{"paper_id":"2831eee6-4f86-4cf0-8d57-8ae63bd9808d","body_text":"High Prevalence of Acute Brain Injury on Brain Magnetic Resonance Imaging in Acute Respiratory Distress Syndrome | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article High Prevalence of Acute Brain Injury on Brain Magnetic Resonance Imaging in Acute Respiratory Distress Syndrome Merry Huang, Aron Gedansky, Catherine E. Hassett, Aaron Shoskes, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2587753/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 05 Sep, 2023 Read the published version in Neurocritical Care → Version 1 posted 4 You are reading this latest preprint version Abstract Objective: Acute Respiratory Distress Syndrome(ARDS) is an acute inflammatory respiratory failure condition that may be associated with acute brain injury (ABI). We aimed to describe the prevalence and types of ABI detected by brain MRI among ARDS patients. Methods: We retrospectively reviewed and collected data on ABI as detected by brain MRI during index hospitalization of all ARDS patients at a single tertiary center in the United States from January 2010 to October 2018. ABIs were classified as cerebral ischemia (ischemic infarct and hypoxic ischemic brain injury) or cerebral hemorrhage (intraparenchymal hemorrhage, cerebral microbleeds, subarachnoid hemorrhage, and subdural hematoma). Descriptive statistics were conducted. Results: Of the 678 ARDS patients, 66 (9.7%) underwent brain MRI during their ARDS illness. The most common indication for brain MRI was encephalopathy (45.4%) and the median time from hospital admission to MRI was 10 days (interquartile range 4-17). Of 66, 29 (44%) had MRI evidence of ABI including cerebral ischemia in 33% (22/66) and cerebral hemorrhage in 21% (14/66). Among those with cerebral ischemia, common findings were bilateral globus pallidus infarcts (n=7, 32%), multifocal infarcts (n=5, 23%), and diffuse hypoxic ischemic brain injury (n=3, 14%). Of those with cerebral hemorrhage, common findings were cerebral microbleeds (n=12, 86%) and intraparenchymal hemorrhage (n=2, 14%). ARDS patients with cerebral hemorrhage had significantly greater use of rescue therapies including prone positioning (28.6% vs 5.8%, p = 0.03), inhaled vasodilator (35.7% vs 11.5%, p = 0.046), and recruitment maneuver (14.3% vs 0%, p = 0.04). Conclusion: Among selected patients with ARDS who underwent brain MRI, almost a half had ABI most commonly including bilateral globus pallidus infarcts and cerebral microbleeds. Acute respiratory distress syndrome acute brain injury Lung-brain interaction cerebral infarction cerebral hemorrhage Figures Figure 1 Figure 2 Figure 3 Introduction Acute respiratory distress syndrome (ARDS) is an acute inflammatory lung condition characterized by bilateral noncardiogenic pulmonary edema, severe hypoxemia, and respiratory failure requiring mechanical ventilatory support ( 1 ). ARDS is a common cause of acute hypoxemic respiratory failure (67.2%) and represents 10.4% of all intensive care unit (ICU) admissions and 23.4% of all mechanically ventilated patients worldwide 2 . Patients with ARDS have a high hospital mortality rate of 35 to 48% and long term morbidity including pulmonary dysfunction, functional disability, cognitive impairment, and psychological morbidity ( 3 – 6 ). ARDS can be associated with secondary acute brain injury (ABI), which may further impact survival and functional outcome ( 7 – 9 ). Hypoxic ischemic brain injury (HIBI), cerebral microbleeds (CMBs), and ischemic and hemorrhagic strokes have been reported in ARDS patients ( 7 , 10 – 12 ). The mechanism of ARDS associated ABI is thought to be related to the lung and brain crosstalk where diffuse pulmonary injury may lead to systemic release of inflammatory markers causing cerebral dysfunction ( 13 – 18 ). Further, specific mechanical ventilatory strategies such as low tidal volume and high positive end expiratory pressure in select patients may alter cerebrovascular flow dynamics and raise intracranial pressure, thereby exacerbating existing brain injury ( 19 – 21 ). To date, there is sparse literature on the types of ABI seen in ARDS and even fewer neuroimaging data characterizing these brain injuries. Further information on this topic is needed to better understand the pathophysiological mechanisms of ARDS mediated ABI. Herein, we specifically review brain magnetic resonance imaging (MRI) of ARDS patients and describe radiographic types of ABI and investigate the risk factors associated with specific types of ABI. Materials And Methods Study Design and Population This study was approved by the Cleveland Clinic Institutional Review Board (IRB) with IRB number 14-1431 on 11/16/2021 entitled “Medical Records: Assessment of Severity of Acute Respiratory Distress Syndrome and its outcome”. The need for informed consent was waived by the IRB. Procedures of this study were followed in accordance with the ethical standards of the Cleveland Clinic IRB. We retrospectively reviewed medical records of patients diagnosed with ARDS at a single tertiary medical center between January 2010 to October 2018. Patients’ charts were screened for the presence of brain MRI during admission for review. Inclusion criteria included ( 1 ) patients ≥ 18 years of age; ( 2 ) patients diagnosed with ARDS satisfying the Berlin criteria ( 22 ); ( 3 ) patients who underwent brain MRI during the hospital course after diagnosis of ARDS. ARDS patients with MRIs that did not have the appropriate radiographic sequences necessary to assess for cerebral ischemia or hemorrhage were excluded. Data Collection and Synthesis We reviewed all brain MRI images of ARDS patients and collected MRI features of ABIs. All MRI scans were completed with 1.5 or 3 Tesla scanners and included T1-, T2-weighted, fluid-attenuated inversion recovery, diffusion weighted imaging (DWI), and susceptibility weighted imaging (SWI) or gradient echo (GRE) imaging. The standard acquisition time for the SWI sequence was 3 min at our institution. Two neurologists (M.H. and A.G.) independently reviewed MRI images and radiographic interpretations. Ischemic injury data was collected including acute ischemic infarct defined as hyperintense signal on DWI associated with hypodense signal on apparent diffusion coefficient imaging ( 23 ) and HIBI defined as symmetric hyperintensity on DWI in the cerebral cortex, cerebellar hemispheres, basal ganglia, thalami, or brainstem correlating with a clinical hypoxic event ( 24 ). Cerebral hemorrhage data was collected and included CMBs, intraparenchymal hemorrhage (IPH), subdural hematoma (SDH), and subarachnoid hemorrhage (SAH). CMBs were defined as small round foci (< 5 mm in diameter) of hypodensity on SWI or GRE imaging ( 25). Isolated petechial hemorrhages associated with the area of hemorrhagic transformation of ischemic infarct were not considered to be CMBs. MRI and computerized tomography (CT) images when available were reviewed to determine acute versus chronic hemorrhages. Data on baseline demographics, ARDS risk factors, ARDS severity, indication for brain MRI, and time from admission to brain MRI were collected. Hospital characteristics were gathered including presence of sepsis, septic shock, cardiac arrest, use of extracorporeal membrane oxygenation (ECMO) and antiplatelet/anticoagulation use during admission, duration of mechanical ventilation, and use of ARDS rescue therapies. Admission ICU morality scores and laboratory data were collected including Acute Physiology, Age, Chronic Health Evaluation (APACHE) III, Charlson comorbidity index (CCI), Sequential Organ Failure Assessment (SOFA), and Glasgow Coma Score (GCS). Worst hospital laboratory data were collected including lowest PaO 2 /FiO 2 ratio (P:F ratio), lowest mean arterial pressure (MAP), lowest serum pH, lowest platelet count, highest creatinine, and highest lactate. Outcomes Primary outcome was type of ABI including cerebral ischemia and hemorrhage and secondary outcomes were ICU and in-hospital mortality. Statistical Analysis Patient demographics, hospital characteristics, and outcome were compared between ARDS patients with and without ABI, ARDS patients with and without acute cerebral ischemia, and ARDS patients with and without hemorrhagic injury. A subgroup of ARDS patients who had cerebral ischemia with and without bilateral globus pallidus infarction were additionally analyzed. The results are presented as median and interquartile range (IQR). Statistical comparisons were performed using student t-test for continuous variables and Fisher’s exact or Chi-Square test for categorical variables A p value less than 0.05 was considered significant. Results Overall Patient Characteristics Of the 678 patients with ARDS, 66 (9.7%) underwent brain MRI imaging during their hospital course (Table 1 ). The median age was 53 years (IQR: 41-62.8) with 44% (22/66) being male. Median time from admission to brain MRI was 10 days (IQR: 4–17). The most common indication for brain MRI was encephalopathy (45.4%) ( Supplemental Table 1 ). Out of the 66 patients, 23% had mild ARDS, 42% had moderate ARDS, and 35% had severe ARDS at admission. Sepsis was the most common ARDS risk factor (85%). Table 1 Characteristics of Acute Respiratory Distress Syndrome Patients with Brain MRI Demographics Acute Respiratory Distress Syndrome Patients with Brain MRI (n = 66) Median Age (IQR) 53 (41–62.8) Median BMI (IQR) 31.4 (25.9–37.7) Male (%) 29 (44%) Comorbidities Hypertension 20 (30%) Hyperlipidemia 27 (41%) Atrial Fibrillation 32 (48%) Smoker 19 (29%) Diabetes 7 (11%) ARDS Risk Factors Pneumonia 49 (74%) Sepsis 56 (85%) Aspiration 16 (24%) ARDS Severity Mild 15 (23%) Moderate 28 (42%) Severe 23 (35%) Median Duration of Mechanical Ventilation (IQR) 19 (11–31) Outcome Median Hospital Length of Stay in Days (IQR) 25 (19–33) Hospital Mortality 24 (36%) Acute Brain Injury Of the 66 ARDS patients undergoing brain MRI, 29 (44%) had evidence of ABI including both cerebral ischemia (22/66, 33%) and cerebral hemorrhage (14/66, 21%) (Table 2 ). There were no significant differences in age, co-morbidities, ARDS risk factors, and ARDS severity between patients with and without ABI ( Supplemental Table 2 ). ARDS patients with ABI had a significantly worse lowest pH value during admission (7.16 [IQR: 7.06–7.27] vs 7.26 [IQR: 7.17–7.36], p = 0.004). ARDS patient with ABI did not significantly differ in median ICU or hospital length of stay, but had a trend toward higher mortality (48.3% vs 27%, p = 0.07) compared to ARDS patients without ABI. Table 2 Types of Acute Brain Injury on Brain MRI in Acute Respiratory Distress Syndrome Patients Type of ABI Number of Patients with ABI (n = 29) Acute Cerebral Ischemia n = 22 a (76%) Bilateral Globus Pallidus Infarcts 7 (31.8%) Multifocal Infarcts 5 (22.3%) Hypoxic Ischemic Brain Injury 3 (13.6%) Other Infarcts b 7 (31.8%) Cerebral Hemorrhage n = 14 a (48%) Cerebral Microbleeds 12 (86%) Intraparenchymal Hemorrhage 2 (14.3%) Subarachnoid Hemorrhage 1 (7.1%) Subdural Hematoma 1 (7.1%) a Number/percentages of patients listed in subset of intracranial hemorrhage and ischemic injury may not add up to overall number/percentage due to patients simultaneously having more than one type of cerebral hemorrhage and/or ischemic injury. b Other areas of infarct included the frontal lobe, cerebellum, posterior limb of the internal capsule, basal ganglia, and splenium of the corpus collosum. Acute Cerebral Ischemia Of the 29 ARDS patients with ABI, 22 (76%) had acute cerebral ischemia. The most common findings were bilateral globus pallidus infarcts (31.8%), multifocal infarcts (22.3%), and HIBI (13.6%) (Table 2 ). There were no significant differences in age, co-morbidities, ARDS severity, ARDS risk factors, and hospital characteristics including lowest PF ratio and cardiac arrest among ARDS patients with and without acute cerebral ischemia (Table 3 ). Although not significantly different, ARDS patients with acute cerebral ischemia tended to have worse lowest pH (7.16 [7.1–7.3] vs 7.25 [IQR: 7.2–7.4], p = 0.06) during admission ( Supplemental Table 3 ). ARDS patients with acute cerebral ischemia had significantly greater ICU and hospital mortality (54.5% vs 27.3%, p = 0.03). Table 3 Characteristics of Acute Respiratory Distress Syndrome Patients with and without Cerebral Ischemia and Hemorrhage Demographics Patient without Acute Cerebral Ischemia (n = 44) Patients with Acute Cerebral Ischemia (n = 22) P Value Patients without Cerebral Hemorrhage (n = 52) Patients with Cerebral Hemorrhage (n = 14) P Value Median Age (IQR) 51 (39.5–59.5) 57.5 (44–66) 0.16 50.5 (39.5–59.5) 57.00 (41–70) 0.27 Median BMI (IQR) 30.45 (25.9–37.8) 31.6 (25.2–35.3) 0.74 31.5 (25.9 − 39.4) 31.1 (25.2–35.3) 0.79 Male (%) 19 (43.2%) 10 (45.5%) 0.86 20 (38.5%) 9 (64.3%) 0.08 Comorbidities Hypertension 20 (45.5%) 11 (50%) 0.73 22 (42.5%) 9 (64.3%) 0.14 Hyperlipidemia 19 (43.2%) 8 (36.4%) 0.60 18 (34.6%) 9 (64.3%) 0.045 a Atrial Fibrillation 14 (31.8%) 4 (18.2%) 0.24 12 (23.1%) 6 (42.9%) 0.18 Smoker 22 (50.0%) 10 (45.5%) 0.73 27 (51.9%) 5 (35.7%) 0.28 Diabetes 15 (34.1%) 4 (18.2%) 0.18 15 (28.8%) 4 (28.6%) 1.00 ARDS Severity Mild 8 (18.2%) 7 (31.8%) 0.21 12 (23.1%) 3 (21.4%) 1.00 Moderate 20 (45.5%) 8 (36.4%) 0.48 21 (40.4%) 7 (50.0%) 0.52 Severe 16 (36.4%) 7 (31.8%) 0.71 19 (36.5%) 4 (8.6%) 0.75 Hospital Characteristics Septic Shock 21 (47.7%) 10 (45.5%) 0.86 20 (38.5%) 11 (78.6%) 0.01 a Cardiac Arrest 6 (13.6%) 8 (36.4%) 0.053 10 (19.2%) 4 (28.6%) 0.47 ECMO 3 (6.8%) 0 (0.0%) 0.55 1 (1.9%) 2 (14.3%) 0.11 Prone Positioning 4 (9.1%) 3 (13.6%) 0.68 3 (5.8%) 4 (28.6%) 0.03 a Inhaled Vasodilator 8 (18.2) 3 (13.6%) 0.74 6 (11.5%) 5 (35.7%) 0.046 a Recruitment Maneuver 2 (4.5%) 0 (0.0%) 0.55 0 (0.0%) 14.3% (2/14) 0.04 a Anticoagulation Use 7 (15.9%) 4 (18.2%) 1.00 8 (15.4%) 3 (21.4%) 0.69 Median Duration of Mechanical Ventilation (IQR) 20.50 (12.5–35.5) 16 (10–27) 0.54 18.5 (12–29) 23 (11–41) 0.14 Outcome Median Hospital Length of Stay in Days (IQR) 26.50 (19–35) 24.50 (19–30) 0.36 25.5 (19–33) 24.5 (19–35) 0.40 Hospital Mortality 12 (27.3%) 12 (54.5%) 0.03 a 34.6% (18/52) 42.9% (6/14) 0.57 a Indicates significant p-valve Abbreviations : ECMO: extracorporeal membrane oxygenation, IQR: interquartile range, PF ratio: PaO2/FiO2 Bilateral Globus Pallidus Infarct Of the 22 ARDS patients with acute cerebral ischemia, 7 (32%) had bilateral globus pallidus infarcts (Fig. 1 ). There were no significant differences in co-morbidities, and ARDS severity, and ARDS risk factors between ARDS patients with and without globus pallidus infarcts ( Supplemental Table 4 ). Patients with globus pallidus infarcts had significantly worse lowest pH during admission (7.14 [IQR: 7.01–7.16] vs 7.26 [IQR:7.16–7.36], p = 0.004) with a trend toward higher frequency of aspiration as ARDS risk factor (57.1% vs 20.3%, p = 0.05) and a trend toward more severe highest lactate during admission (6.7 [IQR: 1.2–11.3] vs 3.05 [IQR: 1.6–5.8], p = 0.07) compared to those without globus pallidus infarct. Patients with globus pallidus infarct did not significantly differ in hospital/ICU length of stay (25 vs 26 days and 21 vs 19 days) and hospital/ICU morality (14.3% vs 39%, p = 0.41) compared to those without globus pallidus infarct. Cerebral hemorrhage Of the 29 ARDS patient undergoing brain MRI, 14 (48%) had cerebral hemorrhage. Types of cerebral hemorrhage included CMBs (86%), intraparenchymal hemorrhage (14.3%), SAH (7.1%), and SDH (7.1%) (Table 1 ). ARDS patients with cerebral hemorrhage had a significantly greater frequency of hyperlipidemia (64.3% vs 34.6%, p = 0.045) (Table 3 ). There were no significant differences in ARDS severity and risk factors between patients with and without cerebral hemorrhage. ARDS patients with cerebral hemorrhage had significantly greater frequency of septic shock (78.6% vs 38.5%, p = 0.01), higher admission glucose (190.5 [IQR: 148–395] vs 144.5 [IQR: 120.5–206], p = 0.03), and use of rescue therapies including prone positioning (28.6% vs 5.8%, p = 0.03), inhaled vasodilator (35.7% vs 11.5%, p = 0.046), and recruitment maneuver (14.3% vs 0%, p = 0.04). ARDS patients with cerebral hemorrhage had a trend towards more severe lowest platelet count (157 [IQR: 58–178] vs 175.5 [IQR: 117.5–230.5], p = 0.07). There were no significant differences in remainder of hospital characteristics including antiplatelet use, anticoagulation use, and endocarditis ( Supplemental Table 3 ). ARDS patients with and without cerebral hemorrhage did not significantly differ in ICU and hospital length of stay or mortality. Discussion Our study found a high prevalence (44%) of ABI including acute cerebral ischemia (33%) and cerebral hemorrhage (21%) in ARDS patients who underwent brain MRI during index admission. ARDS patients with ABI had an overall high in-hospital mortality of 48%. These findings are similar to a recent literature review reporting 25% of hemorrhagic stroke and 30% of acute cerebral ischemia in ARDS patients with an overall morality of 53% ( 26 ). The most common acute cerebral ischemia was bilateral globus pallidus infarction and the most common hemorrhagic injury was CMBs. Overall, ARDS patients with ABI had a significantly worse serum pH during admission and a trend toward greater use of ARDS rescue therapies, possibly suggesting that prolonged hypoxia may play a role in cerebral endothelial dysfunction. Our study highlights that ABI is common in ARDS and may be associated with increased mortality. Among the ischemic injuries, we found a high prevalence (32%) of bilateral globus pallidus infarcts in ARDS patients. Given that the basal ganglia are associated with high metabolic demand and rich vascular supply ( 27 ), ARDS patients may be vulnerable to injury to this area due to associated hypoxemia from poor oxygenation and hypotension from concomitant septic shock ( 28 , 29 ). We congruously found that ARDS patients with bilateral globus pallidus infarcts had significantly higher frequency of aspiration event and greater percentage of cardiac arrest. Further, these patients had more severe hypoxemia with lower PF ratio and poor end organ perfusion as reflected by significantly lower serum pH and trend toward higher lactate. Bilateral globus pallidus infarcts have also been described in patients with illicit drug use including cocaine ( 30 , 31 ). Among 7 ARDS patients with globus pallidus infarcts, 3 patients had positive urine toxicology that included cocaine, heroin, opiates, and tetrahydrocannabinol. The use of these drugs may further predispose ARDS patients to globus pallidus injury due to direct drug effects on cerebral vasospasm and hypoxia from secondary effects of hypoventilation ( 32 ). The remaining 4 ARDS patient who did not have known illicit drug exposure suggest that severe ARDS alone may lead to such injuries. ARDS patients with globus pallidus infarction did not have higher in-hospital mortality compared to those without globus pallidus infarction likely due to the fact that injury to such areas often result in cognitive deficit rather than motor weakness that could cause immobility and dysphagia leading aspiration and increased mortality ( 33 ). Other ischemic injuries seen in our ARDS cohort included HIBI, multifocal infarcts, watershed infarcts, and lacunar infarcts. Two ARDS patients who had HIBI suffered from cardiac arrest and two of three patients who had central embolic appearing strokes suffered from active infectious endocarditis while the third had Lambl's excrescences. ARDS patients are also at increased for risk atrial fibrillation in the setting of critical illness and therefore cardioembolic stroke. However, we did not find a greater frequency of atrial fibrillation in ARDS patients with cerebral ischemia likely due to the fact that stroke risk associated with atrial fibrillation is distributed annually rather than during acute hospitalization period. Two other acute cerebral ischemia reported in ARDS patients were thought to be due to direct infection from rhizopus and aspergillosis although this was not confirmed. These findings suggest that ARDS patients may have concomitant sepsis that may further contribute to ABI whether from direct invasion versus peripheral effects of systemic inflammation. Notably, all ARDS patients with acute cerebral ischemia in our cohort had sepsis. Both ARDS and sepsis are characterized by a diffuse systemic inflammatory state, which may lead to endothelial dysfunction and contribute to cerebral small vessel disease as evidenced by two ARDS patients with infarcts involving the splenium of the corpus collosum and posterior limb internal capsule ( 33 – 35 ). Overall, ARDS patients with acute cerebral ischemia had a significantly higher in-hospital mortality compared to those without acute cerebral ischemia. We found CMBs to be the most common type of hemorrhagic injury in ARDS patients. Patterns of CMBs varied from few scattered CMBs to diffuse involvement of both deep and lobar structures (Fig. 2 ). Since the SARS-CoV-2 (COVID-19) pandemic, there is now emerging literature on diffuse CMBs in COVID-19 ARDS patients. The etiology of these CMBs is thought to be related to severe hypoxemia leading to blood brain barrier dysfunction and extravasation of erythrocytes given similar pattern of microbleeds seen in high-altitude cerebral edema ( 36 – 38 ). Although we did not find a significant difference in ARDS severity or lowest PF ratio in ARDS patients with cerebral hemorrhage compared to those without, patients with hemorrhagic injury had significantly greater frequency of ARDS rescue therapies including prone positioning, inhaled vasodilation, and recruitment maneuvers, suggesting the severity of impaired oxygenation. Diffuse CMBs have also been described with use of ECMO, which is thought to be possibly related to heparin infusion among other theories including ECMO circuit activation of proinflammatory cascade ( 39 , 40 ). Our results did not show a significantly greater use of ECMO or anticoagulation/antiplatelet use during admission in ARDS patients with cerebral hemorrhage although this finding may be limited by selection bias given that those with ECMO may not have been hemodynamically stable to undergo brain MRI. Interestingly, one patient our ARDS cohort underwent two separate brain MRIs during the course of her admission with the second MRI demonstrating severe progression of diffuse CMBs in absence of ECMO use (Fig. 3 ). This finding suggests that ARDS pathology alone may contribute to CMBs independent of ECMO. It is important to note that many of the ECMO patients with CMBs reported in the literature had prolonged proinflammatory state related to sepsis and it is also thought that CMBs may possibly related to cytokinopathy leading to endothelial dysfunction and blood brain barrier breakdown ( 41 , 42 ). In support of this theory, ARDS patient with cerebral hemorrhage in our cohort had a significantly higher frequency of septic shock compared of those without cerebral hemorrhage. It is plausible that the CMBs seen in ARDS patient may overlap with CMBs seen in ECMO patients due to shared mechanism of diffuse systemic proinflammatory state. Other hemorrhagic injuries seen in our ARDS cohort included two patients with intracranial parenchymal hemorrhage in the setting of coagulopathy and sepsis and another patient with subdural hematoma in the setting of heparin use. Our study has several limitations. First, our study may overestimate the prevalence of ABI in ARDS patients given that the majority of patients underwent brain MRI for encephalopathy or stroke evaluation. On the other hand, our study may have excluded critically ill ARDS patients who were too hemodynamically unstable to undergo brain MRI due to proning or on ECMO. A further limitation was our strict focus on MRI imaging without necessarily the clinical neurological context as patients with clinical brain injuries sufficiently captured on CT imaging may not have proceeded to undergo MRI. Second, although we attempted to review CT images when available to determine chronicity of hemorrhages, CT is not sensitive to assess for CMBs. Further, patients did not have pre-morbid brain MRI for comparison to definitively assess the acuity of CMBs. Future studies with pre and post brain MRI for ARDS patients are needed to further confirm the development and pattern of CMBs during acute ARDS. Third, ARDS patients who had cerebral hemorrhage had a significantly higher admission glucose level and greater frequency of hyperlipidemia as a comorbidity. Both elevated glucose and hyperlipidemia are known risk factors for small vessel disease and therefore could contribute to the CMBs seen in ARDS ( 43 , 44 ). Despite this, CMBs have been robustly demonstrated in COVID ARDS patients without such comorbidities and as a result this may instead suggest that existing small vessel disease risk factors may further predispose ARDS patients to CMBs. Lastly, the limited sample size may contribute to underpowering of variables and future studies with larger population is necessary for further investigation. Our study demonstrates that ABI is common in patients with ARDS. Both cerebral ischemia and hemorrhage are seen in ARDS patient with bilateral globus pallidus infarction and CMBs being the most common pathologies. ARDS patients with acute cerebral ischemia have a significantly higher in-hospital mortality compared to those without acute cerebral ischemia. It is important to recognize ABI in ARDS as lung protective ventilatory strategies such as permissive hypercapnia and use of high positive end-expiratory pressure may worsen pre-existing brain injury. A limitation of our study includes possibly overestimating the prevalence of ABI given that brain MRIs are selectively done on patients with neurological symptoms. Further, it may be difficult to ascertain the acuity of CMBs seen in ARDS patients as this was limited by absence of pre-morbid brain MRI for comparison. Future studies with pre-ARDS and post-ARDS brain MRI are needed to better understand the pattern and extent of CMBs seen. Declarations This manuscript complies with all instructions to authors. All authors have made substantial contributions to all of the following: 1) substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; 2) drafting the article or revising it critically for important intellectual content; and 3) final approval of the version to be published. The manuscript has not been published totally or partly, accepted for publication, or under editorial review for publication elsewhere and has no overlap with previous publications. All ethical guidelines and use of informed consent were followed. All authors listed in this manuscript have nothing to disclose. This manuscript was completed in accordance to STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) checklist. Sources of Funding: None Authors' contributions: Study concept and design: Huang, Gedansky, Duggal, Uchino, Cho, Buletko Acquisition, analysis, or interpretation of data: Huang, Gedansky, Hassett Statistical analysis: Huang Tables and figures: Huang First drafting of the manuscript: Huang Critical revision for important intellectual content and final approval of the manuscript: Gedansky, Shoskes, Hassett, Duggal, Cho, Uchino, Buletko References Matthay MA, Zemans RL, Zimmerman GA et al. 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Bilateral Basal Ganglia Infarction After Intranasal Use of Cocaine: A Case Report. Cureus; 2019. Parekh MA. Bilateral globus pallidus lesions.BMJ Case Rep. 2021;14(2). Kaufman MJ, Levin JM, Ross MH et al. Cocaine-Induced Cerebral Vasoconstriction Detected in Humans With Magnetic Resonance Angiography [Internet]. Available from: https://jamanetwork.com/ Nelson S, Toma H, LaMonica H, Chabrashvili T. Major Cognitive Changes and Micrographia following Globus Pallidus Infarct. Case Rep Neurol Med. 2014;2014:1–4. Meduri GU, Annane D, Chrousos GP, Marik PE, Sinclair SE. Activation and regulation of systemic inflammation in ARDS: Rationale for prolonged glucocorticoid therapy. Chest. 2009;136(6):1631–43. Fanou EM, Coutinho JM, Shannon P, et al. Crit Illness-Associated Cereb Microbleeds Stroke. 2017;48(4):1085–7. Lersy F, Willaume T, Brisset JC, et al. Critical illness-associated cerebral microbleeds for patients with severe COVID-19: etiologic hypotheses. J Neurol. 2021;268(8):2676–84. Kallenberg K, Dehnert C, Dörfler A, et al. Microhemorrhages in nonfatal high-altitude cerebral edema. J Cereb Blood Flow Metab. 2008;28(9):1635–42. Riech S, Kallenberg K, Moerer O, et al. The Pattern of Brain Microhemorrhages after Severe Lung Failure Resembles the One Seen in High-Altitude Cerebral Edema. Crit Care Med. 2015;43(9):e386–9. CORRESPONDENCE Diffuse Cerebral Microbleeds after Extracorporeal Membrane Oxygenation Support [Internet]. 2015. Available from: www.atsjournals.org Millar JE, Fanning JP, McDonald CI, McAuley DF, Fraser JF. The inflammatory response to extracorporeal membrane oxygenation (ECMO): A review of the pathophysiology.Crit Care. 2016;20(1). Erickson MA, Banks WA. Neuroimmune axes of the blood-brain barriers and blood-brain interfaces: Bases for physiological regulation, disease states, and pharmacological interventions. Pharmacol Rev. 2018;70(2):278–314. Varga Z, Flammer AJ, Steiger P, et al. Endothelial cell infection and endotheliitis in COVID-19. The Lancet. 2020;395(10234):1417–8. Lei C, Zhong L, Ling Y, Chen T. Blood glucose levels are associated with cerebral microbleeds in patients with acute ischaemic stroke. Eur Neurol. 2019;80(3–4):187–92. Agarwal S, Jain R, Dogra S et al. Cerebral Microbleeds and Leukoencephalopathy in Critically Ill Patients with COVID-19.Stroke2020;2649–55. Supplementary Files SupplementalFiles.docx Cite Share Download PDF Status: Published Journal Publication published 05 Sep, 2023 Read the published version in Neurocritical Care → Version 1 posted Reviewers agreed at journal 03 Mar, 2023 Editor invited by journal 03 Mar, 2023 Editor assigned by journal 27 Feb, 2023 First submitted to journal 27 Feb, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-2587753\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":180659267,\"identity\":\"81328f2c-8393-4d2a-a541-d8fd44b83ecc\",\"order_by\":0,\"name\":\"Merry Huang\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAvElEQVRIiWNgGAWjYBACAwhVI8fAwPiAJC3HjBkYmA1I0sKc2EC0FnOJ5GcPv+awpfe3H2Zg+LinlrAWyxlp5say22RyZ5xJZmCc8ew4EQ67kWAmLbmNLXeDBP8BZp4Dx4jRkv4NqIU53UCCmYFYLTlmkh+3MSdAtdQQoeXMmzJpxm3HDEF+OTjjwAEitBxP3yb5c1uNPH/7YcYHHw7UEdYCAsw8UAbQisPEaWH8gWATacsoGAWjYBSMKAAAYHY5dQxZ+88AAAAASUVORK5CYII=\",\"orcid\":\"\",\"institution\":\"Cleveland Clinic Neurological Institute\",\"correspondingAuthor\":true,\"submittingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Merry\",\"middleName\":\"\",\"lastName\":\"Huang\",\"suffix\":\"\"},{\"id\":180659268,\"identity\":\"396c03b6-89bb-404d-bed1-521aac8a1ac9\",\"order_by\":1,\"name\":\"Aron Gedansky\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Cleveland Clinic Neurological Institute\",\"correspondingAuthor\":false,\"submittingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Aron\",\"middleName\":\"\",\"lastName\":\"Gedansky\",\"suffix\":\"\"},{\"id\":180659269,\"identity\":\"cab5f237-4da1-47b9-8f64-f8c780d068c9\",\"order_by\":2,\"name\":\"Catherine E. Hassett\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Cleveland Clinic Neurological Institute\",\"correspondingAuthor\":false,\"submittingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Catherine\",\"middleName\":\"E.\",\"lastName\":\"Hassett\",\"suffix\":\"\"},{\"id\":180659270,\"identity\":\"8f64bf8b-e112-4fbb-96ad-525ed119a6c5\",\"order_by\":3,\"name\":\"Aaron Shoskes\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Miami Miller School of Medicine: University of Miami School of Medicine\",\"correspondingAuthor\":false,\"submittingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Aaron\",\"middleName\":\"\",\"lastName\":\"Shoskes\",\"suffix\":\"\"},{\"id\":180659271,\"identity\":\"44fa5f1e-63be-4cc2-a7e2-87cb32d7ded9\",\"order_by\":4,\"name\":\"Abhijit Duggal\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Cleveland Clinic Health System: Cleveland Clinic\",\"correspondingAuthor\":false,\"submittingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Abhijit\",\"middleName\":\"\",\"lastName\":\"Duggal\",\"suffix\":\"\"},{\"id\":180659272,\"identity\":\"4cc08d46-0d6c-40f0-beab-db2598f373a9\",\"order_by\":5,\"name\":\"Ken Uchino\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Cleveland Clinic Neurological Institute\",\"correspondingAuthor\":false,\"submittingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Ken\",\"middleName\":\"\",\"lastName\":\"Uchino\",\"suffix\":\"\"},{\"id\":180659273,\"identity\":\"65cc351d-7fe5-48ad-b049-8bf5df937d01\",\"order_by\":6,\"name\":\"Sung-Min Cho\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Johns Hopkins Medicine School of Medicine: Johns Hopkins University School of Medicine\",\"correspondingAuthor\":false,\"submittingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Sung-Min\",\"middleName\":\"\",\"lastName\":\"Cho\",\"suffix\":\"\"},{\"id\":180659274,\"identity\":\"ce8c4cd1-2fbb-4648-8900-3a0e3b09356b\",\"order_by\":7,\"name\":\"Andrew Blake Buletko\",\"email\":\"\",\"orcid\":\"https://orcid.org/0000-0002-1595-0602\",\"institution\":\"Cleveland Clinic Neurological Institute\",\"correspondingAuthor\":false,\"submittingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Andrew\",\"middleName\":\"Blake\",\"lastName\":\"Buletko\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2023-02-14 19:17:12\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-2587753/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-2587753/v1\",\"draftVersion\":[],\"editorialEvents\":[{\"content\":\"https://doi.org/10.1007/s12028-023-01823-0\",\"type\":\"published\",\"date\":\"2023-09-05T15:02:09+00:00\"}],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":33968726,\"identity\":\"fac9ca8b-31d4-4a7b-b2ba-9f0eb903e540\",\"added_by\":\"auto\",\"created_at\":\"2023-03-08 15:20:18\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":2184171,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eDiffusion weighted (DWI) magnetic resonance imaging of seven acute respiratory syndrome patients with acute bilateral globus pallidus infarcts. All areas of DWI had corresponding hypodensity on apparent diffusion coefficient imaging.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Figure1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-2587753/v1/55931cee6221c0d33ee4a393.png\"},{\"id\":33968725,\"identity\":\"51dd3b0c-09cb-4f85-95c4-521a53780df4\",\"added_by\":\"auto\",\"created_at\":\"2023-03-08 15:20:18\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":1655711,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eSusceptibility weighted imaging of a 41-year-old male with a history of hypertension, hyperlipidemia, and diabetes admitted for multifocal pneumonia complicated by acute respiratory distress syndrome requiring veno-venous extracorporeal membrane oxygenation showing diffuse cerebral microbleeds involving bilateral cerebral lobes (A, B), deep subcortical structures including the genu and splenium of the corpus collosum (C), and cerebellum (D).\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Figure2.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-2587753/v1/ce08b04fe81997fb32fa5190.png\"},{\"id\":33968727,\"identity\":\"e07057ab-91e3-40b4-a26b-aeb83505ede6\",\"added_by\":\"auto\",\"created_at\":\"2023-03-08 15:20:18\",\"extension\":\"png\",\"order_by\":3,\"title\":\"Figure 3\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":1465043,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eSusceptibility weighted imaging of a 62-year-old female with a history of multiple sclerosis who was admitted after cardiac arrest and developed ARDS with brain MRI on day 5 of admission showing multiple diffuse scattered cerebral microbleeds (CMBs) in the bilateral cerebral lobes (A to B), and cerebellum and multifocal ischemic stroke in setting of patent foramen ovale. Repeat MRI brain on day 20 of admission showed progression of CMBs involving the supra (C and D) and infratentorial regions. This patient was not on extracorporeal membrane oxygenation.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Figure3.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-2587753/v1/6dcd77988069b6166d4d0cad.png\"},{\"id\":42947270,\"identity\":\"f4937ae5-4570-4958-9862-ac852b21926e\",\"added_by\":\"auto\",\"created_at\":\"2023-09-11 15:07:49\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":2574442,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-2587753/v1/149fac8d-1fb2-45b3-9fbc-278b0237e221.pdf\"},{\"id\":33968728,\"identity\":\"29e3af35-41b0-49aa-9d95-bfa9d1741439\",\"added_by\":\"auto\",\"created_at\":\"2023-03-08 15:20:18\",\"extension\":\"docx\",\"order_by\":12,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":43327,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"SupplementalFiles.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-2587753/v1/1339cab8ade11a6bc7c3efe4.docx\"}],\"financialInterests\":\"\",\"formattedTitle\":\"High Prevalence of Acute Brain Injury on Brain Magnetic Resonance Imaging in Acute Respiratory Distress Syndrome\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eAcute respiratory distress syndrome (ARDS) is an acute inflammatory lung condition characterized by bilateral noncardiogenic pulmonary edema, severe hypoxemia, and respiratory failure requiring mechanical ventilatory support (\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e). ARDS is a common cause of acute hypoxemic respiratory failure (67.2%) and represents 10.4% of all intensive care unit (ICU) admissions and 23.4% of all mechanically ventilated patients worldwide \\u003csup\\u003e2\\u003c/sup\\u003e. Patients with ARDS have a high hospital mortality rate of 35 to 48% and long term morbidity including pulmonary dysfunction, functional disability, cognitive impairment, and psychological morbidity (\\u003cspan additionalcitationids=\\\"CR4 CR5\\\" citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eARDS can be associated with secondary acute brain injury (ABI), which may further impact survival and functional outcome (\\u003cspan additionalcitationids=\\\"CR8\\\" citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e). Hypoxic ischemic brain injury (HIBI), cerebral microbleeds (CMBs), and ischemic and hemorrhagic strokes have been reported in ARDS patients (\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e, \\u003cspan additionalcitationids=\\\"CR11\\\" citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e). The mechanism of ARDS associated ABI is thought to be related to the lung and brain crosstalk where diffuse pulmonary injury may lead to systemic release of inflammatory markers causing cerebral dysfunction (\\u003cspan additionalcitationids=\\\"CR14 CR15 CR16 CR17\\\" citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e). Further, specific mechanical ventilatory strategies such as low tidal volume and high positive end expiratory pressure in select patients may alter cerebrovascular flow dynamics and raise intracranial pressure, thereby exacerbating existing brain injury (\\u003cspan additionalcitationids=\\\"CR20\\\" citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eTo date, there is sparse literature on the types of ABI seen in ARDS and even fewer neuroimaging data characterizing these brain injuries. Further information on this topic is needed to better understand the pathophysiological mechanisms of ARDS mediated ABI. Herein, we specifically review brain magnetic resonance imaging (MRI) of ARDS patients and describe radiographic types of ABI and investigate the risk factors associated with specific types of ABI.\\u003c/p\\u003e\"},{\"header\":\"Materials And Methods\",\"content\":\"\\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eStudy Design and Population\\u003c/h2\\u003e \\u003cp\\u003e This study was approved by the Cleveland Clinic Institutional Review Board (IRB) with IRB number 14-1431 on 11/16/2021 entitled \\u0026ldquo;Medical Records: Assessment of Severity of Acute Respiratory Distress Syndrome and its outcome\\u0026rdquo;. The need for informed consent was waived by the IRB. Procedures of this study were followed in accordance with the ethical standards of the Cleveland Clinic IRB.\\u003c/p\\u003e \\u003cp\\u003e We retrospectively reviewed medical records of patients diagnosed with ARDS at a single tertiary medical center between January 2010 to October 2018. Patients\\u0026rsquo; charts were screened for the presence of brain MRI during admission for review. Inclusion criteria included (\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e) patients\\u0026thinsp;\\u0026ge;\\u0026thinsp;18 years of age; (\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e) patients diagnosed with ARDS satisfying the Berlin criteria (\\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e); (\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e) patients who underwent brain MRI during the hospital course after diagnosis of ARDS. ARDS patients with MRIs that did not have the appropriate radiographic sequences necessary to assess for cerebral ischemia or hemorrhage were excluded.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec4\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eData Collection and Synthesis\\u003c/h2\\u003e \\u003cp\\u003eWe reviewed all brain MRI images of ARDS patients and collected MRI features of ABIs. All MRI scans were completed with 1.5 or 3 Tesla scanners and included T1-, T2-weighted, fluid-attenuated inversion recovery, diffusion weighted imaging (DWI), and susceptibility weighted imaging (SWI) or gradient echo (GRE) imaging. The standard acquisition time for the SWI sequence was 3 min at our institution. Two neurologists (M.H. and A.G.) independently reviewed MRI images and radiographic interpretations. Ischemic injury data was collected including acute ischemic infarct defined as hyperintense signal on DWI associated with hypodense signal on apparent diffusion coefficient imaging (\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e) and HIBI defined as symmetric hyperintensity on DWI in the cerebral cortex, cerebellar hemispheres, basal ganglia, thalami, or brainstem correlating with a clinical hypoxic event (\\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e). Cerebral hemorrhage data was collected and included CMBs, intraparenchymal hemorrhage (IPH), subdural hematoma (SDH), and subarachnoid hemorrhage (SAH). CMBs were defined as small round foci (\\u0026lt;\\u0026thinsp;5 mm in diameter) of hypodensity on SWI or GRE imaging \\u003csup\\u003e(\\u003c/sup\\u003e25). Isolated petechial hemorrhages associated with the area of hemorrhagic transformation of ischemic infarct were not considered to be CMBs. MRI and computerized tomography (CT) images when available were reviewed to determine acute versus chronic hemorrhages.\\u003c/p\\u003e \\u003cp\\u003eData on baseline demographics, ARDS risk factors, ARDS severity, indication for brain MRI, and time from admission to brain MRI were collected. Hospital characteristics were gathered including presence of sepsis, septic shock, cardiac arrest, use of extracorporeal membrane oxygenation (ECMO) and antiplatelet/anticoagulation use during admission, duration of mechanical ventilation, and use of ARDS rescue therapies. Admission ICU morality scores and laboratory data were collected including Acute Physiology, Age, Chronic Health Evaluation (APACHE) III, Charlson comorbidity index (CCI), Sequential Organ Failure Assessment (SOFA), and Glasgow Coma Score (GCS). Worst hospital laboratory data were collected including lowest PaO\\u003csub\\u003e2\\u003c/sub\\u003e/FiO\\u003csub\\u003e2\\u003c/sub\\u003e ratio (P:F ratio), lowest mean arterial pressure (MAP), lowest serum pH, lowest platelet count, highest creatinine, and highest lactate.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec5\\\" class=\\\"Section3\\\"\\u003e \\u003ch2\\u003eOutcomes\\u003c/h2\\u003e \\u003cp\\u003ePrimary outcome was type of ABI including cerebral ischemia and hemorrhage and secondary outcomes were ICU and in-hospital mortality.\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec6\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eStatistical Analysis\\u003c/h2\\u003e \\u003cp\\u003ePatient demographics, hospital characteristics, and outcome were compared between ARDS patients with and without ABI, ARDS patients with and without acute cerebral ischemia, and ARDS patients with and without hemorrhagic injury. A subgroup of ARDS patients who had cerebral ischemia with and without bilateral globus pallidus infarction were additionally analyzed. The results are presented as median and interquartile range (IQR). Statistical comparisons were performed using student t-test for continuous variables and Fisher\\u0026rsquo;s exact or Chi-Square test for categorical variables A p value less than 0.05 was considered significant.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cdiv id=\\\"Sec8\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eOverall Patient Characteristics\\u003c/h2\\u003e \\u003cp\\u003eOf the 678 patients with ARDS, 66 (9.7%) underwent brain MRI imaging during their hospital course (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). The median age was 53 years (IQR: 41-62.8) with 44% (22/66) being male. Median time from admission to brain MRI was 10 days (IQR: 4\\u0026ndash;17). The most common indication for brain MRI was encephalopathy (45.4%) (\\u003cb\\u003eSupplemental Table\\u0026nbsp;1\\u003c/b\\u003e). Out of the 66 patients, 23% had mild ARDS, 42% had moderate ARDS, and 35% had severe ARDS at admission. Sepsis was the most common ARDS risk factor (85%).\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eCharacteristics of Acute Respiratory Distress Syndrome Patients with Brain MRI\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"2\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eDemographics\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eAcute Respiratory Distress Syndrome Patients with Brain MRI\\u003c/p\\u003e \\u003cp\\u003e(n\\u0026thinsp;=\\u0026thinsp;66)\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMedian Age (IQR)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e53 (41\\u0026ndash;62.8)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMedian BMI (IQR)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e31.4 (25.9\\u0026ndash;37.7)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMale (%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e29 (44%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eComorbidities\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eHypertension\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e20 (30%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eHyperlipidemia\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e27 (41%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAtrial Fibrillation\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e32 (48%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSmoker\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e19 (29%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eDiabetes\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e7 (11%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eARDS Risk Factors\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePneumonia\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e49 (74%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSepsis\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e56 (85%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAspiration\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e16 (24%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eARDS Severity\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMild\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e15 (23%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eModerate\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e28 (42%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSevere\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e23 (35%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMedian Duration of Mechanical Ventilation (IQR)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e19 (11\\u0026ndash;31)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eOutcome\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMedian Hospital Length of Stay in Days (IQR)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e25 (19\\u0026ndash;33)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eHospital Mortality\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e24 (36%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec9\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eAcute Brain Injury\\u003c/h2\\u003e \\u003cp\\u003eOf the 66 ARDS patients undergoing brain MRI, 29 (44%) had evidence of ABI including both cerebral ischemia (22/66, 33%) and cerebral hemorrhage (14/66, 21%) (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e). There were no significant differences in age, co-morbidities, ARDS risk factors, and ARDS severity between patients with and without ABI (\\u003cb\\u003eSupplemental Table\\u0026nbsp;2\\u003c/b\\u003e). ARDS patients with ABI had a significantly worse lowest pH value during admission (7.16 [IQR: 7.06\\u0026ndash;7.27] vs 7.26 [IQR: 7.17\\u0026ndash;7.36], p\\u0026thinsp;=\\u0026thinsp;0.004). ARDS patient with ABI did not significantly differ in median ICU or hospital length of stay, but had a trend toward higher mortality (48.3% vs 27%, p\\u0026thinsp;=\\u0026thinsp;0.07) compared to ARDS patients without ABI.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eTypes of Acute Brain Injury on Brain MRI in Acute Respiratory Distress Syndrome Patients\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"2\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eType of ABI\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eNumber of Patients with ABI\\u003c/p\\u003e \\u003cp\\u003e(n\\u0026thinsp;=\\u0026thinsp;29)\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAcute Cerebral Ischemia\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003en\\u0026thinsp;=\\u0026thinsp;22\\u003csup\\u003e\\u003cem\\u003ea\\u003c/em\\u003e\\u003c/sup\\u003e (76%)\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eBilateral Globus Pallidus Infarcts\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e7 (31.8%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMultifocal Infarcts\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e5 (22.3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eHypoxic Ischemic Brain Injury\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e3 (13.6%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eOther Infarcts \\u003csup\\u003e\\u003cspan type=\\\"BoldItalic\\\" class=\\\"BoldItalic\\\" name=\\\"Emphasis\\\"\\u003eb\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e7 (31.8%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eCerebral Hemorrhage\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003en\\u0026thinsp;=\\u0026thinsp;14\\u003c/b\\u003e\\u003csup\\u003e\\u003cspan type=\\\"BoldItalic\\\" class=\\\"BoldItalic\\\" name=\\\"Emphasis\\\"\\u003ea\\u003c/span\\u003e\\u003c/sup\\u003e\\u003cb\\u003e(48%)\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCerebral Microbleeds\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e12 (86%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eIntraparenchymal Hemorrhage\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e2 (14.3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSubarachnoid Hemorrhage\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1 (7.1%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSubdural Hematoma\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1 (7.1%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003ctfoot\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"2\\\"\\u003e\\u003csup\\u003e\\u003cspan type=\\\"BoldItalic\\\" class=\\\"BoldItalic\\\" name=\\\"Emphasis\\\"\\u003ea\\u003c/span\\u003e\\u003c/sup\\u003e Number/percentages of patients listed in subset of intracranial hemorrhage and ischemic injury may not add up to overall number/percentage due to patients simultaneously having more than one type of cerebral hemorrhage and/or ischemic injury.\\u003c/td\\u003e\\u003c/tr\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"2\\\"\\u003e\\u003csup\\u003e\\u003cspan type=\\\"BoldItalic\\\" class=\\\"BoldItalic\\\" name=\\\"Emphasis\\\"\\u003eb\\u003c/span\\u003e\\u003c/sup\\u003e Other areas of infarct included the frontal lobe, cerebellum, posterior limb of the internal capsule, basal ganglia, and splenium of the corpus collosum.\\u003c/td\\u003e\\u003c/tr\\u003e \\u003c/tfoot\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec10\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eAcute Cerebral Ischemia\\u003c/h2\\u003e \\u003cp\\u003eOf the 29 ARDS patients with ABI, 22 (76%) had acute cerebral ischemia. The most common findings were bilateral globus pallidus infarcts (31.8%), multifocal infarcts (22.3%), and HIBI (13.6%) (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e). There were no significant differences in age, co-morbidities, ARDS severity, ARDS risk factors, and hospital characteristics including lowest PF ratio and cardiac arrest among ARDS patients with and without acute cerebral ischemia (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e). Although not significantly different, ARDS patients with acute cerebral ischemia tended to have worse lowest pH (7.16 [7.1\\u0026ndash;7.3] vs 7.25 [IQR: 7.2\\u0026ndash;7.4], p\\u0026thinsp;=\\u0026thinsp;0.06) during admission (\\u003cb\\u003eSupplemental Table\\u0026nbsp;3\\u003c/b\\u003e). ARDS patients with acute cerebral ischemia had significantly greater ICU and hospital mortality (54.5% vs 27.3%, p\\u0026thinsp;=\\u0026thinsp;0.03).\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab3\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 3\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eCharacteristics of Acute Respiratory Distress Syndrome Patients with and without Cerebral Ischemia and Hemorrhage\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"7\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c6\\\" colnum=\\\"6\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c7\\\" colnum=\\\"7\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eDemographics\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003ePatient without\\u003c/p\\u003e \\u003cp\\u003eAcute Cerebral Ischemia\\u003c/p\\u003e \\u003cp\\u003e(n\\u0026thinsp;=\\u0026thinsp;44)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003ePatients with\\u003c/p\\u003e \\u003cp\\u003eAcute Cerebral Ischemia\\u003c/p\\u003e \\u003cp\\u003e(n\\u0026thinsp;=\\u0026thinsp;22)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eP Value\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003ePatients without\\u003c/p\\u003e \\u003cp\\u003eCerebral Hemorrhage\\u003c/p\\u003e \\u003cp\\u003e(n\\u0026thinsp;=\\u0026thinsp;52)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003ePatients with\\u003c/p\\u003e \\u003cp\\u003eCerebral Hemorrhage\\u003c/p\\u003e \\u003cp\\u003e(n\\u0026thinsp;=\\u0026thinsp;14)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eP Value\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMedian Age (IQR)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e51 (39.5\\u0026ndash;59.5)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e57.5 (44\\u0026ndash;66)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.16\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e50.5 (39.5\\u0026ndash;59.5)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e57.00 (41\\u0026ndash;70)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e0.27\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMedian BMI (IQR)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e30.45 (25.9\\u0026ndash;37.8)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e31.6 (25.2\\u0026ndash;35.3)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.74\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e31.5 (25.9 \\u0026minus;\\u0026thinsp;39.4)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e31.1 (25.2\\u0026ndash;35.3)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e0.79\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMale (%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e19 (43.2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e10 (45.5%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.86\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e20 (38.5%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e9 (64.3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e0.08\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eComorbidities\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eHypertension\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e20 (45.5%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e11 (50%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.73\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e22 (42.5%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e9 (64.3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e0.14\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eHyperlipidemia\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e19 (43.2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e8 (36.4%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.60\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e18 (34.6%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e9 (64.3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e0.045\\u003c/b\\u003e\\u003csup\\u003e\\u003cspan type=\\\"BoldItalic\\\" class=\\\"BoldItalic\\\" name=\\\"Emphasis\\\"\\u003ea\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAtrial Fibrillation\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e14 (31.8%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e4 (18.2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.24\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e12 (23.1%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e6 (42.9%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e0.18\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSmoker\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e22 (50.0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e10 (45.5%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.73\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e27 (51.9%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e5 (35.7%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e0.28\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eDiabetes\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e15 (34.1%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e4 (18.2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.18\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e15 (28.8%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e4 (28.6%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e1.00\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eARDS Severity\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMild\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e8 (18.2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e7 (31.8%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.21\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e12 (23.1%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e3 (21.4%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e1.00\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eModerate\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e20 (45.5%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e8 (36.4%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.48\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e21 (40.4%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e7 (50.0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e0.52\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSevere\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e16 (36.4%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e7 (31.8%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.71\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e19 (36.5%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e4 (8.6%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e0.75\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eHospital Characteristics\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSeptic Shock\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e21 (47.7%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e10 (45.5%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.86\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e20 (38.5%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e11 (78.6%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e0.01\\u003c/b\\u003e\\u003csup\\u003e\\u003cspan type=\\\"BoldItalic\\\" class=\\\"BoldItalic\\\" name=\\\"Emphasis\\\"\\u003ea\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCardiac Arrest\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e6 (13.6%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e8 (36.4%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.053\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e10 (19.2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e4 (28.6%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e0.47\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eECMO\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e3 (6.8%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0 (0.0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.55\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e1 (1.9%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e2 (14.3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e0.11\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eProne Positioning\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e4 (9.1%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e3 (13.6%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.68\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e3 (5.8%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e4 (28.6%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e0.03\\u003c/b\\u003e\\u003csup\\u003e\\u003cspan type=\\\"BoldItalic\\\" class=\\\"BoldItalic\\\" name=\\\"Emphasis\\\"\\u003ea\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eInhaled Vasodilator\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e8 (18.2)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e3 (13.6%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.74\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e6 (11.5%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e5 (35.7%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e0.046\\u003c/b\\u003e\\u003csup\\u003e\\u003cspan type=\\\"BoldItalic\\\" class=\\\"BoldItalic\\\" name=\\\"Emphasis\\\"\\u003ea\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eRecruitment Maneuver\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e2 (4.5%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0 (0.0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.55\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e0 (0.0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e14.3% (2/14)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e0.04\\u003c/b\\u003e\\u003csup\\u003e\\u003cspan type=\\\"BoldItalic\\\" class=\\\"BoldItalic\\\" name=\\\"Emphasis\\\"\\u003ea\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAnticoagulation Use\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e7 (15.9%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e4 (18.2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e1.00\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e8 (15.4%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e3 (21.4%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e0.69\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMedian Duration of Mechanical Ventilation (IQR)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e20.50 (12.5\\u0026ndash;35.5)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e16 (10\\u0026ndash;27)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.54\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e18.5 (12\\u0026ndash;29)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e23 (11\\u0026ndash;41)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e0.14\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eOutcome\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMedian Hospital Length of Stay in Days (IQR)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e26.50 (19\\u0026ndash;35)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e24.50 (19\\u0026ndash;30)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.36\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e25.5 (19\\u0026ndash;33)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e24.5 (19\\u0026ndash;35)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e0.40\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eHospital Mortality\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e12 (27.3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e12 (54.5%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e0.03\\u003c/b\\u003e\\u003csup\\u003e\\u003cspan type=\\\"BoldItalic\\\" class=\\\"BoldItalic\\\" name=\\\"Emphasis\\\"\\u003ea\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e34.6% (18/52)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e42.9% (6/14)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e0.57\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003ctfoot\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"7\\\"\\u003e\\u003csup\\u003e\\u003cspan type=\\\"BoldItalic\\\" class=\\\"BoldItalic\\\" name=\\\"Emphasis\\\"\\u003ea\\u003c/span\\u003e\\u003c/sup\\u003e Indicates significant p-valve\\u003c/td\\u003e\\u003c/tr\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"7\\\"\\u003e\\u003cb\\u003eAbbreviations\\u003c/b\\u003e: ECMO: extracorporeal membrane oxygenation, IQR: interquartile range, PF ratio: PaO2/FiO2\\u003c/td\\u003e\\u003c/tr\\u003e \\u003c/tfoot\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cdiv id=\\\"Sec11\\\" class=\\\"Section3\\\"\\u003e \\u003ch2\\u003eBilateral Globus Pallidus Infarct\\u003c/h2\\u003e \\u003cp\\u003eOf the 22 ARDS patients with acute cerebral ischemia, 7 (32%) had bilateral globus pallidus infarcts (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). There were no significant differences in co-morbidities, and ARDS severity, and ARDS risk factors between ARDS patients with and without globus pallidus infarcts (\\u003cb\\u003eSupplemental Table\\u0026nbsp;4\\u003c/b\\u003e). Patients with globus pallidus infarcts had significantly worse lowest pH during admission (7.14 [IQR: 7.01\\u0026ndash;7.16] vs 7.26 [IQR:7.16\\u0026ndash;7.36], p\\u0026thinsp;=\\u0026thinsp;0.004) with a trend toward higher frequency of aspiration as ARDS risk factor (57.1% vs 20.3%, p\\u0026thinsp;=\\u0026thinsp;0.05) and a trend toward more severe highest lactate during admission (6.7 [IQR: 1.2\\u0026ndash;11.3] vs 3.05 [IQR: 1.6\\u0026ndash;5.8], p\\u0026thinsp;=\\u0026thinsp;0.07) compared to those without globus pallidus infarct. Patients with globus pallidus infarct did not significantly differ in hospital/ICU length of stay (25 vs 26 days and 21 vs 19 days) and hospital/ICU morality (14.3% vs 39%, p\\u0026thinsp;=\\u0026thinsp;0.41) compared to those without globus pallidus infarct.\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec12\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eCerebral hemorrhage\\u003c/h2\\u003e \\u003cp\\u003eOf the 29 ARDS patient undergoing brain MRI, 14 (48%) had cerebral hemorrhage. Types of cerebral hemorrhage included CMBs (86%), intraparenchymal hemorrhage (14.3%), SAH (7.1%), and SDH (7.1%) (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). ARDS patients with cerebral hemorrhage had a significantly greater frequency of hyperlipidemia (64.3% vs 34.6%, p\\u0026thinsp;=\\u0026thinsp;0.045) (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e). There were no significant differences in ARDS severity and risk factors between patients with and without cerebral hemorrhage. ARDS patients with cerebral hemorrhage had significantly greater frequency of septic shock (78.6% vs 38.5%, p\\u0026thinsp;=\\u0026thinsp;0.01), higher admission glucose (190.5 [IQR: 148\\u0026ndash;395] vs 144.5 [IQR: 120.5\\u0026ndash;206], p\\u0026thinsp;=\\u0026thinsp;0.03), and use of rescue therapies including prone positioning (28.6% vs 5.8%, p\\u0026thinsp;=\\u0026thinsp;0.03), inhaled vasodilator (35.7% vs 11.5%, p\\u0026thinsp;=\\u0026thinsp;0.046), and recruitment maneuver (14.3% vs 0%, p\\u0026thinsp;=\\u0026thinsp;0.04). ARDS patients with cerebral hemorrhage had a trend towards more severe lowest platelet count (157 [IQR: 58\\u0026ndash;178] vs 175.5 [IQR: 117.5\\u0026ndash;230.5], p\\u0026thinsp;=\\u0026thinsp;0.07). There were no significant differences in remainder of hospital characteristics including antiplatelet use, anticoagulation use, and endocarditis (\\u003cb\\u003eSupplemental Table\\u0026nbsp;3\\u003c/b\\u003e). ARDS patients with and without cerebral hemorrhage did not significantly differ in ICU and hospital length of stay or mortality.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eOur study found a high prevalence (44%) of ABI including acute cerebral ischemia (33%) and cerebral hemorrhage (21%) in ARDS patients who underwent brain MRI during index admission. ARDS patients with ABI had an overall high in-hospital mortality of 48%. These findings are similar to a recent literature review reporting 25% of hemorrhagic stroke and 30% of acute cerebral ischemia in ARDS patients with an overall morality of 53% (\\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e). The most common acute cerebral ischemia was bilateral globus pallidus infarction and the most common hemorrhagic injury was CMBs. Overall, ARDS patients with ABI had a significantly worse serum pH during admission and a trend toward greater use of ARDS rescue therapies, possibly suggesting that prolonged hypoxia may play a role in cerebral endothelial dysfunction. Our study highlights that ABI is common in ARDS and may be associated with increased mortality.\\u003c/p\\u003e \\u003cp\\u003eAmong the ischemic injuries, we found a high prevalence (32%) of bilateral globus pallidus infarcts in ARDS patients. Given that the basal ganglia are associated with high metabolic demand and rich vascular supply (\\u003cspan citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e27\\u003c/span\\u003e), ARDS patients may be vulnerable to injury to this area due to associated hypoxemia from poor oxygenation and hypotension from concomitant septic shock (\\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e28\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e). We congruously found that ARDS patients with bilateral globus pallidus infarcts had significantly higher frequency of aspiration event and greater percentage of cardiac arrest. Further, these patients had more severe hypoxemia with lower PF ratio and poor end organ perfusion as reflected by significantly lower serum pH and trend toward higher lactate. Bilateral globus pallidus infarcts have also been described in patients with illicit drug use including cocaine (\\u003cspan citationid=\\\"CR30\\\" class=\\\"CitationRef\\\"\\u003e30\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR31\\\" class=\\\"CitationRef\\\"\\u003e31\\u003c/span\\u003e). Among 7 ARDS patients with globus pallidus infarcts, 3 patients had positive urine toxicology that included cocaine, heroin, opiates, and tetrahydrocannabinol. The use of these drugs may further predispose ARDS patients to globus pallidus injury due to direct drug effects on cerebral vasospasm and hypoxia from secondary effects of hypoventilation (\\u003cspan citationid=\\\"CR32\\\" class=\\\"CitationRef\\\"\\u003e32\\u003c/span\\u003e). The remaining 4 ARDS patient who did not have known illicit drug exposure suggest that severe ARDS alone may lead to such injuries. ARDS patients with globus pallidus infarction did not have higher in-hospital mortality compared to those without globus pallidus infarction likely due to the fact that injury to such areas often result in cognitive deficit rather than motor weakness that could cause immobility and dysphagia leading aspiration and increased mortality (\\u003cspan citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eOther ischemic injuries seen in our ARDS cohort included HIBI, multifocal infarcts, watershed infarcts, and lacunar infarcts. Two ARDS patients who had HIBI suffered from cardiac arrest and two of three patients who had central embolic appearing strokes suffered from active infectious endocarditis while the third had Lambl's excrescences. ARDS patients are also at increased for risk atrial fibrillation in the setting of critical illness and therefore cardioembolic stroke. However, we did not find a greater frequency of atrial fibrillation in ARDS patients with cerebral ischemia likely due to the fact that stroke risk associated with atrial fibrillation is distributed annually rather than during acute hospitalization period. Two other acute cerebral ischemia reported in ARDS patients were thought to be due to direct infection from rhizopus and aspergillosis although this was not confirmed. These findings suggest that ARDS patients may have concomitant sepsis that may further contribute to ABI whether from direct invasion versus peripheral effects of systemic inflammation. Notably, all ARDS patients with acute cerebral ischemia in our cohort had sepsis. Both ARDS and sepsis are characterized by a diffuse systemic inflammatory state, which may lead to endothelial dysfunction and contribute to cerebral small vessel disease as evidenced by two ARDS patients with infarcts involving the splenium of the corpus collosum and posterior limb internal capsule (\\u003cspan additionalcitationids=\\\"CR34\\\" citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR35\\\" class=\\\"CitationRef\\\"\\u003e35\\u003c/span\\u003e). Overall, ARDS patients with acute cerebral ischemia had a significantly higher in-hospital mortality compared to those without acute cerebral ischemia.\\u003c/p\\u003e \\u003cp\\u003eWe found CMBs to be the most common type of hemorrhagic injury in ARDS patients. Patterns of CMBs varied from few scattered CMBs to diffuse involvement of both deep and lobar structures (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e). Since the SARS-CoV-2 (COVID-19) pandemic, there is now emerging literature on diffuse CMBs in COVID-19 ARDS patients. The etiology of these CMBs is thought to be related to severe hypoxemia leading to blood brain barrier dysfunction and extravasation of erythrocytes given similar pattern of microbleeds seen in high-altitude cerebral edema (\\u003cspan additionalcitationids=\\\"CR37\\\" citationid=\\\"CR36\\\" class=\\\"CitationRef\\\"\\u003e36\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR38\\\" class=\\\"CitationRef\\\"\\u003e38\\u003c/span\\u003e). Although we did not find a significant difference in ARDS severity or lowest PF ratio in ARDS patients with cerebral hemorrhage compared to those without, patients with hemorrhagic injury had significantly greater frequency of ARDS rescue therapies including prone positioning, inhaled vasodilation, and recruitment maneuvers, suggesting the severity of impaired oxygenation. Diffuse CMBs have also been described with use of ECMO, which is thought to be possibly related to heparin infusion among other theories including ECMO circuit activation of proinflammatory cascade (\\u003cspan citationid=\\\"CR39\\\" class=\\\"CitationRef\\\"\\u003e39\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR40\\\" class=\\\"CitationRef\\\"\\u003e40\\u003c/span\\u003e). Our results did not show a significantly greater use of ECMO or anticoagulation/antiplatelet use during admission in ARDS patients with cerebral hemorrhage although this finding may be limited by selection bias given that those with ECMO may not have been hemodynamically stable to undergo brain MRI. Interestingly, one patient our ARDS cohort underwent two separate brain MRIs during the course of her admission with the second MRI demonstrating severe progression of diffuse CMBs in absence of ECMO use (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e). This finding suggests that ARDS pathology alone may contribute to CMBs independent of ECMO. It is important to note that many of the ECMO patients with CMBs reported in the literature had prolonged proinflammatory state related to sepsis and it is also thought that CMBs may possibly related to cytokinopathy leading to endothelial dysfunction and blood brain barrier breakdown (\\u003cspan citationid=\\\"CR41\\\" class=\\\"CitationRef\\\"\\u003e41\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR42\\\" class=\\\"CitationRef\\\"\\u003e42\\u003c/span\\u003e). In support of this theory, ARDS patient with cerebral hemorrhage in our cohort had a significantly higher frequency of septic shock compared of those without cerebral hemorrhage. It is plausible that the CMBs seen in ARDS patient may overlap with CMBs seen in ECMO patients due to shared mechanism of diffuse systemic proinflammatory state. Other hemorrhagic injuries seen in our ARDS cohort included two patients with intracranial parenchymal hemorrhage in the setting of coagulopathy and sepsis and another patient with subdural hematoma in the setting of heparin use.\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003eOur study has several limitations. First, our study may overestimate the prevalence of ABI in ARDS patients given that the majority of patients underwent brain MRI for encephalopathy or stroke evaluation. On the other hand, our study may have excluded critically ill ARDS patients who were too hemodynamically unstable to undergo brain MRI due to proning or on ECMO. A further limitation was our strict focus on MRI imaging without necessarily the clinical neurological context as patients with clinical brain injuries sufficiently captured on CT imaging may not have proceeded to undergo MRI. Second, although we attempted to review CT images when available to determine chronicity of hemorrhages, CT is not sensitive to assess for CMBs. Further, patients did not have pre-morbid brain MRI for comparison to definitively assess the acuity of CMBs. Future studies with pre and post brain MRI for ARDS patients are needed to further confirm the development and pattern of CMBs during acute ARDS. Third, ARDS patients who had cerebral hemorrhage had a significantly higher admission glucose level and greater frequency of hyperlipidemia as a comorbidity. Both elevated glucose and hyperlipidemia are known risk factors for small vessel disease and therefore could contribute to the CMBs seen in ARDS (\\u003cspan citationid=\\\"CR43\\\" class=\\\"CitationRef\\\"\\u003e43\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR44\\\" class=\\\"CitationRef\\\"\\u003e44\\u003c/span\\u003e). Despite this, CMBs have been robustly demonstrated in COVID ARDS patients without such comorbidities and as a result this may instead suggest that existing small vessel disease risk factors may further predispose ARDS patients to CMBs. Lastly, the limited sample size may contribute to underpowering of variables and future studies with larger population is necessary for further investigation.\\u003c/p\\u003e \\u003cp\\u003eOur study demonstrates that ABI is common in patients with ARDS. Both cerebral ischemia and hemorrhage are seen in ARDS patient with bilateral globus pallidus infarction and CMBs being the most common pathologies. ARDS patients with acute cerebral ischemia have a significantly higher in-hospital mortality compared to those without acute cerebral ischemia. It is important to recognize ABI in ARDS as lung protective ventilatory strategies such as permissive hypercapnia and use of high positive end-expiratory pressure may worsen pre-existing brain injury. A limitation of our study includes possibly overestimating the prevalence of ABI given that brain MRIs are selectively done on patients with neurological symptoms. Further, it may be difficult to ascertain the acuity of CMBs seen in ARDS patients as this was limited by absence of pre-morbid brain MRI for comparison. Future studies with pre-ARDS and post-ARDS brain MRI are needed to better understand the pattern and extent of CMBs seen.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003eThis manuscript complies with all instructions to authors. All authors have made substantial contributions to all of the following: 1) substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; 2) drafting the article or revising it critically for important intellectual content; and 3) final approval of the version to be published. The manuscript has not been published totally or partly, accepted for publication, or under editorial review for publication elsewhere and has no overlap with previous publications. All ethical guidelines and use of informed consent were followed. All authors listed in this manuscript have nothing to disclose. This manuscript was completed in accordance to \\u003cstrong\\u003eSTrengthening the Reporting of OBservational studies in Epidemiology\\u003c/strong\\u003e (STROBE) checklist.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eSources of Funding:\\u003c/strong\\u003e None\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthors' contributions:\\u003c/strong\\u003e\\u003cbr /\\u003e \\u003cstrong\\u003eStudy concept and design:\\u003c/strong\\u003e Huang, Gedansky, Duggal, Uchino, Cho, Buletko\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAcquisition, analysis, or interpretation of data:\\u003c/strong\\u003e Huang, Gedansky, Hassett\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eStatistical analysis:\\u003c/strong\\u003e Huang\\u003cbr /\\u003e \\u003cstrong\\u003eTables and figures:\\u003c/strong\\u003e Huang\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFirst drafting of the manuscript:\\u003c/strong\\u003e Huang\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCritical revision for important intellectual content and final approval of the manuscript: \\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eGedansky, Shoskes, Hassett, Duggal, Cho, Uchino, Buletko\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eMatthay MA, Zemans RL, Zimmerman GA et al. 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J Crit CareJournal of critical care. 2010;25(3):538e7\\u0026ndash;12.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHopkins RO, Suchyta MR, Beene K, Jackson JC. Critical illness acquired brain injury: Neuroimaging and implications for rehabilitation. Rehabil Psychol. 2016;61(2):151\\u0026ndash;64.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBreit H, Jhaveri M, John S. Concomitant delayed posthypoxic leukoencephalopathy and critical illness microbleeds. Neurol Clin Pract. 2018;8(5):e31\\u0026ndash;3.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBurad J, Bhakta P, George J, Kiruchennan S. Development of acute ischemic stroke in a patient with acute respiratory distress syndrome (ARDS) resulting from H1N1 pneumonia. Acta Anaesthesiologica Taiwanica. 2012;50(1):41\\u0026ndash;5.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eDe Stefano P, Nencha U, De Stefano L, M\\u0026eacute;gevand P, Seeck M. Focal EEG changes indicating critical illness associated cerebral microbleeds in a Covid-19 patient. Clin Neurophysiol Pract. 2020;5:125\\u0026ndash;9.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBlanch L, Quintel M. Lung\\u0026ndash;brain cross talk in the critically ill. Intensive Care Med. 2017;43(4):557\\u0026ndash;9.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBilotta F, Giordano G, Sergi PG, Pugliese F. Harmful effects of mechanical ventilation on neurocognitive functions. Crit Care. 2019;23(1):1\\u0026ndash;3.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eRodr\\u0026iacute;guez-Gonz\\u0026aacute;lez R, Ramos-Nuez \\u0026Aacute;, Mart\\u0026iacute;n-Barrasa JL, et al. 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JAMA - Journal of the American Medical Association. 2012;307(23):2526\\u0026ndash;33.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLatchaw RE, Alberts MJ, Lev MH, et al. Recommendations for imaging of acute ischemic stroke: A scientific statement from the american heart association. Stroke. 2009;40(11):3646\\u0026ndash;78.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHuang BY, Castillo M. Hypoxic-Ischemic brain injury: Imaging findings from birth to adulthood. Radiographics. 2008;28(2):417\\u0026ndash;39.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eGreenberg SM, Eng JA, Ning MM, Smith EE, Rosand J. Hemorrhage burden predicts recurrent intracerebral hemorrhage after lobar hemorrhage. Stroke. 2004;35(6):1415\\u0026ndash;20.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHuang M, Gedansky A, Hassett CE, et al. Pathophysiology of Brain Injury and Neurological Outcome in Acute Respiratory Distress Syndrome: A Scoping Review of Preclinical to Clinical Studies. Neurocrit Care. 2021;35(2):518\\u0026ndash;27.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHegde AN, Mohan S, Lath N, Lim CCT. Differential diagnosis for bilateral abnormalities of the basal ganglia and thalamus. Radiographics. 2011;31(1):5\\u0026ndash;30.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBein T, Grasso S, Moerer O, et al. The standard of care of patients with ARDS: ventilatory settings and rescue therapies for refractory hypoxemia. Intensive Care Med. 2016;42(5):699\\u0026ndash;711.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLuecke T, Pelosi P. Clinical review: Positive end-expiratory pressure and cardiac output. Crit Care. 2005;9(6):607\\u0026ndash;21.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eCisneros O, Garcia de de Jesus K, Then EO, Rehmani R. Bilateral Basal Ganglia Infarction After Intranasal Use of Cocaine: A Case Report. Cureus; 2019.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eParekh MA. Bilateral globus pallidus lesions.BMJ Case Rep. 2021;14(2).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eKaufman MJ, Levin JM, Ross MH et al. Cocaine-Induced Cerebral Vasoconstriction Detected in Humans With Magnetic Resonance Angiography [Internet]. Available from: \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://jamanetwork.com/\\u003c/span\\u003e\\u003cspan address=\\\"https://jamanetwork.com/\\\" targettype=\\\"URL\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eNelson S, Toma H, LaMonica H, Chabrashvili T. Major Cognitive Changes and Micrographia following Globus Pallidus Infarct. Case Rep Neurol Med. 2014;2014:1\\u0026ndash;4.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMeduri GU, Annane D, Chrousos GP, Marik PE, Sinclair SE. Activation and regulation of systemic inflammation in ARDS: Rationale for prolonged glucocorticoid therapy. Chest. 2009;136(6):1631\\u0026ndash;43.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eFanou EM, Coutinho JM, Shannon P, et al. Crit Illness-Associated Cereb Microbleeds Stroke. 2017;48(4):1085\\u0026ndash;7.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLersy F, Willaume T, Brisset JC, et al. Critical illness-associated cerebral microbleeds for patients with severe COVID-19: etiologic hypotheses. J Neurol. 2021;268(8):2676\\u0026ndash;84.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eKallenberg K, Dehnert C, D\\u0026ouml;rfler A, et al. Microhemorrhages in nonfatal high-altitude cerebral edema. J Cereb Blood Flow Metab. 2008;28(9):1635\\u0026ndash;42.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eRiech S, Kallenberg K, Moerer O, et al. The Pattern of Brain Microhemorrhages after Severe Lung Failure Resembles the One Seen in High-Altitude Cerebral Edema. Crit Care Med. 2015;43(9):e386\\u0026ndash;9.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eCORRESPONDENCE Diffuse Cerebral Microbleeds after Extracorporeal Membrane Oxygenation Support [Internet]. 2015. Available from: www.atsjournals.org\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMillar JE, Fanning JP, McDonald CI, McAuley DF, Fraser JF. The inflammatory response to extracorporeal membrane oxygenation (ECMO): A review of the pathophysiology.Crit Care. 2016;20(1).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eErickson MA, Banks WA. Neuroimmune axes of the blood-brain barriers and blood-brain interfaces: Bases for physiological regulation, disease states, and pharmacological interventions. Pharmacol Rev. 2018;70(2):278\\u0026ndash;314.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eVarga Z, Flammer AJ, Steiger P, et al. Endothelial cell infection and endotheliitis in COVID-19. The Lancet. 2020;395(10234):1417\\u0026ndash;8.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLei C, Zhong L, Ling Y, Chen T. Blood glucose levels are associated with cerebral microbleeds in patients with acute ischaemic stroke. Eur Neurol. 2019;80(3\\u0026ndash;4):187\\u0026ndash;92.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAgarwal S, Jain R, Dogra S et al. Cerebral Microbleeds and Leukoencephalopathy in Critically Ill Patients with COVID-19.Stroke2020;2649\\u0026ndash;55.\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":true,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":true,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"neurocritical-care\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"neca\",\"sideBox\":\"Learn more about [Neurocritical Care](http://link.springer.com/journal/12028)\",\"snPcode\":\"12028\",\"submissionUrl\":\"https://www.editorialmanager.com/neca/default2.aspx\",\"title\":\"Neurocritical Care\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"Springer Hybrid\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false},\"keywords\":\"Acute respiratory distress syndrome, acute brain injury, Lung-brain interaction, cerebral infarction, cerebral hemorrhage \",\"lastPublishedDoi\":\"10.21203/rs.3.rs-2587753/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-2587753/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003eObjective: \\u003c/strong\\u003eAcute Respiratory Distress Syndrome(ARDS) is an acute inflammatory respiratory failure condition that may be associated with acute brain injury (ABI). We aimed to describe the prevalence and types of ABI detected by brain MRI among ARDS patients.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eMethods: \\u003c/strong\\u003eWe retrospectively reviewed and collected data on ABI as detected by brain MRI during index hospitalization of all ARDS patients at a single tertiary center in the United States from January 2010 to October 2018. ABIs were classified as cerebral ischemia (ischemic infarct and hypoxic ischemic brain injury) or cerebral hemorrhage (intraparenchymal hemorrhage, cerebral microbleeds, subarachnoid hemorrhage, and subdural hematoma). Descriptive statistics were conducted.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eResults: \\u003c/strong\\u003eOf the 678 ARDS patients, 66 (9.7%) underwent brain MRI during their ARDS illness. The most common indication for brain MRI was encephalopathy (45.4%) and the median time from hospital admission to MRI was 10 days (interquartile range 4-17). Of 66, 29 (44%) had MRI evidence of ABI including cerebral ischemia in 33% (22/66) and cerebral hemorrhage in 21% (14/66). Among those with cerebral ischemia, common findings were bilateral globus pallidus infarcts (n=7, 32%), multifocal infarcts (n=5, 23%), and diffuse hypoxic ischemic brain injury (n=3, 14%). Of those with cerebral hemorrhage, common findings were cerebral microbleeds (n=12, 86%) and intraparenchymal hemorrhage (n=2, 14%). ARDS patients with cerebral hemorrhage had significantly greater use of rescue therapies including prone positioning (28.6% vs 5.8%, p = 0.03), inhaled vasodilator (35.7% vs 11.5%, p = 0.046), and recruitment maneuver (14.3% vs 0%, p = 0.04).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConclusion: \\u003c/strong\\u003eAmong selected patients with ARDS who underwent brain MRI, almost a half had ABI most commonly including bilateral globus pallidus infarcts and cerebral microbleeds.\\u003c/p\\u003e\",\"manuscriptTitle\":\"High Prevalence of Acute Brain Injury on Brain Magnetic Resonance Imaging in Acute Respiratory Distress Syndrome\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2023-03-08 15:20:13\",\"doi\":\"10.21203/rs.3.rs-2587753/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"reviewerAgreed\",\"content\":\"\",\"date\":\"2023-03-03T19:36:36+00:00\",\"index\":0,\"fulltext\":\"\"},{\"type\":\"editorInvited\",\"content\":\"Neurocritical Care\",\"date\":\"2023-03-03T17:08:38+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2023-02-27T19:02:03+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"Neurocritical Care\",\"date\":\"2023-02-27T10:58:47+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"neurocritical-care\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"neca\",\"sideBox\":\"Learn more about [Neurocritical Care](http://link.springer.com/journal/12028)\",\"snPcode\":\"12028\",\"submissionUrl\":\"https://www.editorialmanager.com/neca/default2.aspx\",\"title\":\"Neurocritical Care\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"Springer Hybrid\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false}}],\"origin\":\"\",\"ownerIdentity\":\"07482d7e-361a-4beb-82d2-68945fc277c8\",\"owner\":[],\"postedDate\":\"March 8th, 2023\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"published-in-journal\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2023-09-11T15:04:46+00:00\",\"versionOfRecord\":{\"articleIdentity\":\"rs-2587753\",\"link\":\"https://doi.org/10.1007/s12028-023-01823-0\",\"journal\":{\"identity\":\"neurocritical-care\",\"isVorOnly\":false,\"title\":\"Neurocritical Care\"},\"publishedOn\":\"2023-09-05 15:02:09\",\"publishedOnDateReadable\":\"September 5th, 2023\"},\"versionCreatedAt\":\"2023-03-08 15:20:13\",\"video\":\"\",\"vorDoi\":\"10.1007/s12028-023-01823-0\",\"vorDoiUrl\":\"https://doi.org/10.1007/s12028-023-01823-0\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-2587753\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-2587753\",\"identity\":\"rs-2587753\",\"version\":[\"v1\"]},\"buildId\":\"7rjqhiLT3MXkJMwkYKINL\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}