What is the best neurologic management approach for a 50-year-old female with a new right occipital infarct, who is currently in shock, has acute kidney injury (AKI) on dialysis, hepatic impairment, disseminated intravascular coagulation (DIC), on extracorporeal membrane oxygenation (ECMO) and intra-aortic balloon pump (IABP), and requires therapeutic anticoagulation?

Management of Right Occipital Infarct in a Patient on ECMO with Multiple Complications

For this critically ill patient with a new right occipital infarct while on ECMO with multiple complications, mechanical thrombectomy is recommended if there is large vessel occlusion, while avoiding tissue plasminogen activator (tPA) due to high bleeding risk, especially with DIC. 1

Neurological Assessment and Management

Initial Approach

• Obtain urgent neurological consultation for comprehensive assessment 1
• Perform detailed neurological examination focusing on:
  • Visual field deficits (homonymous hemianopia is common with occipital infarcts) 2
  • Central vision and color vision impairment 2
  • Visual associative function

Imaging

• Obtain CT angiogram to assess for large vessel occlusion 1
• Consider CT perfusion scan to evaluate salvageable penumbra if large vessel occlusion is detected 1

Treatment Options

1. Mechanical thrombectomy

   • Recommended if large vessel occlusion is detected 1
   • Preferred over thrombolysis in this patient due to multiple bleeding risks

2. Avoid tPA

   • tPA is contraindicated due to:
     • Systemic anticoagulation requirements for ECMO
     • Active DIC
     • Recent surgical procedures
     • High risk of bleeding complications 1

3. Intracranial pressure management

   • Implement stepwise management of intracranial hypertension if present 1
   • Elevate head of bed by 30 degrees 1
   • Consider hyperosmolar therapy (mannitol or hypertonic saline) if cerebral edema develops
   • Maintain adequate sedation and analgesia

Anticoagulation Management

Balancing Risks

• ECMO requires anticoagulation to prevent circuit thrombosis
• Patient has high bleeding risk due to:
  • DIC
  • Recent surgical procedures
  • New cerebral infarct
  • Hepatic impairment
  • Renal failure requiring dialysis

Recommended Approach

1. For VA ECMO (which this patient is on):

   • Therapeutic anticoagulation is necessary but must be carefully balanced 1, 3
   • Monitor anticoagulation closely with activated partial thromboplastin time (aPTT) 3
   • Target lower therapeutic range (e.g., aPTT 45-60 seconds rather than 60-80 seconds)
   • Consider using unfractionated heparin as it can be quickly reversed if bleeding occurs 3

2. Monitoring parameters:

   • Use thromboelastography/thromboelastometry if available for more comprehensive assessment of coagulation status 3
   • Monitor for signs of bleeding (neurological deterioration, decreasing hemoglobin)
   • Perform serial neuroimaging to assess for hemorrhagic transformation

Physiological Parameter Optimization

1. Blood pressure management:

   • Maintain mean arterial pressure >70 mmHg to ensure adequate cerebral perfusion 1
   • Avoid hypotension which may worsen ischemic injury
   • Avoid excessive hypertension which may increase risk of hemorrhagic transformation

2. Oxygenation and ventilation:

   • Maintain PaO₂ >70 mmHg to prevent hypoxemia-associated brain injury 1
   • Avoid hyperoxemia (PaO₂ >300 mmHg) as it may contribute to oxidative stress 1
   • Target normocapnia (PaCO₂ 35-45 mmHg) 1
   • Avoid rapid PaCO₂ changes which can alter cerebral blood flow 1

3. Temperature management:

   • Maintain normothermia and actively prevent fever (>37.7°C) 1
   • Consider mild-moderate hypothermia (33-36°C) for 24-48 hours if not contraindicated 1

Multidisciplinary Approach

• Coordinate care between:
  • Neurology
  • Cardiology
  • Critical care
  • Vascular surgery
  • Hematology (for DIC management)
  • Nephrology (for dialysis management)

Prognosis and Monitoring

• Monitor for:

  • Neurological deterioration
  • Hemorrhagic transformation of the infarct
  • Extension of the infarct
  • Visual field deficits and other visual symptoms 2

• Perform serial neurological examinations and repeat neuroimaging if clinical deterioration occurs

Key Pitfalls to Avoid

1. Do not use tPA for the occipital infarct due to extremely high bleeding risk with DIC, recent surgery, and ECMO 1

2. Do not discontinue anticoagulation completely for prolonged periods as this significantly increases thrombotic risk to the ECMO circuit 1, 3

3. Do not delay neurological consultation as early intervention may improve outcomes 1

4. Avoid overaggressive anticoagulation given the patient's multiple bleeding risk factors 4

5. Do not rely on a single factor for prognostication - use a multimodality approach 1