Ch 28 (s28.15, stopgap); Part VI (unowned)
Because thrombolysis is off the table, thrombectomy becomes the only reperfusion option — which means the interventional pathway for a cannulated patient must be arranged before it is needed, not during the event.
Non-contrast head computed tomography is imperative to rule out intracranial haemorrhage with any acute neurological examination change; computed tomographic angiography is needed to assess for large vessel occlusion. Intravenous tissue plasminogen activator in the setting of ECMO carries a high risk of bleeding, especially with systemic anticoagulation and platelet dysfunction; given these risks the use of tPA is generally not indicated in ECMO patients and the consensus among experts is to avoid it. Mechanical thrombectomy should be pursued for patients with large vessel occlusion detected by computed tomographic angiography, accompanied by a perfusion scan to assess salvageable penumbra, by consulting stroke specialists. Decompressive craniectomy may be indicated for space-occupying lesions with acute intracranial hypertension; hyperosmolar therapy is indicated for cerebral oedema.
Acute ischaemic stroke on ECMO