A 20-year-old woman, with a history of IgG deficiency, presented at her local outpatient clinic with shortness of breath and was prescribed antibiotics. One week later the patient was admitted to her local hospital with signs indicative of septic shock, and shortly thereafter she went into cardiac arrest and cardiopulmonary resuscitation (CPR) was initiated. Extracorporeal cardiopulmonary resuscitation (ECPR) was commenced using VA ECMO. Shortly after cannulation the patient developed bilateral mydriasis but the cranial CT scan did not show any apparent ischemia or intracranial mass lesions. To prevent development of cerebral edema, the patient was managed with hyperosmolar therapy, hyperventilation, hypothermia and heavy sedation (Pentobarbital coma monitored with burst suppression on continuous electroencephalography (EEG)). Despite this, a CT scan performed on ECMO day (ED) 6 revealed increased cerebral edema, and the patient underwent ICP catheter (Codman®) placement. No significant bleeding events occurred during the procedure, however, post-operatively her right-sided mydriasis increased. A cranial CT scan revealed a frontal IPH (6.75 ml, largest diameter 27 mm) and a SDH with 14 mm midline shift (). The ongoing heparin infusion was withdrawn, and 30 minutes later an emergency SDH hematoma evacuation was performed. The pre-operative coagulation parameters were: platelet count 69 x109/mL, APTT 55 seconds, ACT 204 seconds and INR 1.0. Intra-operatively, no significant bleeding events occurred. However, the post-operative cranial CT scan revealed a subgaleal hemorrhage and an SDH recurrence with 14 mm midline-shift (). A new hematoma evacuation was performed without any significant intra-operative bleeding. A post-operative CT scan showed a decrease in the midline shift without any signs of hematoma recurrence (). However, the following morning her ICP increased drastically, and a new CT scan revealed a SDH and 20 mm midline shift, as well as epidural and subgaleal bleeding with impending uncal herniation (). Again, emergency hematoma evacuation was performed. Following this, the pupils regained their normal size and the CT scan showed a decreased midline shift without any signs of hematoma recurrence (). The ECMO treatment continued without heparin while prophylactic Levetirecetam was administered to prevent epileptic seizures. On ED 11 rewarming was successfully initiated, and the patient was decannulated from ECMO. At this stage, the patients had been without the heparin infusion for five days without any sign of complications. The patient was transferred to the neurosurgical ICU department, where extubation was successfully performed. After this the patient was transferred to a neurological care unit for rehabilitation. Within a year the patient had made a full recovery, with no neurological sequelae or physiological deficits, and had returned to work.
A 67-year old man, with a history of alcohol addiction and rheumatoid arthritis, was admitted to his local hospital with a respiratory tract infection. Despite treatment with antibiotics, the patient developed septic shock with refractory respiratory failure. ECMO was indicated and cannulation for VV ECMO initiated. However, during cannulation the patient suffered multiple transient cardiac arrests and VA ECMO was commenced instead. On ED 3 a routine cranial CT scan showed no abnormalities. By ED 6, the patient’s native lung function had improved to a degree that the sedation was reduced, with the patient subsequently decannulated and withdrawn from ECMO. However, the patient did not wake up and a CT scan showed a cerebellar IPH (10 mL, largest diameter 25 mm), several minimal parietal IPHs as well as hydrocephalus and imminent cerebral herniation. Two hours later the patient underwent emergency EVD placement and evacuation of the cerebellar hematoma. Because enough time had passed since decannulation (24 hours), pre-operative hemostatic intervention was deemed unnecessary. The pre-operative coagulation parameters were: platelet count 77, APTT 30, ACT N/A, INR 1.2. Intra-operatively no significant bleeding occurred. Post-operatively, the patient was taken back to the ICU where ICP was further managed through hyperosmolar therapy and hyperventilation. After three days the EVD was removed. However, while the cranial CT scan showed resorption of IPHs, his GCS was still 3. An EEG showed slow wave activity indicative of an unspecific cerebral pathology, but a magnetic resonance imaging scan and lumbar puncture revealed no signs of encephalopathy. After transfer to the neurological ward the patient began to show signs of minor neurological improvement, but a few weeks later the patient suffered a massive pulmonary embolism. Showing no signs of further neurological improvement, life-sustaining treatment was withdrawn and the patient passed away.\nsummarizes the clinical course of these five patients.