Estimated prevalence of ABI in ECMO varies from 10% to 59% by neuroimaging and  46% to 63% at autopsy. Mechanism and timing of ABI are not well described, as it may occur due to hypoxia or hemodynamic instability prior to ECMO and/or due to adverse events during ECMO course. 

Twenty-four venoarterial ECMO neonatal and infant patients had postmortem examination with brain autopsy. Median age at initiation of ECMO was 82 days (IQR, 11-263); median age at time of death was 20 weeks (IQR, 5-44); median ECMO support duration was 108 hours (IQR, 35-366). Most common ABI was hypoxic-ischemic brain injury (HIBI; 50%) followed by intracranial hemorrhage (29%). Of 19 patients with ABI, 14 (74%) had documented neurological injury prior to autopsy based on clinical (4, 29%) or radiological (10, 71%) findings. Median time from cannulation to diagnosis of brain injury was 3.7 days (IQR: 0.33-8), and 3 (21%) patients had ABI before cannulation. Most common types of intracranial hemorrhage were intracerebral (17%), subarachnoid (17%), and subdural (8%). Risk factors for ABI included low pre-ECMO oxygen saturation as well as elevated liver enzymes, bilirubin, and lactate on days 1 and 3 of ECMO. Gestational age, Apgar scores, birth weight, ECMO duration, cannulation method, antithrombotic therapy, renal and hepatic impairment were not associated with ABI.