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 The ongoing heparin infusion was withdrawn, and 30 minutes later an emergency SDH hematoma evacuation was performed.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 68-year-old woman, with a history of hypertension, was admitted to her local hospital after three days of dyspnea. She was diagnosed with pneumonia with respiratory failure and was therefore intubated and administered intravenous antibiotics. Despite this, respiratory function continued to decline and ECMO treatment was advocated, and the patient was started on VV ECMO. On ED 1, RVF developed and the patient was converted to VA ECMO. On ED 6, after days of low platelet count despite transfusions, the patient developed right-sided mydriasis and decreased level of consciousness. A CT scan revealed a SAH (Fisher grade 4) with IVH (Le Roux grade 4) as well as hydrocephalus and absent basal cisterns. A cerebral angiography could not detect any bleeding source. Heparin was withdrawn, and four hours later an emergency EVD placement was performed. The pre-operative coagulation parameters were: platelet count 118, APTT 33, ACT 153 and INR 1.1. Intra-operatively, no significant bleeding events occurred. Post-operatively, a decision was made to keep the ECMO system running without heparin and to administer platelets. ICP was managed with hyperosmolar therapy and hyperventilation. Despite these measures, the patient did not regain consciousness. The following day the patient experienced a cardiac arrest and passed away.