Impairment of cerebral autoregulation in pediatric extracorporeal membrane oxygenation associated with neuroimaging abnormalities

Fenghua Tian, Michael Craig Morriss, Lina Chalak, Ramgopal Venkataraman, Chul Ahn, Hanli Liu, Lakshmi Raman, Fenghua Tian, Michael Craig Morriss, Lina Chalak, Ramgopal Venkataraman, Chul Ahn, Hanli Liu, Lakshmi Raman

Abstract

Extracorporeal membrane oxygenation (ECMO) is a life-supporting therapy for critically ill patients with severe respiratory and/or cardiovascular failure. Cerebrovascular impairment can result in hemorrhagic and ischemic complications commonly seen in the patients supported on ECMO. We investigated the degree of cerebral autoregulation impairment during ECMO as well as whether it is predictive of neuroimaging abnormalities. Spontaneous fluctuations of mean arterial pressure (MAP) and cerebral tissue oxygen saturation ([Formula: see text]) were continuously measured during the ECMO run. The dynamic relationship between the MAP and [Formula: see text] fluctuations was assessed based on wavelet transform coherence (WTC). Neuroimaging was conducted during and/or after ECMO as standard of care, and the abnormalities were evaluated based on a scoring system that had been previously validated among ECMO patients. Of the 25 patients, 8 (32%) had normal neuroimaging, 7 (28%) had mild to moderate neuroimaging abnormalities, and the other 10 (40%) had severe neuroimaging abnormalities. The degrees of cerebral autoregulation impairment quantified based on WTC showed significant correlations with the neuroimaging scores ([Formula: see text]; [Formula: see text]). Evidence that cerebral autoregulation impairment during ECMO was related to the patients' neurological outcomes was provided.

Keywords: blood pressure; cerebral autoregulation; cerebral tissue oxygen saturation; extracorporeal membrane oxygenation; neurological injury; wavelet transform coherence.

Figures

Fig. 1
Fig. 1
Autoregulation and neuroimaging results from a patient (patient 6: neonatal male) who was placed on VV ECMO for meconium aspiration secondary to PPHN. (a) Partial enlarged figure of WTC between the spontaneous fluctuations of MAP and SctO2. In this graph, the x-axis represents the time, the y-axis represents the wavelet scale (in inverse proportion to Fourier frequency), the color scale represents the squared cross-wavelet coherence (R2) that ranges from 0 to 1, and the black line contours designate the areas of significant coherence (p<0.05) identified through Monte Carlo simulation. The arrows designate the relative phase between MAP and SctO2: a rightward-pointing arrow indicates in-phase coherence and leftward-pointing arrow indicates antiphase coherence. (b) A segment of real-time MAP and SctO2 data. (c) MRI brain image acquired 2 days after ECMO.
Fig. 2
Fig. 2
Autoregulation and neuroimaging results from a patient (patient 5: 8-year-old female) who was placed on VV ECMO for pulmonary contusion secondary to ARDS s/p motor vehicle collision. (a) Partial enlarged figures of WTC between the spontaneous fluctuations of MAP and SctO2. In this graph, the x-axis represents the time, the y-axis represents the wavelet scale (in inverse proportion to Fourier frequency), the color scale represents the squared cross-wavelet coherence (R2) that ranges from 0 to 1, and the black line contours designate the areas of significant coherence (p<0.05) identified through Monte Carlo simulation. The arrows designate the relative phase between MAP and SctO2: a rightward-pointing arrow indicates in-phase coherence and leftward-pointing arrow indicates antiphase coherence. (b) A segment of real-time MAP and SctO2 data. (c) CT brain image acquired during ECMO.
Fig. 3
Fig. 3
Percentage of significant coherence, P(s), derived from the in-phase MAP→SctO2 coherence (i.e., Δφ∈0±π/4). In this graph, the x-axis represents the wavelet scale, s, which is in inverse proportion to Fourier frequency. The y-axis represents the percentage of time during which the MAP→SctO2 coherence was statistically significant over the background noise (p<0.05). Therefore, P(s) represented the scale/frequency characteristics of the MAP→SctO2 coherence. For ECMO patients, predominant in-phase MAP→SctO2 coherence was seen in a wavelet scale range of 8 to 32 min (the shaded area), which corresponded to a frequency range of 0.0005 to 0.002 Hz. This range was selected to calculate the autoregulation index.
Fig. 4
Fig. 4
Correlation between autoregulation index and neuroimaging score.

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