Veno-arterial extracorporeal membrane oxygenation under dual antiplatelet therapy, immediately after craniotomy

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Introduction: Extracorporeal membrane oxygenation (ECMO) is often considered a relative contraindication for traumatic brain injury and cerebral hemorrhage because fatal intracranial hemorrhage can occur. Moreover, dual antiplatelet therapy (DAPT)-related cerebral hemorrhage is associated with a high mortality rate. Herein, we report a case in which the patient was placed on ECMO under DAPT and managed without anticoagulation immediately after craniotomy. Case Report: A 51-year-old man was hospitalized for surgery for Moyamoya disease. The surgery was performed as scheduled; however, the patient experienced cardiac arrest while awakening from anesthesia. After return of spontaneous circulation, during the emergency percutaneous coronary intervention (PCI), he was placed on ECMO for cardiac arrest which caused an electrical storm. Because computed tomography (CT) after PCI revealed a new cerebral hemorrhage, ECMO was managed with DAPT without anticoagulation. Subsequently, the CT showed no increase in hematoma; however, a thrombus was observed in the membrane of the ECMO, and ECMO was withdrawn on the 4th intensive care unit day. Conclusion: Anticoagulation therapy with or without DAPT should not be used because of the risk of bleeding associated with veno-arterial ECMO immediately after craniotomy. Additionally, the risk of thrombosis may be high; therefore, additional care must be taken, and it is necessary to manage the ECMO circuit to consider the possibility of early replacement it too.

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