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lung function had improved to a degree that the sedation was reduced, with the patient subsequently decannulated and withdrawn from ECMO.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 Showing no signs of further neurological improvement, life-sustaining treatment was withdrawn and the patient passed away.\nsummarizes the clinical course of these five patients.
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.