A predictive model for intracranial hemorrhage in adult patients receiving extracorporeal membrane oxygenation

doi:10.5847/wjem.j.1920-8642.2025.037

Abstract

Abstract:

BACKGROUND: Intracranial hemorrhage (ICH), a severe complication among adults receiving extracorporeal membrane oxygenation (ECMO), is often related to poor outcomes. This study aimed to establish a predictive model for ICH in adults receiving ECMO treatment.
METHODS: Adults who received ECMO between January 2017 and June 2022 were the subjects of a single-center retrospective study. Patients under the age of 18 years old, with acute ICH before ECMO, with less than 24 h of ECMO support, and with incomplete data were excluded. ICH was diagnosed by a head computed tomography scan. The outcomes included the incidence of ICH, in-hosptial mortality and 28-day mortality. Multivariate logistic regression analysis was used to identify relevant risk factors of ICH, and a predictive model of ICH with a nomogram was constructed.
RESULTS: Among the 227 patients included, 22 developed ICH during ECMO. Patients with ICH had higher in-hospital mortality (90.9% vs. 47.8%, P=0.001) and higher 28-day mortality (81.8% vs. 47.3%, P=0.001) than patients with non-ICH. ICH was associated with decreased grey-white-matter ratio (GWR) (OR=0.894, 95%CI: 0.841-0.951, P<0.001), stroke history (OR=4.265, 95%CI: 1.052-17.291, P=0.042), fresh frozen plasma (FFP) transfusion (OR=1.208, 95%CI: 1.037-1.408, P=0.015) and minimum platelet (PLT) count during ECMO support (OR=0.977, 95%CI: 0.958-0.996, P=0.019). The area under the receiver operating characteristic curve of the ICH predictive model was 0.843 (95%CI: 0.762-0.924, P<0.001).
CONCLUSION: ECMO-treated patients with ICH had a higher risk of death. GWR, stroke history, FFP transfusion, and the minimum PLT count were independently associated with ICH, and the ICH predictive model showed that these parameters performed well as diagnostic tools.

Key words: Extracorporeal membrane oxygenation, Intracranial hemorrhage, Predictive model, Grey-white-matter ratio

Yi Zhu, Lina Mao, Zhongman Zhang, Sae Rom Lee, Tianshi Li, Hao Zhou, Yanbin Dong, Di An, Wei Li, Xufeng Chen. A predictive model for intracranial hemorrhage in adult patients receiving extracorporeal membrane oxygenation[J]. World Journal of Emergency Medicine, 2025, 16(2): 153-160.

Figures/Tables 8

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Variables	All patients (n=227)	ICH group (n=22)	Non-ICH group (n=205)	P-value
Demographics
Age, years	48 (33, 60)	44 (28, 55)	49 (34, 61)	0.088
Male gender	153 (67.4)	14 (63.6)	139 (67.8)	0.657
Body mass index, kg/m²	24.0 ± 3.2	24.1 ± 3.5	24.0 ± 3.2	0.825
Comorbidity
Hypertension	68 (30.0)	6 (27.3)	62 (30.2)	0.772
Diabetes mellitus	39 (17.2)	3 (13.6)	36 (17.6)	0.774
Coronary heart disease	33 (14.5)	1 (4.5)	32 (15.6)	0.214
Stroke	18 (7.9)	4 (18.2)	14 (6.8)	0.081
Chronic renal disease	6 (2.6)	1 (4.5)	5 (2.4)	0.461
Chronic hepatic disease	6 (2.6)	0 (0.0)	6 (2.9)	1.000
ECMO mode				0.482
Veno-venous	48 (21.1)	4 (18.2)	44 (21.5)
Veno-arterial	72 (31.7)	5 (22.7)	67 (32.7)
ECPR	107 (47.1)	13 (59.1)	94 (45.9)
Recent bleeding history	41 (18.1)	6 (27.3)	35 (17.1)	0.247
Anti-platelet therapy	14 (6.2)	1 (4.5)	13 (6.3)	1.000
Anti-coagulant therapy	8 (3.5)	1 (4.5)	7 (3.4)	0.564
Pre-ECMO cardiac arrest	109 (48.0)	14 (63.6)	95 (46.3)	0.123
MAP pre-ECMO, mmHg	58 (37, 80)	44 (34, 68)	60 (38, 81)	0.080
Lab findings pre-ECMO
Hematocrit	0.340 ± 0.767	0.330 ± 0.817	0.341 ± 0.763	0.503
Platelet count, ×10⁹/L	160 (104, 219)	127 (56, 194)	166 (107, 220)	0.126
Creatinine, μmol/L	107.0 (73.1, 150.7)	134.1 (75.4, 156.2)	106.4 (70.7, 150.7)	0.263
Fibrinogen, g/L	2.29 (1.41, 3.58)	1.57 (0.47, 2.44)	2.35 (1.53, 3.66)	0.003
INR	1.45 (1.23, 2.04)	1.93 (1.40, 2.82)	1.43 (1.22, 1.93)	0.005
GWR	1.31 (1.26, 1.35)	1.23 (1.17, 1.29)	1.32 (1.27, 1.35)	<0.001

Variables	All patients (n=227)	ICH group (n=22)	Non-ICH group (n=205)	P-value
Lab findings during ECMO^a
Minimum HCT	0.256 ± 0.534	0.242 ± 0.522	0.257 ± 0.534	0.201
Minimum platelet count, ×10⁹/L	61 (41, 93)	43 (18, 65)	62 (43, 94)	0.001
Peak creatinine, μmol/L	113.7 (75.6, 154.6)	130.9 (81.6, 171.2)	112.2 (73.0, 153.3)	0.290
Minimum fibrinogen, g/L	1.75 (1.16, 2.55)	1.71 (0.73, 2.46)	1.75 (1.20, 2.57)	0.285
Peak INR	1.58 (1.33, 2.18)	1.49 (1.20, 2.90)	1.58 (1.34, 2.13)	0.650
Transfused blood products ^a
RBC, mL/(kg·d)	2.35 (0.46, 4.98)	1.98 (1.02, 4.36)	2.34 (0, 5.20)	0.968
Platelet, mL/(kg·d)	0.29 (0, 1.64)	1.34 (0.22, 3.06)	0 (0, 1.54)	0.006
FFP, mL/(kg·d)	0 (0, 1.43)	1.13 (0, 4.40)	0 (0, 1.05)	0.004
Extracranial bleeding ^a	81 (35.7)	11 (50.0)	70 (34.1)	0.140
Hepatic failure^a	34 (15.0)	6 (27.2)	28 (13.7)	0.112
Duration of MV, days	7 (3, 12)	7 (4, 9)	7 (2, 12)	0.930
Duration of CRRT, days	3 (0, 9)	4 (1, 7)	3 (0, 9)	0.523
28-day mortality	115 (50.7)	18 (81.8)	97 (47.3)	0.001
In-hospital mortality	118 (52.0)	20 (90.9)	98 (47.8)	0.001

Variables	AUC	95%CI	Optimal cut-off value	Youden index	Sensitivity (%)	Specificity (%)	PPV (%)	NPV (%)	P-value
Age	0.611	0.496-0.726	49	0.199	51.7	68.2	13.2	93.8	0.088
MAP pre-ECMO	0.614	0.489-0.738	48	0.230	63.9	59.1	14.9	93.6	0.080
Fibrinogen pre-ECMO	0.690	0.575-0.805	1.96	0.321	63.9	68.2	16.8	94.9	0.003
INR pre-ECMO	0.681	0.571-0.790	2.68	0.314	45.5	85.9	25.6	93.6	0.005
PLT transfusion	0.667	0.551-0.783	0.77	0.342	72.7	61.5	16.8	95.5	0.010
FFP transfusion	0.671	0.542-0.801	2.07	0.294	45.5	83.9	23.3	93.5	0.008
Minimum PLT count	0.716	0.604-0.828	29	0.357	45.5	90.2	33.3	93.9	<0.001
GWR	0.788	0.701-0.876	1.27	0.503	72.7	77.6	25.8	96.4	<0.001

Variables	Univariate analysis			Multivariate analysis
Variables	OR	95%CI	P-value	OR	95%CI	P-value
Age	0.978	0.952-1.004	0.096	-	-	-
GWR	0.891	0.843-0.942	<0.001	0.894	0.841-0.951	<0.001
MAP pre-ECMO	0.988	0.972-1.004	0.136	-	-	-
Fibrinogen pre-ECMO	0.645	0.455-0.916	0.014	-	-	-
INR pre-ECMO	1.168	0.931-1.466	0.178	-	-	-
Stroke	3.032	0.902-10.184	0.073	4.265	1.052-17.291	0.042
PLT transfusion	1.185	1.012-1.388	0.035	-	-	-
FFP transfusion	1.274	1.108-1.465	0.001	1.208	1.037-1.408	0.015
Minimum PLT count	0.973	0.956-0.990	0.002	0.977	0.958-0.996	0.019

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