Ultralow-field portable MRI feasibility and safety in pediatric and neonatal ECMO: a single center year-long experience

Ultralow-field portable MRI feasibility and safety in pediatric and neonatal ECMO: a single center year-long experience | medRxiv /* */ /* */ <!-- <!-- /*! * yepnope1.5.4 * (c) WTFPL, GPLv2 */ (function(a,b,c){function d(a){return"[object Function]"==o.call(a)}function e(a){return"string"==typeof a}function f(){}function g(a){return!a||"loaded"==a||"complete"==a||"uninitialized"==a}function h(){var a=p.shift();q=1,a?a.t?m(function(){("c"==a.t?B.injectCss:B.injectJs)(a.s,0,a.a,a.x,a.e,1)},0):(a(),h()):q=0}function i(a,c,d,e,f,i,j){function k(b){if(!o&&g(l.readyState)&&(u.r=o=1,!q&&h(),l.onload=l.onreadystatechange=null,b)){"img"!=a&&m(function(){t.removeChild(l)},50);for(var d in y[c])y[c].hasOwnProperty(d)&&y[c][d].onload()}}var j=j||B.errorTimeout,l=b.createElement(a),o=0,r=0,u={t:d,s:c,e:f,a:i,x:j};1===y[c]&&(r=1,y[c]=[]),"object"==a?l.data=c:(l.src=c,l.type=a),l.width=l.height="0",l.onerror=l.onload=l.onreadystatechange=function(){k.call(this,r)},p.splice(e,0,u),"img"!=a&&(r||2===y[c]?(t.insertBefore(l,s?null:n),m(k,j)):y[c].push(l))}function j(a,b,c,d,f){return q=0,b=b||"j",e(a)?i("c"==b?v:u,a,b,this.i++,c,d,f):(p.splice(this.i++,0,a),1==p.length&&h()),this}function k(){var a=B;return a.loader={load:j,i:0},a}var l=b.documentElement,m=a.setTimeout,n=b.getElementsByTagName("script")[0],o={}.toString,p=[],q=0,r="MozAppearance"in l.style,s=r&&!!b.createRange().compareNode,t=s?l:n.parentNode,l=a.opera&&"[object Opera]"==o.call(a.opera),l=!!b.attachEvent&&!l,u=r?"object":l?"script":"img",v=l?"script":u,w=Array.isArray||function(a){return"[object Array]"==o.call(a)},x=[],y={},z={timeout:function(a,b){return b.length&&(a.timeout=b[0]),a}},A,B;B=function(a){function b(a){var a=a.split("!"),b=x.length,c=a.pop(),d=a.length,c={url:c,origUrl:c,prefixes:a},e,f,g;for(f=0;f<d;f++)g=a[f].split("="),(e=z[g.shift()])&&(c=e(c,g));for(f=0;f<b;f++)c=x[f](c);return c}function g(a,e,f,g,h){var i=b(a),j=i.autoCallback;i.url.split(".").pop().split("?").shift(),i.bypass||(e&&(e=d(e)?e:e[a]||e[g]||e[a.split("/").pop().split("?")[0]]),i.instead?i.instead(a,e,f,g,h):(y[i.url]?i.noexec=!0:y[i.url]=1,f.load(i.url,i.forceCSS||!i.forceJS&&"css"==i.url.split(".").pop().split("?").shift()?"c":c,i.noexec,i.attrs,i.timeout),(d(e)||d(j))&&f.load(function(){k(),e&&e(i.origUrl,h,g),j&&j(i.origUrl,h,g),y[i.url]=2})))}function h(a,b){function c(a,c){if(a){if(e(a))c||(j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}),g(a,j,b,0,h);else if(Object(a)===a)for(n in m=function(){var b=0,c;for(c in a)a.hasOwnProperty(c)&&b++;return b}(),a)a.hasOwnProperty(n)&&(!c&&!--m&&(d(j)?j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}:j[n]=function(a){return function(){var b=[].slice.call(arguments);a&&a.apply(this,b),l()}}(k[n])),g(a[n],j,b,n,h))}else!c&&l()}var h=!!a.test,i=a.load||a.both,j=a.callback||f,k=j,l=a.complete||f,m,n;c(h?a.yep:a.nope,!!i),i&&c(i)}var i,j,l=this.yepnope.loader;if(e(a))g(a,0,l,0);else if(w(a))for(i=0;i (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];var j=d.createElement(s);var dl=l!='dataLayer'?'&l='+l:'';j.src='//www.googletagmanager.com/gtm.js?id='+i+dl;j.type='text/javascript';j.async=true;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-P4HH5NV'); Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search Ultralow-field portable MRI feasibility and safety in pediatric and neonatal ECMO: a single center year-long experience View ORCID Profile Jessica S Wallisch , View ORCID Profile Asdis Finnsdottir Wagner , View ORCID Profile John M Daniel , View ORCID Profile Allison Taber , View ORCID Profile Maura Sien , View ORCID Profile Sarah Foster , View ORCID Profile Nathan Artz , View ORCID Profile Jose A Pineda , View ORCID Profile Patrick M Kochanek , View ORCID Profile Sherwin S Chan doi: https://doi.org/10.1101/2025.05.12.25327194 Jessica S Wallisch 1 Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children’s Mercy Hospital , Kansas City, MO 2 University of Missouri-Kansas City School of Medicine , Kansas City, MO MD Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Jessica S Wallisch For correspondence: jwallisch{at}cmh.edu Asdis Finnsdottir Wagner 1 Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children’s Mercy Hospital , Kansas City, MO 2 University of Missouri-Kansas City School of Medicine , Kansas City, MO DO Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Asdis Finnsdottir Wagner John M Daniel 2 University of Missouri-Kansas City School of Medicine , Kansas City, MO 3 Division of Neonatology, Department of Pediatrics, Children’s Mercy Hospital , Kansas City, MO MD, MS Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for John M Daniel Allison Taber 1 Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children’s Mercy Hospital , Kansas City, MO 2 University of Missouri-Kansas City School of Medicine , Kansas City, MO MD Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Allison Taber Maura Sien 4 Department of Radiology, Children’s Mercy Hospital , Kansas City, MO MSML, RT(R), CCRC Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Maura Sien Sarah Foster 4 Department of Radiology, Children’s Mercy Hospital , Kansas City, MO BS, RT(R) Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Sarah Foster Nathan Artz 3 Division of Neonatology, Department of Pediatrics, Children’s Mercy Hospital , Kansas City, MO 4 Department of Radiology, Children’s Mercy Hospital , Kansas City, MO PhD Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Nathan Artz Jose A Pineda 5 Division of Critical Care, Department of Pediatrics, DGSOM at UCLA MD MSCI Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Jose A Pineda Patrick M Kochanek 6 Department of Critical Care Medicine, Safar Center for Resuscitation Research, School of Medicine, University of Pittsburgh , Pittsburgh, PA MD Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Patrick M Kochanek Sherwin S Chan 3 Division of Neonatology, Department of Pediatrics, Children’s Mercy Hospital , Kansas City, MO 4 Department of Radiology, Children’s Mercy Hospital , Kansas City, MO MD, PhD Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Sherwin S Chan Abstract Full Text Info/History Metrics Data/Code Preview PDF ABSTRACT Introduction Extracorporeal membrane oxygenation (ECMO) outcomes continue to improve, yet high rates of acute brain injury (ABI) threaten survival with significant morbidity for ECMO survivors. Currently available imaging modalities [ultrasound and computed tomography (CT)] have low early detection rates for hypoxic-ischemic and cerebrovascular injuries, delaying the diagnosis of ABI while on ECMO. CT sensitivity increases only when it may be too late to effectively intervene. High-field (>1.5 Tesla) magnetic resonance imaging (MRI), the gold standard to diagnose ischemic brain injury, is not compatible with ECMO. An FDA-cleared ultralow-field (0.064 Tesla) portable MRI (pMRI) has been studied in diverse types of ABI and with equipment that is typically not MRI compatible. There is very limited experience using pMRI in ECMO and even less in pediatric ECMO patients, therefore additional feasibility and safety data is needed in this cohort. Methods This single center, IRB approved study was conducted at a free-standing quaternary children’s hospital. All neonatal and pediatric patients cannulated onto ECMO were screened for eligibility. Subjects underwent bedside ultralow-field pMRI with Swoop (Hyperfine, Guilford, CT). Data on ECMO variables, time for patient positioning and scan, MRI sequences, concurrent critical care equipment, changes in ECMO flow and vital signs, and cannula displacement was collected. Results Over a 1-year period (Aug 2023-Aug 2024) 41 patients were screened. 16 out of 20 enrolled subjects had pMRI attempted and 13 (81.25%) received the full imaging protocol (T1, T2, FLAIR and DWI). The median staff members for pMRI positioning was 6 [5, 7] compared to 7 [7,7] for head CT (0.03). The median positioning and pMRI imaging time was 66 min [56, 70] compared to 75 min [70,79] for intrahospital transport for head CT. One subject had a ≥ 20% decrease in mean arterial pressure, however remained within the clinical goals without intervention. Unlike during head CT imaging acquisition, continuous renal replacement therapy was not interrupted during pMRI. Conclusions pMRI is safe and feasible in pediatric ECMO with no clinically relevant complications seen in our cohort. Resource utilization and delivery of concurrent critical care is superior for bedside imaging compared to intrahospital transport to CT. Clinical Trial Registration NCT06074406 https://clinicaltrials.gov/study/NCT06074406?term=NCT06074406Crank=1 What is new? This study expands the experience of ultralow-field portable MRI to pediatric ECMO patients. Ultralow-field portable MRI is feasible and less resource-intense to perform on pediatric ECMO patients compared to intrahospital transport for head CT. Pediatric ECMO patients tolerate bedside MRI without clinically significant changes in ECMO flows, perfusion, or oxygenation. What are the clinical implications? Ultralow-field portable MRI can expand time-sensitive head imaging options for pediatric patients on ECMO with less interruptions of critical care therapies, decreased resource utilization, and eliminated risks of travel and radiation exposure. Timely diagnosis of acute brain injury while on ECMO can prompt changes in neuromonitoring, anticoagulation management, and delivery of neuroprotective care with the intent to improve neurologic outcomes of pediatric ECMO survivors. INTRODUCTION Significant advances in extracorporeal membrane oxygenation (ECMO) management and technology have expanded its use and improved survival rates, yet rates of poor neurologic outcomes remain unchanged following this level of support 1 – 7 . There are considerable risks to the development of acute brain injury (ABI) in this population across the continuum of care (before ECMO, during cannulation, and during ECMO support) due to a myriad of patient, disease, and treatment factors. Hypoxia, hypotension, and cardiac arrest (which occurs in 40% of pediatric ECMO patients) are among the known factors implicated in the pre-ECMO period with alterations in cerebral blood flow, thromboembolic events, and use of systemic anticoagulation being well described risks during ECMO support. The totality of these risk factors results in half of pediatric ECMO survivors having poor neurologic outcomes and disability 5 , 8 . There are different types of ABI that occur in this population including hypoxic-ischemic, cerebrovascular (stroke), and hemorrhagic injuries. The ability of clinicians to diagnose these different types of ABI is limited by multiple factors including 1) most pediatric ECMO patients require sedation — limiting the neurologic examination, 2) significant limitations to noninvasive neuromonitoring, 3) risks of invasive neuromonitoring, and 4) lack of sensitivity in available imaging modalities for early hypoxic-ischemic and cerebrovascular type injuries. Head ultrasound is one imaging modality that can be easily obtained at the bedside in patients younger than 1 year old with an open fontanelle, but ultrasound tends to miss ischemic and posterior fossa injuries with only a 41% sensitivity (94% positive predictive value and 36% negative predictive value) for ABI on ECMO 9 . CT can be used across all ages of pediatric patients on ECMO but adds significant risks and logistical challenges related to intrahospital transport and uses ionizing radiation 10 – 12 . Furthermore, CT’s detection of early ischemia is inferior, with only 27.3% sensitivity in acute pediatric arterial ischemic stroke, which leads to delays in management 13 , 14 . While some institutions have access to portable CT, this does not increase its diagnostic accuracy for all types of ABI on ECMO nor eliminate risks related to radiation exposure. Traditional MRI is the gold-standard to diagnose hypoxic-ischemic and cerebrovascular injuries, but it is incompatible with ECMO 15 . It is estimated that less than half of pediatric ECMO patients receive head imaging with CT or a post-decannulation MRI, yet 21-60% of those who receive imaging have acute neuroimaging abnormalities 8 , 16 , 17 . This leaves clinicians with diagnostic uncertainty during a critical time window, when ABI is suspected, resulting in delayed diagnosis and missed opportunity for neuroprotective or directed interventions 18 – 20 . Patients might also receive unnecessary empiric treatment that also carries risks such as hyperosmolar therapy or changes to anticoagulation management in cases of suspected ABI without neuroimaging confirmation. Ultralow-field portable MRI (pMRI) is a newer FDA cleared imaging modality that has fewer patient support equipment limitations, eliminates ionizing radiation exposure and the need for transport, and experience with its use is rapidly expanding in adult ABI including after cardiac arrest, stroke, and intracerebral hemorrhage 21 – 25 . However, there is limited experience in pediatric patients because of the need for programming modifications when imaging the developing brain (i.e. differences in brain-tissue composition in neonates) 26 , 27 . There is even more limited published experience with the use of ultralow-field pMRI in ECMO with only two small adult case series and a multicenter prospective observational cohort study of 50 adult patients 28 – 30 . Pediatric experience lags with one reported case series of 4 patients 31 . The primary aim of this study was to expand the feasibility and safety data for use of pMRI in pediatric ECMO patients. METHODS Study Design This was a single center cohort study at a quaternary free-standing children’s hospital with high ECMO volume and ELSO Platinum Center of Excellence designation. Neonates and children (age 0 to <18 years) admitted to the Neonatal Intensive Care Unit (NICU), Pediatric Intensive Care Unit (PICU), or Cardiac Intensive Care Unit (CICU) and receiving venovenous (VV) or venoarterial (VA) ECMO support between September 2023 and August 2024 were prospectively screened and enrolled. Patients were excluded for pregnancy, active implants (permanent pacemaker or defibrillator, deep brain stimulator, cochlear implant, vagal nerve stimulator, programmable shunt), and MRI incompatible surgical hardware or shrapnel. The study was approved by the Institutional Review Board of Children’s Mercy Hospital (STUDY00002824). Study Procedure Ultralow-field portable MRI imaging was completed with Swoop (device version 1.8 with software 8.7 beta, Hyperfine, Guilford, CT) which has a static magnetic field strength of 0.064 Tesla (T). The imaging protocol included T1-weighted, T2-weighted, Fluid Attenuated Inversion Recovery (FLAIR), and Diffusion Weighted Imaging (DWI with calculated Apparent Diffusion Coefficient) using the standard product sequences excepting modified sequences for patients < 1 year. Scanning procedures were coordinated with bedside staff and ECMO teams to avoid clinical care interference with goal scan time occurring within 72 hours of ECMO cannulation as this would capture injuries occurring in the pre-cannulation, peri-cannulation, and immediate post-cannulation periods where the largest changes occur in cerebral blood flow and oxygenation. Radiology research coordinators who are trained radiology technologists transported the pMRI to the bedside of enrolled subjects. Subjects were positioned into the pMRI head coil by a team of bedside staff (critical care nurses, respiratory therapists, intensivists) and ECMO team members (perfusionists and specialists). The ECMO team monitored vital signs, flows, oxygenation, and support devices per clinical protocol for the duration of the scanning procedure. Data Collection Data was collected on patient variables (age and weight at cannulation, sex, race and ethnicity, ICU location, survival), ECMO variables (type and indication for ECMO, cannula type and location, pump type and circuit size, cannulation and decannulation dates), and pMRI variables (rate of scan completion, reason for lack of completion, timing of scan, sequences run, reason exam ended early if applicable). Data was also collected on imaging procedure metrics (positioning/prep time, scan duration, total imaging procedure time, number of staff required for positioning, concurrent ICU therapies/devices), rates of adverse or safety events, and if head CT was obtained by the medical team during the study period. Data was recorded and stored in REDCap (v14.6.8). Outcomes The primary feasibility outcome was defined as rate of imaging completion with all needed sequences (T1, T2, FLAIR and diffusion weighted imaging) relative to scans attempted. Secondary feasibility outcomes included total time for positioning and imaging, the number of staff required for positioning, and rates of concurrent therapies that were paused. Primary safety outcomes were modeled after the SAFE-MRI ECMO study 29 and defined as change in ECMO cannula positioning requiring repositioning by surgeon, ≥20% decrease in ECMO flow, ≥ 20% decrease in mean arterial pressure (MAP), or ≥ 10% in pulse oximetry (SpO 2 ). Statistical Analysis Descriptive statistics were reported as median with interquartile range and frequency (%). Analysis was conducted in SPSS (IBM, v29). RESULTS Patient Demographics and ECMO Details All patients cannulated onto ECMO at Children’s Mercy Hospital over a one-year period beginning August 2023 (n=41) were screened for eligibility. There were 19 unique subjects consented and enrolled that comprised 20 total ECMO courses ( Figure 1 ). The median age of our cohort was 4.21 months [0.16, 5.85] with a median weight of 4.55 kg [3.20, 7.91]. Half of the subjects enrolled were admitted to the CICU. The patient demographics are summarized in Table 1 . Download figure Open in new tab Figure 1 Consort flow diagram of patient selection. ECMO, extracorporeal membrane oxygenation; pMRI, portable magnetic resonance imaging. View this table: View inline View popup Download powerpoint Table 1. Patient Demographics, ECMO variables and Clinical outcomes Abbreviations: Pediatric Intensive Care Unit (PICU), Cardiac Intensive Care Unit (CICU), Intensive Care Nursery (ICN), extracorporeal membrane oxygenation (ECMO), venovenous (VV), venoarterial (VA), extracorporeal cardiopulmonary resuscitation (eCPR) A majority (85%) of the cohort was cannulated onto VA ECMO with 80% having neck cannulation sites. The indications and other ECMO details are summarized in Table 1 . The median ECMO duration of our cohort was 177 hours [127, 371]. A total of 15 subjects (78.95%) survived greater than 30 days following ECMO decannulation with 14 subjects (73.68%) surviving to ICU discharge. pMRI Feasibility Imaging with pMRI was attempted in 16 out of 20 enrolled subjects (80%). Reasons imaging was not attempted included competing clinical needs (1), patient instability (1), study withdrawal prior to imaging (1), and study team withdrawal due to need for safety clarification for temporary pacing wires (1). The majority of subjects in which a scan was attempted (9, 56.25%) were scanned less than 72 hours following cannulation with 5 subjects (31.25%) completing pMRI less than 24 hours from cannulation. The median ECMO duration at the time of pMRI was 41.83 hours [19.78, 106.43]. Thirteen out of 16 (81.25%) subjects were able to complete the full imaging sequence protocol. A sample of acquired images is provided in Figure 2 . Two subjects only had a localizer image obtained and reasons for early imaging termination included a sequence malfunction during diffusion weighted imaging acquisition (1) and patient return to the cardiac catheterization laboratory for reasons unrelated to pMRI (1). Download figure Open in new tab Figure 2 Representative images acquired by pMRI with comparison head imaging on pediatric ECMO patients. (a-b) Brain imaging of a toddler age subject with intraparenchymal hemorrhage in the right frontal lobe. (a) Axial T1 image from the ultralow-field pMRI. (b) Axial T1 image from a standard of care high-field MRI performed 6 days prior to the pMRI. (c-f) Brain imaging of a toddler age subject who underwent resection of a posterior fossa tumor and placement of a right frontal approach intraventricular catheter. (c) Axial T2 image from the ultralow-field pMRI showing some of the post-surgical changes around the resection cavity (arrow). Also note the signal dropout from the ECMO catheter (circle). (d) A more superior axial T2 image shows the course of the intraventricular catheter. Axial CT images performed 5 days after the pMRI show the resection changes (e) and the catheter tract (f). pMRI, portable magnetic resonance imaging; ECMO, extracorporal membrane oxygenation; CT, computed tomography. The median time for positioning was 23 min [16, 24] with median pMRI scan duration of 33 min [31.50, 39.50]. The median number of staff present was 6 [5, 7] with 5 [4, 5] actively involved in positioning the patient for pMRI. The only concurrent critical care monitoring or therapy paused during pMRI was continuous electroencephalogram (EEG) monitoring due to interference; however, MRI-compatible leads remained on the patient minimizing the duration off monitoring ( Table 2 ). View this table: View inline View popup Download powerpoint Table 2. Portable MRI Outcomes Relative to CT Values are expressed as median [IQR]. Abbreviations: minutes (min), portable MRI (pMRI), computed tomography (CT), electroencephalogram (EEG), continuous renal replacement therapy (CRRT) Safety During image acquisition one patient had a predefined safety event with ≥20% decline in MAP, but still remained within the clinical goals and did not require intervention or early study procedure termination. One patient required ECMO arterial cannula repositioning 8 days following pMRI, however the cannula positioning was stable on subsequent chest x-ray and echocardiography obtained later on the same day after pMRI imaging. No other adverse events or serious adverse events were attributed to study interventions. pMRI relative to CT Half of the patients (10, 50%) traveled to CT during study enrollment. A majority (7, 70%) of CT scans were obtained for head imaging followed by chest (2, 20%) then abdomen/pelvis (1,10%). Two of the head CTs (28.57%) were completed during study coordinator working hours and available for tracking. The median time outside the ICU was 26.5 minutes [21, 32] with median total preparation, imaging, and travel time of 75 minutes [66, 84] ( Table 2 ). Both head CTs utilized 7 staff members, which was more resource-intense compared to pMRI. Two subjects had continuous renal replacement therapy (CRRT) interrupted and one patient had their EEG leads temporarily removed prior to travel for CT. DISCUSSION This study completed pMRI in the largest cohort of pediatric ECMO patients to date. We demonstrated expanded feasibility with similar preparation plus imaging time and less resource-intensity including staff members with lack of transport out of the intensive care unit as compared to the currently clinically available modality of head CT. Additionally, a majority (81.2%) of imaging attempts were completed with all planned sequences. Imaging was deemed safe with no subjects having clinically relevant changes to ECMO flows, MAP, or oxygenation during study procedures nor did we experience any migration of ECMO cannulas attributable to study interventions. Our study evaluated similar safety metrics to the SAFE MRI ECMO study which evaluated the use of pMRI in 50 adult ECMO patients 28 , 32 . With the exception of a non-clinically relevant decline in MAP, subjects in our smaller cohort did not experience any adverse events or pre-defined safety outcomes attributable to study interventions unlike the 3 (6%) reported by Cho et al. One subject required an arterial cannula repositioning which was deemed unrelated to study interventions as it occurred 8 days after pMRI imaging with evidence of stable cannula positioning on x-ray and echocardiography immediately following the study intervention. It was noted that this subject underwent intrahospital transport to obtain a head CT on the day prior to observing a change in arterial cannula position via x-ray which was then confirmed on echocardiography. While there is a temporal association with intrahospital transport, the true etiology or etiologies of the cannula displacement could not be determined. Nevertheless, as this is a known complication of intrahospital transport on ECMO and this requires a much larger patient and circuit movement, it could be hypothesized that the risks of intrahospital transport are greater than those for pMRI. Adult and pediatric ECMO populations have different risk factors and patterns of ABI, cannulation sites, and brain water content requiring modifications in the approach to imaging. The only prior published experience with pMRI in pediatric ECMO was in 4 peripherally cannulated patients with no adverse events while obtaining only T1 and T2 weighted sequences, resulting a shorter scan duration without the ability to detect acute ischemia 31 . Therefore, while the work of Sabir et al was fundamental to exploring the use of pMRI in pediatric ECMO, our study built upon their findings by increasing the cohort size, using a more complete pMRI protocol that included DWI, additional granularity of feasibility and safety outcomes, and comparison to CT imaging. We met our goal to obtain imaging with pMRI within 72 hours of cannulation in a majority of subjects (56.25%) with a median time to scan of 41.83 hours. We identified this goal timeframe due to the vulnerability and higher risk of acute brain injury during the pre- and peri-cannulation time periods 2 , 33 – 36 . As we prioritized clinical care needs during this feasibility pilot, the scan time was subject to downtime between patient care, coordination and availability of all team members required to move a patient on ECMO, and the research coordinators’ work hours and other responsibilities. Nonetheless, the fact that 31.25% of imaged subjects’ scans were obtained in under 24 hours from cannulation provides proof of concept that pMRI could be utilized to better delineate and ascribe patterns of ABI within the timeframe of high risk for ABI in this patient population. Our feasibility data will inform future efforts to determine optimal timing of pMRI imaging and guide implementation strategies. As this was a single center cohort study conducted over 1 year, our cohort size is limited. Our institution averages 40-50 ECMO runs annually, thus the number of subjects screened was typical. Our enrollment was limited by not only exclusion criteria but also inability to approach families/surrogate decision makers due to language barriers (2), timing of presence at the bedside (2), clinical instability (2), and rapid decannulation or death (3). Our study team’s effort to avoid interrupting clinical care and the standard research coordinator work hours impacted the timing of scan attempts and completion. Many of these limitations would not be a factor if this imaging modality becomes standard of care. Our study cohort had a high short-term survival rate with overall all-cause mortality of 26.32%, which is consistent with our center ELSO registry data of 29.70%, however could skew our findings toward less severe ABI. Notably our institution had 3 ECMO patients declared deceased by neurologic criteria (1.7%), a total of 23 patients with ischemic brain injury (12.7%), and a total of 21 patients with hemorrhagic brain injury (11.6%) over the same 3-year span as the reference mortality data (2020 – 2023). As our feasibility study did not assess imaging findings or rate of acute brain injury detection, this limitation did not impact the interpretation of our results. Finally, this pilot study was not powered for safety outcomes. At a 7.7% cannula displacement prevalence in our cohort, we calculate the 95% CI to be [1.2%, 36.0%] CONCLUSION pMRI is feasible and less resource-intense than intrahospital transport to CT for pediatric ECMO patients. Future work will expand safety data and determine the diagnostic yield of ultralow-field portable MRI for ischemic and hemorrhagic acute brain injuries in pediatric ECMO patients. This has the potential to significantly improve neuroimaging and neurocritical care for pediatric ECMO patients by allowing for earlier and more accurate diagnosis, better-informed decision making and treatment, and ultimately better neurologic outcomes and survival. Data Availability Data is available upon reasonable request. SOURCES OF FUNDING JSW is supported by the American Heart Association Grant #24IPA1272935/Wallisch/2024 for her work on portable MRI in pediatric ECMO. This study was investigator initiated and no funding was provided by Hyperfine, Inc. DISCLOSURES The Children’s Mercy Research Institute has received in kind and research contracts from Hyperfine, Inc. ACKNOWLEDGMENTS The authors would like to thank Hung-Wen Yeh PhD, Division of Health Services and Outcomes Research, Children’s Mercy Research Institute, Kansas City, MO, for statistical consultation services. Non-standard Abbreviations and Acronyms ECMO extracorporeal membrane oxygenation ABI acute brain injury CT computed tomography MRI magnetic resonance imaging pMRI portable magnetic resonance imaging FDA Food and Drug Administration T Tesla VV venovenous VA venoarterial ELSO Extracorporeal Life Support Organization ICN Intensive Care Nursery PICU Pediatric Intensive Care Unit CICU or Cardiac Intensive Care Unit FLAIR Fluid-attenuated inversion recovery DWI diffusion-weighted imaging EEG electroencephalogram CRRT continuous renal replacement therapy REFERENCES 1. ↵ Alsoufi B , Al-Radi OO , Nazer RI , Gruenwald C , Foreman C , Williams WG , Coles JG , Caldarone CA , Bohn DG , Van Arsdell GS . Survival outcomes after rescue extracorporeal cardiopulmonary resuscitation in pediatric patients with refractory cardiac arrest . 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Share Ultralow-field portable MRI feasibility and safety in pediatric and neonatal ECMO: a single center year-long experience Jessica S Wallisch , Asdis Finnsdottir Wagner , John M Daniel , Allison Taber , Maura Sien , Sarah Foster , Nathan Artz , Jose A Pineda , Patrick M Kochanek , Sherwin S Chan medRxiv 2025.05.12.25327194; doi: https://doi.org/10.1101/2025.05.12.25327194 Share This Article: Copy Citation Tools Ultralow-field portable MRI feasibility and safety in pediatric and neonatal ECMO: a single center year-long experience Jessica S Wallisch , Asdis Finnsdottir Wagner , John M Daniel , Allison Taber , Maura Sien , Sarah Foster , Nathan Artz , Jose A Pineda , Patrick M Kochanek , Sherwin S Chan medRxiv 2025.05.12.25327194; doi: https://doi.org/10.1101/2025.05.12.25327194 Citation Manager Formats BibTeX Bookends EasyBib EndNote (tagged) EndNote 8 (xml) Medlars Mendeley Papers RefWorks Tagged Ref Manager RIS Zotero Tweet Widget Facebook Like Google Plus One Subject Area Intensive Care and Critical Care Medicine Subject Areas All Articles Addiction Medicine (568) Allergy and Immunology (863) Anesthesia (300) Cardiovascular Medicine (4435) Dentistry and Oral Medicine (444) Dermatology (382) Emergency Medicine (608) Endocrinology (including Diabetes Mellitus and Metabolic Disease) (1509) Epidemiology (15228) Forensic Medicine (30) Gastroenterology (1124) Genetic and Genomic Medicine (6599) Geriatric Medicine (668) Health Economics (997) Health Informatics (4536) Health Policy (1368) Health Systems and Quality Improvement (1613) Hematology (540) HIV/AIDS (1264) Infectious Diseases (except HIV/AIDS) (15916) Intensive Care and Critical Care Medicine (1103) Medical Education (623) Medical Ethics (146) Nephrology (667) Neurology (6599) Nursing (346) Nutrition (998) Obstetrics and Gynecology (1144) Occupational and Environmental Health (957) Oncology (3332) Ophthalmology (974) Orthopedics (369) Otolaryngology (420) Pain Medicine (436) Palliative Medicine (130) Pathology (663) Pediatrics (1693) Pharmacology and Therapeutics (691) Primary Care Research (711) Psychiatry and Clinical Psychology (5447) Public and Global Health (9231) Radiology and Imaging (2198) Rehabilitation Medicine and Physical Therapy (1370) Respiratory Medicine (1196) Rheumatology (593) Sexual and Reproductive Health (712) Sports Medicine (530) Surgery (712) Toxicology (99) Transplantation (289) Urology (265) (function(){function c(){var b=a.contentDocument||a.contentWindow.document;if(b){var d=b.createElement('script');d.innerHTML="window.__CF$cv$params={r:'a00605069c264eda',t:'MTc3OTU1OTg1MA=='};var a=document.createElement('script');a.src='/cdn-cgi/challenge-platform/scripts/jsd/main.js';document.getElementsByTagName('head')[0].appendChild(a);";b.getElementsByTagName('head')[0].appendChild(d)}}if(document.body){var a=document.createElement('iframe');a.height=1;a.width=1;a.style.position='absolute';a.style.top=0;a.style.left=0;a.style.border='none';a.style.visibility='hidden';document.body.appendChild(a);if('loading'!==document.readyState)c();else if(window.addEventListener)document.addEventListener('DOMContentLoaded',c);else{var e=document.onreadystatechange||function(){};document.onreadystatechange=function(b){e(b);'loading'!==document.readyState&&(document.onreadystatechange=e,c())}}}})();