HOPE or hopeless? Unexpected neurological recovery after ECPR rewarming in a patient with severely hypothermic cardiac arrest with multiple haemorrhagic complications: a case report.

BACKGROUND: A high Hypothermia Outcome Prediction after Extracorporeal Life Support (HOPE) score may indicate favourable neurological outcomes in hypothermic cardiac arrest, even among elderly adults. Although the score does not account for life-threatening complications arising during hospitalisation, outcomes may nevertheless align with its favourable estimates.

CASE PRESENTATION: A 90-year-old woman with a history of hypertension and mild dementia was found collapsed in a cold environment. On arrival, her core temperature was 22.0 ℃, and she developed ventricular fibrillation during transport. After 90 min of cardiac arrest, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was initiated. Her HOPE-estimated survival probability was 76%. Shortly after admission to the intensive care unit, cardiac tamponade secondary to myocardial contusion was suspected and managed conservatively with pericardial drainage and massive transfusion. Following ECMO weaning on day 2, an acute subdural haematoma with midline shift was diagnosed and surgically evacuated on day 3. Despite these life-threatening complications, the patient was discharged to a long-term care facility on day 70 with a Cerebral Performance Category (CPC) score of 3. After rehabilitation, her condition improved to CPC 2, and she survived for several subsequent years.

CONCLUSIONS: This case demonstrates that favourable neurological recovery is achievable in elderly adults with hypothermic cardiac arrest, even when complicated by severe haemorrhagic events. The HOPE score is a validated tool for estimating survival probabilities in such cases and may support clinical decision-making regarding extracorporeal life support rewarming.