Intracranial Hemorrhage in COVID-19 patients: A Case Series

Hemorrhagic Coagulation Disorders and Ischemic Stroke: How to Reconcile Both?

Coagulation and fibrinolytic system disorders are conditions in which the blood's ability to clot is impaired, resulting in an increased risk of thrombosis or bleeding. Although these disorders are the expression of two opposing tendencies, they can often be associated with or be a consequence of each other, contributing to making the prognosis of acute cerebrovascular events more difficult. It is important to recognize those conditions that are characterized by dual alterations in the coagulation and fibrinolytic systems to reduce the prognostic impact of clinical conditions with difficult treatment and often unfortunate outcomes. Management of these individuals can be challenging, as clinicians must balance the need to prevent bleeding episodes with the potential risk of clot formation. Treatment decisions should be made on an individual basis, considering the specific bleeding disorder, its severity, and the patient's general medical condition. This review aims to deal with all those forms in which coagulation and fibrinolysis represent two sides of the same media in the correct management of patients with acute neurological syndrome. Precision medicine, personalized treatment, advanced anticoagulant strategies, and innovations in bleeding control represent future directions in the management of these complex pathologies in which stroke can be the evolution of two different acute events or be the first manifestation of an occult or unknown underlying pathology.

Intracranial hemorrhages in patients with COVID-19: a systematic review of the literature, regarding six cases in an Amazonian population

BACKGROUND

 Coronavirus disease 2019 (COVID-19) has emerged as a public health emergency worldwide, predominantly affecting the respiratory tract. However, evidence supports the involvement of extrapulmonary sites, including reports of intracranial hemorrhages.

OBJECTIVE

 To describe six original cases and review the literature on intracranial hemorrhages in patients diagnosed with COVID-19 by molecular methods.

METHODS

 A systematic literature review was performed on MEDLINE, PubMed, and NCBI electronic databases to identify eligible studies. Of the total 1,624 articles retrieved, only 53 articles met the inclusion criteria.

RESULTS

 The overall incidence of intracranial hemorrhage in patients hospitalized for COVID-19 was 0.26%. In this patient group, the mean age was 60 years, and the majority were male (68%) with initial respiratory symptoms (73%) and some comorbidity. Before the diagnosis of hemorrhage, 43% of patients were using anticoagulants, 47.3% at therapeutic doses. The intraparenchymal (50%) was the most affected compartment, followed by the subarachnoid (34%), intraventricular (11%), and subdural (7%). There was a predominance of lobar over non-lobar topographies. Multifocal or multicompartmental hemorrhages were described in 25% of cases. Overall mortality in the cohort studies was 44%, while around 55% of patients were discharged from hospital.

CONCLUSION

 Despite the unusual association, the combination of these two diseases is associated with high rates of mortality and morbidity, as well as more severe clinicoradiological presentations. Further studies are needed to provide robust evidence on the exact pathophysiology behind the occurrence of intracranial hemorrhages after COVID-19 infection.

The impact of COVID-19 on clinical outcomes in people undergoing neurosurgery: a systematic review and meta-analysis

BACKGROUND

The coronavirus disease-2019 (COVID-19) pandemic has created a global crisis unique to the healthcare system around the world. It also had a profound impact on the management of neurosurgical patients. In our research, we investigated the effect of the COVID-19 pandemic on clinical outcomes in people undergoing neurosurgery, particularly vascular and oncological neurosurgery.

METHOD

Two investigators independently and systematically searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrail.Gov, and Web of Science to identify relevant studies respecting the criteria for inclusion and exclusion published up to June 30, 2022. The outcomes of our research included mortality rate, length of stay, modified Rankin Score, delay in care, Glasgow outcome scale, and major complications. The risk of bias was assessed using the Methodological Index for Non-randomized Studies (MINORS) checklist.

RESULTS

Two investigators independently and systematically searched 1378 results from MEDLINE, EMBASE, Cochrane database, ClinicalTrail.Gov, and Web of Science and extracted the detailed data from 13 studies that met the review's eligibility criteria. Two articles reported on patients with intracerebral hemorrhages, five on patients with subarachnoid hemorrhages, four on patients undergoing surgery for neuro-oncology, and in two studies the patients' conditions were unspecified. A total of 26,831 patients were included in our research. The number who died was significantly increased in the COVID-19 pandemic group (OR 1.52, 95% CI 1.36-1.69, P < 0.001). No significant difference was found between the two groups in terms of length of stay (SMD - 0.88, 95% CI - 0.18-0.02, P = 0.111), but it differed between regions, according to our subgroup analysis.

CONCLUSION

Compared to the pre-pandemic group, the number who died was significantly increased in the COVID-19 pandemic group. Meanwhile, the effect of the pandemic on clinical outcomes in people undergoing neurosurgery might differ in different regions, according to our subgroup analysis.

Rising Mortality in Coronavirus-19 Patients Supported With Extracorporeal Membrane Oxygenation

We aimed to describe practice patterns and outcomes in patients with extracorporeal membrane oxygenation (ECMO) support throughout the coronavirus 2019 (COVID-19) pandemic, with the hypothesis that mortality would improve as we accumulated knowledge and experience. We included 48 patients supported on veno-venous ECMO (VV-ECMO) at a single institution between April 2020 and December 2021. Patients were categorized into three waves based on cannulation date, corresponding to the wild-type (wave 1), alpha (wave 2), and delta (wave 3) variants. One hundred percent of patients in waves 2 and 3 received glucocorticoids, compared with 29% in wave 1 ( p < 0.01), and the majority received remdesivir (84% and 92% in waves 2 and 3, vs . 35% in wave 1; p < 0.01). Duration of pre-ECMO noninvasive ventilation was longer in waves 2 and 3 (mean 8.8 days and 3.9 days, vs . 0.7 days in wave 1; p < 0.01), as was time to cannulation (mean 17.2 and 14.6 days vs . 8.8 days in wave 1; p < 0.01) and ECMO duration (mean 55.7 days and 43.0 days vs . 28.4 days in wave 1; p = 0.02). Mortality in wave 1 was 35%, compared with 63% and 75% in waves 2 and 3 ( p = 0.05). These results suggest an increased prevalence of medically refractory disease and rising mortality in later variants of COVID-19.

A Non-traumatic Non-aneurysmal Subarachnoid Hemorrhage in a Mild COVID-19 Infection: A Case Report

Both subarachnoid hemorrhage and intraparenchymal hemorrhage have been reported in patients with coronavirus disease 2019 (COVID-19) infection. We report a 38-year-old male patient who was initially admitted for alcoholic hepatitis and had a mild COVID-19 infection that was confirmed 10 days prior to presentation. During his hospitalization, he reported worsening of his occipital headache that started when he tested positive for COVID-19. Neurological examination was intact and no history of trauma, hypertension, illicit drug use, or family history of brain aneurysm was reported. Investigating his worsening headache revealed a tiny, right-sided, posterior subarachnoid hemorrhage. No coagulopathy was evident. No aneurysm was seen on the cerebral angiogram. The patient was managed conservatively. This case raises the point of the importance of investigating headaches even in mild COVID-19 infection, as it may herald intracranial bleeding.

Subarachnoid Hemorrhage in Patients with SARS-CoV-2 Infection: Protocol for A Scoping Review

Subarachnoid hemorrhage (SAH) is a life-threatening condition associated with high mortality and substantial long-term morbidity. The SARS-CoV-2 virus is a new pathogen that causes a disease with variable clinical manifestations. Although the Coronavirus disease 2019 (COVID-19) is associated with hypercoagulopathy, patients may also present with cerebral hemorrhage, including SAH. The present paper reports a protocol for a scoping review that is aimed to provide a comprehensive report on existing literature by examining data on SAH associated with SARS-CoV-2 infection. Our objective is to evaluate the epidemiology, clinical, laboratory, and neuroimaging features of SAH in patients with COVID-19 and to explore the etiology and possible interventions in this pathology. Using appropriate search terms, we will search LitCOVID, the WHO database on COVID-19, and MedRxiv. The inclusion criteria are pre-defined. We will extract the data of eligible studies in standardized forms and will report the results in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). We will provide information for clinicians, healthcare providers, and public health specialists.

Neurological Manifestations Associated With SARS-CoV-2 in Children: A Case Series

Neurological manifestations of COVID-19 may affect both central and peripheral nervous systems. Unlike in adults, in whom majority of severe cases derive from respiratory complications, neurological involvement is one of the main causes of severe COVID-19 in children. This study aimed to detect viral respiratory pathogens, mainly SARS-CoV-2, in nasopharynx and cerebrospinal fluid samples utilizing qRT-PCR (TaqMan) in a pediatric population in Brazil. We evaluated four children with neurological symptoms and laboratory-confirmed SARS-CoV-2 infection: three presenting with meningoencephalitis and one presenting with Guillain-Barré syndrome. All four patients had mild respiratory symptoms. SARS-CoV-2 RNA was identified in two cerebrospinal fluid samples. SARS-CoV-2 involvement should be considered for differential diagnosis in pediatric cases presenting neurological alterations even if symptoms such as headache, anosmia, or dizziness are absent.

Clinical features of thrombosis and bleeding in COVID-19

Infection with the SARS-CoV-2 virus, resulting in COVID-19 disease has presented a unique scenario associated with high thrombotic rates. The risk of venous thrombosis is some 3-6 fold higher than for patients admitted to hospital for other indications and for patients who have thrombosis, mortality appears increased. Thrombosis may be a presenting feature of COVID-19. Pulmonary thrombi are the most frequent events, some related to deep vein thrombosis, but also in situ micro- and macrovascular thrombosis. Other venous thromboses include catheter and circuit-associated in patients requiring haemofiltration and ECMO. Arterial thrombosis is less commonly documented, with 3% of ICU patients having major arterial strokes and up to 9% myocardial infarction, which is likely multifactorial. Risk factors for thrombosis above those already documented in hospital settings include duration of COVID-19 symptoms before admission to hospital. Laboratory parameters associated with higher thrombotic risk include higher D-dimer, low fibrinogen and low lymphocyte count, with higher FVIII and von Willebrand factor levels indicative of more severe COVID-19 infection. All patients should receive thromboprophylaxis when admitted with COVID-19 infection, but the dose and length of treatment still remain debated. Treatment for thrombosis remains as per standard VTE guidelines, but adjustments may be required depending on other factors relevant to the patient admission.

Severe stroke in patients admitted to intensive care unit after COVID-19 infection: pictorial essay of a case series

Patients infected by COVID-19 could require intensive care unit admission especially due to acute respiratory failure. However, neurological manifestations are very common. Among these, ischemic stroke or cerebral hemorrhage may have unfavorable outcome. The mechanisms leading to cerebral damage by SARS-CoV2 are still under debate. One of the most accepted theories implies an endothelial activation which in turns increase the risk of thrombus formation with the development of stroke, either ischemic or hemorrhagic. The more severe the COVID-19 disease, the higher the risk of stroke. Stroke in ICU patients are not frequent, but cerebral hemorrhage has devastating effects with high mortality. In these pictorial essay of case reports, main clinical aspects are discussed, along with a summary of the evidence about pathophysiology and treatment of these patients.

The relationship between COVID-19 infection and intracranial hemorrhage: A systematic review

INTRODUCTION

In addition to the deleterious effects Covid-19 has on the pulmonary and cardiovascular systems, COVID-19 can also result in damage to the nervous system. This review aims to explore current literature on the association between COVID-19 and intracranial hemorrhage (ICH).

METHODS

We conducted a systematic review of PubMed for literature published on COVID-19 and ICH. Ninety-four of 295 screened papers met inclusion criteria.

RESULTS

The literature addressed incidence and mortality of ICH associated with Covid-19. It also revealed cases of COVID-19 patients with subarachnoid hemorrhage, intraparenchymal hemorrhage, subdural hematomas, and hemorrhage secondary to cerebral venous thrombosis and ischemic stroke. ICH during COVID-19 infections was associated with increased morbidity and mortality. Risk factors for ICH appeared to be therapeutic anticoagulation, ECMO, and mechanical ventilation. Outcomes varied widely, depending on the severity of COVID-19 infection and neurologic injury.

CONCLUSION

Although treatment for severe Covid-19 infections is often aimed at addressing acute respiratory distress syndrome, vasculopathy, and coagulopathy, neurologic injury can also occur. Evidence-based treatments that improve COVID-19 mortality may also increase risk for developing ICH. Providers should be aware of potential neurologic sequelae of COVID-19, diagnostic methods to rule out other causes of ICH, and treatment regimens.

Spontaneous Intracerebral Hemorrhage and Delayed Cerebral Vasospasm in a Patient with COVID-19 Infection

Introduction: The SARS-CoV-2 may cause vasculitis and thromboembolic events. We report on an unusual case of spontaneous intracerebral hemorrhage and delayed cerebral vasospasms in a patient with COVID-19. Case Presentation: A 65-year-old male was transferred to the emergency department due to a short period of unconsciousness. Twenty-two hours prior to presentation, the patient had a 39.5°C fever with breathing difficulties. Initial COVID-19 PCR was positive. While conscious and without any neurological impairment, a large right frontal intracerebral hemorrhage (ICH) was detected. A preoperative angiogram showed no pathological blood vessels or vasospasm. The patients had a generalized tonic-clonic seizure due to ICH progression, which led to an immediate microsurgical ICH removal. Thirteen days thereafter, the patient became unconscious again. Angiography revealed severe cerebral vasospasm (CV) that required repetitive percutaneous transluminal angioplasty (PTA) and intra-arterial nimodipine treatment. Conclusions: We present the first case of ICH and delayed vasospasm associated with COVID-19. In these patients, combined maximum surgical and endovascular therapy is needed.