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Individuals who survive acute respiratory distress syndrome (ARDS) often face prolonged cognitive impairments. Comparable consequences have been observed in chronic hypoxic conditions, like COPD and obstructive sleep apnea syndrome, which have been linked to reduced gray matter volume. We hypothesized that ARDS patients display similar cerebral findings, but those treated with extracorporeal membrane oxygenation (ECMO) show greater structural brain alterations than those treated conservatively, reflecting the severity of hypoxemia.

Eighteen ARDS survivors, seven conservatively treated (ARDS-conv), and eleven treated with ECMO (ARDS-ECMO) were studied and compared with healthy controls. Structural magnetic resonance imaging (MRI) was analyzed using voxel-based morphometry (VBM). Total intracranial volume (TIV), gray matter (GM), white matter (WM), and cerebrospinal fluid (CSF) volumes were quantified and compared between groups.

ARDS patients had lower TIV than healthy controls (1516.50 mL [95% CI 1380.85-1618.72] vs. 1664.07 mL [95% CI 1558.41-1776.06], P=0.008). While intracranial volumes of GM, WM, and CSF were not different between ARDS-conv and healthy controls, CSF volume of ARDS-ECMO was lower than in healthy controls, while GM and WM were comparable. Compared to ARDS-ECMO, ARDS-conv had lower GM volumes (ARDS-conv 37.9% [95% CI 36.3-39.2] vs. ARDS-ECMO 41.4% [95% CI 39.9-43.8]; P=0.036), WM and CSF were comparable. VBM also revealed distinct clusters of reduced GM in ARDS-conv patients compared to healthy controls (TFCE, FWE-corrected P<0.05).

ARDS survivors exhibit structural brain changes suggestive of hypoxia-related injury. ECMO treatment may mitigate gray matter loss, supporting early initiation of ECMO in severe ARDS to reduce long-term neurological sequelae. Extracorporeal membrane oxygenation may prevent preterm cerebral atrophy in survivors of acute respiratory distress syndrome: a pilot trial.