Aneurysmal Subarachnoid Hemorrhage in Patients with Coronavirus Disease 2019 (COVID-19): A Case Series

Abstract

Objective The SARS-CoV-2 pandemic is a pressing public health issue. While most cases do not result in severe illness requiring hospitalization, there is increasing evidence that SARS-CoV-2-induced inflammation can exacerbate preexisting diseases. We sought to describe the characteristics of aneurysmal subarachnoid hemorrhage patients who were actively or very recently infected with SARS-CoV-2. Methods We reviewed subarachnoid hemorrhage cases of patients who were also SARS-CoV-2-positive at five high-volume cerebrovascular centers in the U.S from March 2020 to January 2021. Cases of aneurysmal subarachnoid hemorrhage were analyzed. Results A total of ten patients were identified, consisting of five women (50%) and five men (50%). Median age was 38.5 years. Four of the ten patients (40%) were asymptomatic with respect to SARS-CoV-2-related symptoms, three patients (30%) had mild-to-moderate symptoms, and three patients (30%) had severe COVID, with pneumonia and sepsis. Of the ten cases, four had dissecting pseudoaneurysms (40%), three in the posterior circulation and one in the anterior circulation. Among six saccular/blister aneurysms, four (67%) were ≤4 mm in largest diameter. Conclusions Our experience with aneurysmal subarachnoid hemorrhage in COVID-positive patients reveals a possibly distinct pattern compared to traditional aneurysmal subarachnoid hemorrhage, namely a high frequency of small aneurysms, dissecting pseudoaneurysms, and young patients.

Low-Pressure Hydrocephalus in Spontaneous Angiogram-Negative Subarachnoid Hemorrhage Following COVID-19 Infection

“…There have been reports of both spontaneous non-aneurysmal as well as spontaneous aneurysmal SAH in patients acutely infected with COVID-19 [18,19]. To our knowledge, this is the first reported case of spontaneous non-aneurysmal SAH with associated low-pressure hydrocephalus in the setting of recent COVID-19 infection.…”

“…Coronavirus disease 2019 (COVID- 19) is caused by severe acute respiratory disease syndrome coronavirus 2 (SARS-CoV-2) infection and has been declared a Public Health Emergency of International Concern by the World Health Organization [1]. A preliminary report warned that SARS-CoV-2 could have neuro-invasive potential as it was observed that some patients showed neurologic symptoms such as headache, nausea, and vomiting [2].…”

Exacerbation of Pre-existing Neurological Symptoms With COVID-19 in Patients With Chronic Neurological Diseases: An Updated Systematic Review

“…Patients can have confusion and altered states of consciousness due to proinflammatory cytokines that increase markers hypercoagulation increasing the risk of stroke. Dodd et al's study analyzed the inflammatory response triggered by COVID-19 infection could be the factor to cause saccular premature aneurysms to rupture and subarachnoid hemorrhage [ 42 ].…”

"Bridging the Gap Between COVID-19 and Subarachnoid Hemorrhage: A Case Report and Literature Review"

“…Inflammation associated with SARS-CoV-2 and aneurysmal rupture is both heavily influenced by macrophages. The generation of IL-1, IL-6, and tumor necrosis factors by macrophages have a role in SARS-CoV-2 infection and cerebral aneurysm rupture [17]. Studies have shown males had higher rates of severe Sars-Cov-2 symptoms necessitating ICU admission and worse ischemic stroke outcomes upon hospital release while females had higher rates of milder symptoms [18].…”