HOPE or Hopeless? Unexpected Neurological Recovery After ECPR in a Patient with Severely Hypothermic Cardiac Arrest with Multiple Hemorrhagic Complications: A Case Report

Background A high hypothermia outcome prediction after ECLS (HOPE) score may indicate favorable neurological outcomes in hypothermic cardiac arrest, even in older adults. Although it does not account for life-threatening complications arising during hospitalization, outcomes may still align with its favorable estimation. Case Presentation: A 90-year-old woman with a history of hypertension and dementia was found collapsed in a cold environment. She presented with a core temperature of 22.0 ℃ and developed ventricular fibrillation during transport. After 90 min of cardiac arrest, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was initiated. Her HOPE score-predicted survival was 94%. Soon after ICU admission, cardiac tamponade was suspected due to myocardial contusion and was managed conservatively with pericardial drainage and massive transfusion. After ECMO was weaned on day 2, an acute subdural hematoma 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 Glasgow Coma Scale score of E4V4M6, corresponding to a Cerebral Performance Category of 2. Conclusion This case highlights that favorable neurological recovery may still be possible in older adults with hypothermic cardiac arrest, even when complicated by life-threatening hemorrhagic events. Clinicians should not lose hope, as positive outcomes may still be achieved despite advanced age and critical complications.