RESUMO
OBJECTIVE: Right common carotid artery (RCCA) ligation after extracorporeal membrane oxygenation by venoarterial bypass may contribute to lateralized cerebral injury. Reconstruction of this artery after extracorporeal membrane oxygenation has proved feasible but has not been evaluated for neurologic outcome in any substantial series of infants. METHODS: We evaluated RCCA reconstruction in 47 infants treated with ECMO and compared their cerebrovascular and neuroanatomic imaging findings, electroencephalograms, and developmental outcomes with those of 93 infants who had no reconstruction. SUMMARY RESULTS: Color Doppler blood flow imaging revealed that carotid artery patency was usually obtained after RCCA reconstruction. Right internal carotid and bilateral anterior and middle cerebral arterial blood flow velocities were generally higher, and were more symmetrically distributed in infants with reconstructed RCCA. Electroencephalography did not disclose an increased risk of deterioration or marked abnormalities in infants after reconstruction, nor were neuroimaging findings consistent with an increased number of either focal or generalized abnormalities. Neurodevelopmental follow-up revealed no differences in the incidence of delays between those with a reconstructed RCCA and those with a ligated RCCA during the first year of life. CONCLUSIONS: Reconstruction of the RCCA after extracorporeal membrane oxygenation may facilitate normal distribution of cerebral blood flow through the circle of Willis, and may augment both left and right middle cerebral artery blood flow immediately after decannulation. The long-term consequences of either ligation or reconstruction of the RCCA will require careful scrutiny, however, before either course is recommended routinely.
Assuntos
Artéria Carótida Primitiva/cirurgia , Circulação Cerebrovascular , Oxigenação por Membrana Extracorpórea , Velocidade do Fluxo Sanguíneo , Encéfalo/diagnóstico por imagem , Artéria Carótida Primitiva/diagnóstico por imagem , Artéria Carótida Primitiva/fisiologia , Artérias Cerebrais/diagnóstico por imagem , Artérias Cerebrais/fisiologia , Desenvolvimento Infantil , Ecoencefalografia , Eletroencefalografia , Oxigenação por Membrana Extracorpórea/efeitos adversos , Seguimentos , Humanos , Recém-Nascido , Doenças do Sistema Nervoso/etiologia , Insuficiência Respiratória/terapia , Tomografia Computadorizada por Raios XRESUMO
To determine whether flow through the subclavian artery might be affected during extracorporeal membrane oxygenation (ECMO), 40 neonates were examined with color Doppler ultrasound during and after ECMO. Retrograde flow in the right vertebral artery, noted in 12 of the 40 neonates (30%), was consistent with vertebral steal. Brachial systolic velocity was significantly less (P less than .01) on the right than on the left side in neonates both with and without vertebral steal. When the arterial cannula was removed after ECMO, vertebral artery flow became antegrade with symmetric velocity. Brachial velocities became symmetric in infants without vertebral steal, but mild asymmetry persisted in neonates who had had vertebral steal. Only one neonate had clinical signs of arm ischemia, which resolved promptly after removal of the cannula. No surviving neonates (n = 11) had neurologic findings related to the vertebrobasilar insufficiency over a 12-22-month period of observation. Vertebral steal appears to be common during ECMO and is resolved after removal of the cannula.
Assuntos
Cateterismo/efeitos adversos , Oxigenação por Membrana Extracorpórea/efeitos adversos , Insuficiência Vertebrobasilar/diagnóstico por imagem , Artéria Basilar/fisiopatologia , Velocidade do Fluxo Sanguíneo , Artéria Braquial/fisiopatologia , Artérias Carótidas/fisiopatologia , Humanos , Recém-Nascido , Ultrassonografia , Artéria Vertebral/fisiopatologia , Insuficiência Vertebrobasilar/etiologia , Insuficiência Vertebrobasilar/fisiopatologiaRESUMO
Only one of the 65 ECMO patients treated at Thomas Jefferson University Hospital to date has shown progression of pulmonary parenchymal cystic change on serial portable chest radiographs while on ECMO. The radiographic and clinical findings of this unique case are presented.
Assuntos
Cistos/etiologia , Oxigenação por Membrana Extracorpórea/efeitos adversos , Pneumopatias/etiologia , Cistos/diagnóstico por imagem , Feminino , Humanos , Recém-Nascido , Pneumopatias/diagnóstico por imagem , Pneumotórax/terapia , RadiografiaRESUMO
Serial ultrasound imaging of the brain was used to determine the ventricular index (VI), and the ratio (VR) of the VI to the cranial hemidiameter during the nursery course and first year post-term in preterm infants of less than 33 weeks gestation. Twenty-nine of the infant survivors with no intracranial hemorrhage or major medical complication during their nursery course composed group 1. Twenty-two survivors with intracranial hemorrhage unassociated with early ventricular dilation composed group 2. Group 3 was comprised of 10 other survivors who had neonatal intraventricular hemorrhage with early ventriculomegaly; all 10 infants had at least one major medical complication during their neonatal course. In groups 1 and 2 the VR decreased and the VI increased significantly with age post-conception. Infants in group 3, compared with those in groups 1 or 2, had decreased occipitofrontal growth during the early postnatal period and increased VR and VI during the neonatal period and first year post-term. These results suggest that the ventriculomegaly associated with neonatal intracranial hemorrhage cannot be explained by posthemorrhagic hydrocephalus alone and may also be related to cerebral atrophy or decreased brain growth or both. Neurodevelopmental assessments at 20 to 30 months of age disclosed significantly lower Bayley Motor Development scores in group 3 compared with groups 1 or 2. Four infants in group 3, but none in groups 1 or 2, had cerebral palsy. The neurodevelopmental deficits in group 3 infants may reflect the complex pathogenesis of the ventriculomegaly as well as the effects of the intraventricular hemorrhage and posthemorrhagic hydrocephalus.
Assuntos
Hemorragia Cerebral/diagnóstico , Ventrículos Cerebrais/fisiopatologia , Recém-Nascido Prematuro , Ultrassonografia , Cefalometria , Hemorragia Cerebral/fisiopatologia , Ventrículos Cerebrais/patologia , Desenvolvimento Infantil/fisiologia , Dilatação Patológica , Crescimento , Humanos , Hidrocefalia/patologia , Hidrocefalia/fisiopatologia , Recém-Nascido , Estudos Longitudinais , Fatores de TempoRESUMO
Serial ultrasound studies of cerebral ventricular size were obtained in 40 small preterm infants, 26 of whom were believed to be at risk for intracranial hemorrhage or hydrocephalus secondary to ICH or both. Hydrocephalus was diagnosed by ultrasound study in 12 of the high-risk infants, eight of whom required a surgical shunt procedure because of progressive ventricular enlargement. Serial ultrasound studies in the other 28 infants, including the 14 believed to be at low risk for ICH, disclosed normal ventricular size, defined as a ratio of lateral ventricular width to intracranial hemidiameter of less than 35%. The ultrasound methods utilized a portable A-mode echoscope that permitted unidimensional intracranial measurements at the infants' bedside, and a nonportable automated B-scanner that produced two-dimensional gray-scale images of the brain. The serial ultrasound measurements and images proved clinically useful in the initial detection of hydrocephalus and subsequent evaluation of the infant subjects.