Background and Aims Brain injury is an important complication of neonatal Extra Corporeal Membrane Oxygenation (ECMO). Unilateral carotid artery and jugular vein cannulation (often with ligation), in combination with systemic heparinisation, increases the risk of brain injury in an already vulnerable group of patient. The reported prevalence of brain injury ranges from 10–52% of patients treated with neonatal ECMO. Monitoring of intracranial lesions during the ECMO procedure is therefore important for treatment and prediction of outcome.

Our objective is to study incidence and classification of ultrasound proven brain injury during neonatal ECMO in the Netherlands.

Methods Retrospective, nationwide study (Rotterdam and Nijmegen), spanning two decades. Cranial ultrasound images were reviewed by two independent investigators, without knowledge of primary diagnosis, outcome or type of ECMO.

Results 676 neonates with neonatal ECMO were studied. ECMO type was V-A in 88%. Brain abnormalities were detected in 17.3% of patients: primary hemorrhage was diagnosed most frequent (8.8%). A noticeable result was found in stroke patients (5% of the total group), where there was a significant predominance of lesions in the left hemisphere. Lobar haematoma (prevalence 2.2%) was also significantly left sided predominant.

Conclusion Our study shows an incidence of ECMO-associated neonatal brain injury in the Netherlands in 17.3%. Left hemisphere lesion preference suggests that shift of brain perfusion from right to left is more important than large vessel ligation in the neck. Prevention has to focus on embolism and on management of this perfusion shift.