Ischemic and hemorrhagic stroke in pediatric patients after extracorporeal membrane oxygenation decannulation: a systematic review

OBJECTIVE: Extracorporeal membrane oxygenation (ECMO) is a vital support for pediatric patients with severe cardiac or pulmonary failure. However, post-decannulation complications, particularly involving carotid artery ligation (CAL) or carotid artery repair (CAR), can lead to significant neurological morbidity. In this review, the authors hope to outline for the pediatric neurosurgeon the reasons for and types of ECMO cannulation, the surgical options for the decannulation process (CAL vs CAR), the prevalence of neurological complications after decannulation, and the likely pathophysiology behind these complications. Understanding these can help arm the neurosurgeon with a useful basic background in ECMO to aid in the prompt management decision process in the setting of often urgent consultations related to neurological complications. METHODS: A systematic review adhering to PRISMA guidelines was performed using studies published between January 1, 2000, and February 1, 2025, from MEDLINE, Embase, Cochrane Library, and Ovid Emcare. This review includes studies that specifically report neurological complications pertaining to pediatric/neonatal patients who had undergone either veno-arterial (VA)-ECMO or veno-venous (VV)-ECMO. Four cases from the authors' institution are also presented to illustrate the broad categories of neurological complications that can arise in this post-ECMO period. RESULTS: A total of 356 patients were included across 8 studies, with 331 receiving VA-ECMO and 25 receiving VV-ECMO. Neurological injuries (i.e., ischemic stroke, intracranial hemorrhage, or seizures) were reported in 22%-56% in the CAR cohorts and in 45%-83% in the CAL cohorts. Common complications included cerebral infarction, intracerebral hemorrhage, and cerebral atrophy. CAR patency rates ranged from 28% to 100%. CONCLUSIONS: When the internal jugular vein (IJV) and/or the common carotid artery (CCA) are used for access in children for VV-ECMO or VA-ECMO, there is a risk for a variety of neurological complications. If the CCA is repaired, a decision must be made about the need for long-term anticoagulation. If the IJV is ligated, particularly in neonates or young infants in whom cerebral autoregulation may not be fully developed, patients may be at higher risk of venous infarcts and intracranial hypertension. If the CCA is ligated, reduced hemispheric flow places the patient at significant lifetime risk of hypoperfusion injury exacerbated by periods of hypotension. CCA ligation can also increase the risk of early or delayed ipsilateral thromboembolic stroke.