PEDS6: Brain MRI Outcomes Following Carotid Reconstruction vs Ligation in Neonatal Patients Decannulated from VA-ECMO

Background: There is a paucity of data to guide carotid artery management during veno-arterial extracorporeal membrane oxygenation (VA-ECMO) decannulation. In our institution, carotid reconstruction is routinely performed by some surgeons, whereas others prefer ligation. We aimed to compare the radiographic outcomes of the different surgical techniques in our neonatal VA-ECMO survivors. Methods: We performed a single-center retrospective analysis of neonates (<28 days old) in our neonatal intensive care unit (NICU) who survived VA-ECMO decannulation between 6/2009 and 9/2022. Our institutional practice was to obtain daily screening head ultrasounds (HUS) on neonates while on ECMO and a brain MRI once clinically stable following decannulation. Patients who did not have a brain MRI following decannulation were excluded from the study. Carotid reconstruction was only performed on ECMO patients cannulated for less than 10 days, thus all patients cannulated for greater than 10 days were also excluded. The primary outcome parameter was arterial infarcts visualized on brain MRI. Secondary outcomes included extra-axial and intra-axial brain hemorrhage. Results: 82 patients met inclusion criteria for this study, including 38 (46%) that had carotid reconstruction and 44 (54%) that had carotid ligation. The two groups had similar demographics including patient characteristics, ECMO indication and duration, HUS abnormalities on ECMO and survival to hospital discharge. 21 patients (26%) had parenchymal echogenicity or intra-ventricular hemorrhage (IVH) on screening HUS while on ECMO, whereas 43 patients (52%) had either ischemic or hemorrhagic brain injury on post-ECMO MRI. There was no difference in arterial infarcts (24% vs. 27%, p=0.71) and extra-axial hemorrhage (18% vs. 21%, p=0.82) on brain MRI between the reconstructed and ligated patients. However, there was a greater number of patients with intra-axial hemorrhage with carotid reconstruction compared to ligation (45% vs. 16%, p<0.01). Conclusions: Neonates that survive VA-ECMO have multiple risk factors for brain injury. We found no difference in arterial infarcts or extra-axial brain hemorrhage following carotid reconstruction. However, there was a greater number of intra-axial hemorrhagic brain injury in patients with carotid reconstruction. Further studies are needed to discern the mechanisms underlying these radiographic differences and the effects on long-term neurocognitive outcomes.