of mortality in patients under extracorporeal membrane oxygenation (ECMO). The aim of our narrative review is to summarize the existing evidence and provide a deep examination of the diagnosis and treatment of acute ischemic stroke patients undergoing ECMO support. The incidence rate of ISs is estimated to be between 1 and 8%, while the mortality rate ranges from 44 to 76%, depending on several factors, including ECMO type, duration of support and patient characteristics. Several mechanisms leading to ISs during ECMO have been identified, with thromboembolic events and cerebral hypoperfusion being the most common causes. However, considering that most of the ECMO patients are severely ill or under sedation, stroke symptoms are often underdiagnosed. Multimodal monitoring and daily clinical assessment could be useful preventive techniques. Early recognition of neurological deficits is of paramount importance for prompt therapeutic interventions. All ECMO patients with suspected strokes should immediately receive brain computed tomography (CT) and CT angiography (CTA) for the identification of large vessel occlusion (LVO) and assessment of collateral blood flow. CT perfusion (CTP) can further assist in the detection of viable tissue (penumbra), especially in cases of strokes of unknown onset. Catheter angiography is required to confirm LVO detected on CTA. Intravenous thrombolytic therapy is usually contraindicated in ECMO as most patients are on active anticoagulation treatment. Therefore, mechanical thrombectomy is the preferred treatment option in cases where there is evidence of LVO. The choice of the arterial vascular access used to perform mechanical thrombectomy should be discussed between interventional radiologists and an ECMO team. Anticoagulation management during the acute phase of IS should be individualized after the thromboembolic risk has been carefully balanced against hemorrhagic risk. A multidisciplinary approach is essential for the optimal management of ISs in patients treated with ECMO.
缺血性卒中（IS）是体外膜肺氧合（ECMO）治疗患者的严重并发症及主要死亡原因。本叙述性综述的目的是总结现有证据，并深入探讨接受ECMO支持的急性缺血性卒中患者的诊断与治疗。据估计，IS的发生率在1%至8%之间，而死亡率则在44%至76%之间，这取决于多种因素，包括ECMO类型、支持时间及患者特征。已确定了ECMO期间导致IS的多种机制，其中血栓栓塞事件和脑灌注不足是最常见的原因。然而，鉴于大多数ECMO患者病情严重或处于镇静状态，卒中症状往往诊断不足。多模式监测和每日临床评估可能是有用的预防技术。早期识别神经功能缺损对于及时进行治疗干预至关重要。所有疑似卒中的ECMO患者应立即接受脑部计算机断层扫描（CT）和CT血管造影（CTA），以识别大血管闭塞（LVO）并评估侧支血流。CT灌注（CTP）可进一步协助检测存活组织（半暗带），尤其是在发病时间不明的卒中病例中。需要导管血管造影来确认CTA上检测到的LVO。静脉溶栓治疗在ECMO中通常是禁忌的，因为大多数患者正在接受积极的抗凝治疗。因此，在有LVO证据的情况下，机械取栓术是首选的治疗选择。进行机械取栓术所使用的动脉血管通路的选择应在介入放射科医生和ECMO团队之间进行讨论。在仔细权衡血栓栓塞风险与出血风险后，IS急性期的抗凝管理应个体化。多学科方法对于接受ECMO治疗的患者中IS的最佳管理至关重要。
