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 The ongoing heparin infusion was withdrawn, and 30 minutes later an emergency SDH hematoma evacuation was performed.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 35-year-old woman, with a history of depression, overdosed on a combination of antidepressants and alcohol, rendering her unconscious and resulting intubation and mechanical ventilation. Unfortunately, a later extubation attempt resulted in aspiration and severe respiratory failure to a degree that ECMO treatment was advocated, and the patient was started on VV ECMO. During the first week of ECMO, the patient developed progressive right ventricular heart failure (RVF), requiring conversion to VA ECMO. During the following weeks, the patient regained native lung function, but also experienced upper gastrointestinal bleeds requiring replacement of fibrinogen and platelets to prevent coagulopathy. On ED 32, the patient developed right-sided mydriasis and hypertension. A CT scan revealed a cerebellar IPH (23 mL, largest diameter 40 mm) with SAH (Fisher grade 4), IVH (Le Roux grade 4) and absent basal cisterns (). No bleeding source was found on a cerebral angiography. The heparin infusion was withdrawn, and protamine sulfate, fibrinogen, platelets and tranexamic acid was administered to reverse anticoagulation. Half an hour later an emergency cerebellar hematoma evacuation was performed. The pre-operative coagulation parameters were: platelet count 87, APTT 50, ACT 200, INR 1.0. Intra-operatively, opening of the dura resulted in uncontrollable hemorrhaging despite extensive use of local hemostatic agents and transfusions of fibrinogen, protamine sulfate, plasma, platelets, eptacog alfa (NovoSeven®, AryoSeven®) and cryoprecipitate. Due to the poor prognosis, an EVD was not placed. The post-operative CT scan showed increased IPH hematoma volume (41 ml) as well as progress of the hydrocephalus, IVH (LeRoux grade 12), SAH (Fisher grade 4) and tonsillar herniation (). Further ECMO treatment was deemed futile and, consequently, treatment was withdrawn and the patient passed away.