Pediatric Extracorporeal Membrane Oxygenation | Pediatric Radiology Reference Article | Pediatric Imaging

Etiology: long term cardiopulmonary bypass to rest lungs used most often in patients in cardio-pulmonary failure due to persistent pulmonary hypertension / congenital diaphragmatic hernia / overwhelming sepsis / post-operative cardiac patients, arterio-venous (AV) ECMO used for heart-lung support, venous-venous (VV) ECMO used for respiratory support
CXR: body wall edema due to being paralyzed on ventilator, complete opacification of lungs
CXR: arterial-venous ECMO in neonate – tip of arterial cannula placed from right common carotid artery should be in the innominate artery and radiopaque tip of venous cannula placed from right internal jugular vein should be in the right atrium
CXR: venous-venous ECMO in neonate – radiopaque tip of venous cannula placed from right internal jugular vein should be in the right atrium
AXR: arterial-venous ECMO in older child – tip of arterial cannula should be in the iliac artery and tip of venous cannula should be in the inferior vena cava
CXR: venous-venous ECMO in older child – tip of venous cannula should be near the junction of the right atrium and the inferior vena cava
US: neonatal brain needs to be screened before beginning for contraindications to ECMO – pre-existing bleed or brain malformation, brain needs to be screened regularly for intracranial bleeding
Complications: catheter malposition, systemic anticoagulation can lead to bleeding anywhere in body but especially in brain so regular surveillance head ultrasound is performed, cerebral atrophy post ECMO
Clinical: patients are systemically anticoagulated while on ECMO, patients are sedated while on ECMO making clinical exam very difficult, imaging is in the front line when screening for complications

Radiology Cases of Extracorporeal Membrane Oxygenation

Radiology Cases of Arterial-Venous Extracorporeal Membrane Oxygenation Normal Catheter Position

CXR of arterial-venous extracorporeal membrane oxygenation (ECMO) — CXR shows normal position of the arterial catheter tip in the aortic arch (aa) and normal position of the venous catheter tip in the right atrium (ra).

CXR of transesophageal echocardiogram probe — CXR AP shows an open chest with an ECMO arterial catheter tip in the aortic arch and an ECMO venous catheter tip in the right atrium. A wide-diameter tube with a sensor at the end projects over the esophagus which represents a transesophageal echocardiogram probe.

Radiology Cases of Venous-Venous Extracorporeal Membrane Oxygenation Normal Catheter Position

CXR of venous-venous extracorporeal membrane oxygenation (ECMO) — CXR shows normal position of the venous catheter tip in the right atrium.

AXR of arterial-venous extracorporeal membrane oxygenation (ECMO) — AXR shows normal position of the arterial catheter tip in the right iliac artery and normal position of the venous catheter tip in the mid inferior vena cava.

Radiology Cases of Extracorporeal Membrane Oxygenation Catheter Malposition

Radiology Cases of Extracorporeal Membrane Oxygenation Causing Hemothorax

US of hemothorax in patient on extracorporeal membrane oxygenation (ECMO) — Sagittal and transverse US of the right chest shows a complex fluid collection in the right pleural space.

Radiology Cases of Extracorporeal Membrane Oxygenation Causing Intramuscular Hematoma

CT of intramuscular hematoma in patient on extracorporeal membrane oxygenation (ECMO) — Axial CT with contrast of the chest shows hematomas in the right sternocleidomastoid muscle (above) near the ECMO catheter insertion site and left pectoralis major muscle.

Radiology Cases of Extracorporeal Membrane Oxygenation Causing Subdural Hematoma

US of subdural hematoma and intracerebral hemorrhage in patient on extracorporeal membrane oxygenation (ECMO) — Coronal US of the brain (below) shows echogenic material in right subdural space. Coronal and sagittal US of the brain (above) shows a right parietal round mixed echogenicity lesion.

Radiology Cases of Extracorporeal Membrane Oxygenation Causing Intracerebral Hemorrhage

US of intracerebral hemorrhage in a patient on extracorporeal membrane oxygenation (ECMO) — Coronal and sagittal US of the brain shows a large, round echogenic lesion in the left parietal lobe.

CT of intracerebral hemorrhage in a patient on extracorporeal membrane oxygenation (ECMO) — Sagittal, coronal and axial CT without contrast of the brain shows a large, round high density lesion in the right parietal lobe.

Radiology Cases of Extracorporeal Membrane Oxygenation Causing Intraventricular Hemorrhage

CT of intraventricular hemorrhage, intracerebral hemorrhage, and cerebral atrophy in a patient on extracorporeal membrane oxygenation (ECMO) — Axial CT without contrast of the brain shows mixed-density fluid in the left lateral ventricle posteriorly and mixed-density fluid in the left parietal-occipital lobe. There is also diffuse prominence of the sulci and ventricular system.

Radiology Cases of Extracorporeal Membrane Oxygenation Causing Cerebellar Hemorrhage

CT of cerebellar hemorrhage on extracorporeal membrane oxygenation (ECMO) — Axial and coronal CT without contrast of the brain shows three round mixed density lesions in the cerebellum compressing the fourth ventricle and causing hydrocephalus. The fluid-fluid levels in the lesions were felt to represent active bleeding.

Radiology Cases of Extracorporeal Membrane Oxygenation Causing Cerebral Atrophy

CT of cerebral atrophy after being on extracorporeal membrane oxygenation (ECMO) — Axial CT without contrast of the brain shows diffuse prominence of the sulci and ventricular system.