Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used to provide circulatory support in acute cardiac failure. However, it is frequently complicated by neurological injury, which substantially worsens morbidity and mortality.

This narrative review summarizes the incidence, underlying mechanisms, and risk factors for neurological complications during VA-ECMO and examines the potential neuroprotective role of Targeted Temperature Management (TTM), with attention to differences between post–cardiac arrest, extracorporeal cardiopulmonary resuscitation (ECPR) and non-arrest cardiogenic shock populations.

A comprehensive review of published literature was performed to identify studies describing neurological injury associated with VA-ECMO and the use of TTM in this setting.

Neurological complications—including ischemic and hemorrhagic stroke, hypoxic-ischemic brain injury, and seizures—are common during VA-ECMO and strongly associated with poor outcomes. TTM demonstrates potential neuroprotective benefits primarily in ECPR (VA-ECMO during ongoing cardiac arrest) and in post-cardiac arrest patients with sustained ROSC prior to VA-ECMO; however, evidence in non-arrest cardiogenic shock patients is limited and inconsistent. Emerging data also highlight safety concerns regarding the use of hypothermia in patients without preceding cardiac arrest.

Although VA-ECMO is a critical life-saving therapy, neurological injury remains a major and unresolved challenge. No definitive neuroprotective strategy has been established. TTM shows possible benefit in selected populations—particularly ECPR patients—but current evidence is heterogeneous, largely observational, and insufficient to support routine use for neuroprotection in non-arrest VA-ECMO patients.