Neurologically Devastating Intraparenchymal Hemorrhage in COVID-19 Patients on Extracorporeal Membrane Oxygenation: A Case Series

Neurosurgery. 2020 Aug 1;87(2):E147-E151. doi: 10.1093/neuros/nyaa198.


Background and importance: Extracorporeal membrane oxygenation (ECMO) represents a life-saving therapy in cases of refractory hypoxia and has been utilized in patients suffering from the most severe forms of coronavirus disease 2019 (COVID-19). A strikingly high mortality rate of 94% was described in early reports of patients with COVID-19 transitioned to ECMO. Later case reports and series demonstrating successful recovery from COVID-19 after ECMO have revived interest in this therapeutic modality, including the recent approval of ECMO for COVID-19 patients by the Food and Drug Administration (FDA). Here, we present the first reports of devastating intracranial hemorrhage as a complication of veno-venous (VV) ECMO in two COVID-19 patients.

Clinical presentation: We performed a retrospective analysis of 2 cases of devastating intracranial hemorrhage in patients on VV-ECMO for the treatment of COVID-19. Collected data included clinical history, laboratory results, treatment, and review of all available imaging. Both patients demonstrated activated partial thromboplastin times (aPTT) within an appropriate therapeutic range. No risk factors that clearly predicted likelihood of this complication were identified.

Conclusion: Understanding the complications of ECMO in this cohort and developing therapeutic algorithms to aid in optimal patient selection will be critical in the limited resource setting experienced as a result of global pandemic. We propose the use of head computed tomography (CT) to identify devastating neurological complications as early as possible, aiding in the resource allocation of ECMO machines to the most appropriately selected patients.

Keywords: COVID-19; Extracorporeal membrane oxygenation; Intracranial hemorrhage; Intraparenchymal hemorrhage; Patient selection; Resource allocation; SARS-CoV-2.

Publication types

  • Case Reports

MeSH terms

  • Anticoagulants / adverse effects*
  • Betacoronavirus
  • COVID-19
  • Cohort Studies
  • Coronavirus Infections / therapy*
  • Extracorporeal Membrane Oxygenation / adverse effects*
  • Extracorporeal Membrane Oxygenation / methods
  • Fatal Outcome
  • Female
  • Heparin / adverse effects*
  • Humans
  • Intracranial Hemorrhages / diagnostic imaging
  • Intracranial Hemorrhages / etiology*
  • Male
  • Middle Aged
  • Pandemics
  • Pneumonia, Viral / therapy*
  • Respiratory Distress Syndrome / therapy*
  • Retrospective Studies
  • SARS-CoV-2


  • Anticoagulants
  • Heparin