VENKAT B. MERUVA, DO: No financial relationships to disclose
Background: Neurovascular interventions in patients supported on extracorporeal membrane oxygenation (ECMO) are rarely performed due to bleeding risk and anticoagulation requirements. Emerging evidence suggests selected interventions may be feasible when guided by multidisciplinary expertise and physiologic necessity.
Methods: A 33-year-old female with decompensated cirrhosis and adrenal insufficiency presented in adrenal crisis complicated by progressive hypoxemic respiratory failure, ultimately meeting criteria for severe ARDS. She was cannulated for VV-ECMO due to refractory hypoxemia despite maximal ventilatory support. Bronchoscopy was performed for infectious evaluation while on ECMO. Subsequent neurologic deterioration prompted emergent neuroimaging, which revealed subarachnoid hemorrhage with multiple intracranial aneurysms, concerning for an underlying arteriovenous malformation. Therapeutic anticoagulation with enoxaparin was immediately discontinued. Given the risk of aneurysmal rupture and ongoing hemorrhage, the patient underwent endovascular aneurysm coiling while supported on VV-ECMO. The procedure was performed with multidisciplinary coordination between critical care, neurology, neurosurgery, and interventional neuroradiology teams. No intraprocedural complications occurred, and ECMO flows remained stable throughout the intervention.
Outcome: Endovascular coiling was technically successful without procedural complications, hemodynamic instability, or circuit dysfunction. The patient was subsequently weaned from VV-ECMO and successfully decannulated. Despite cessation of anticoagulation and ECMO support, serial neuroimaging demonstrated progressive intracranial hemorrhage expansion. Neurologic examination continued to deteriorate, culminating in loss of brainstem reflexes and radiographic evidence of catastrophic cerebral injury. The patient was declared brain dead. After discussion with family, care was transitioned to hospice, and the patient expired on hospital day 16. This clinical course highlights that while neurovascular intervention on ECMO is technically feasible, outcomes remain heavily influenced by underlying disease severity, baseline coagulopathy, and hemorrhagic risk rather than procedural failure.
Conclusion: Neurovascular interventions are feasible in ECMO-supported patients, with reported technical success rates of 90–100% and post-intervention survival of 60–85%. However, intracranial hemorrhage occurs in 20–40%, largely reflecting baseline disease and anticoagulation rather than procedural failure, underscoring the need for meticulous multidisciplinary management.
