Anticoagulation use and Hemorrhagic Stroke in SARS-CoV-2 Patients Treated at a New York Healthcare System

Abstract

Background and Purpose: While the thrombotic complications of COVID-19 have been well described, there are limited data on clinically significant bleeding complications including hemorrhagic stroke. The clinical characteristics, underlying stroke mechanism, and outcomes in this particular subset of patients are especially salient as therapeutic anticoagulation becomes increasingly common in the treatment and prevention of thrombotic complications of COVID-19. Methods: We conducted a retrospective cohort study of patients with hemorrhagic stroke (both non-traumatic intracerebral hemorrhage and spontaneous non-aneurysmal subarachnoid hemorrhage) who were hospitalized between March 1, 2020, and May 15, 2020, within a major healthcare system in New York, during the coronavirus pandemic. Patients with hemorrhagic stroke on admission and who developed hemorrhage during hospitalization were both included. We compared the clinical characteristics of patients with hemorrhagic stroke and COVID-19 to those without COVID-19 admitted to our hospital system between March 1, 2020, and May 15, 2020 (contemporary controls), and March 1, 2019, and May 15, 2019 (historical controls). Demographic variables and clinical characteristics between the individual groups were compared using Fischer's exact test for categorical variables and nonparametric test for continuous variables. We adjusted for multiple comparisons using the Bonferroni method. Results: During the study period in 2020, out of 4071 patients who were hospitalized with COVID-19, we identified 19 (0.5%) with hemorrhagic stroke. Of all COVID-19 with hemorrhagic stroke, only three had isolated non-aneurysmal SAH with no associated intraparenchymal hemorrhage. Among hemorrhagic stroke in patients with COVID-19, coagulopathy was the most common etiology (73.7%); empiric anticoagulation was started in 89.5% of these patients versus 4.2% in contemporary controls (p ≤ .001) and 10.0% in historical controls (p ≤ .001). Compared to contemporary and historical controls, patients with COVID-19 had higher initial NIHSS scores, INR, PTT, and fibrinogen levels. Patients with COVID-19 also had higher rates of in-hospital mortality (84.6% vs. 4.6%, p ≤ 0.001). Sensitivity analyses excluding patients with strictly subarachnoid hemorrhage yielded similar results.

COVID‐19: Neuroimaging Features of a Pandemic

“…Up to 89.5% of the patients positive to SARS-CoV-2 with ICH were under empiric anticoagulation. 70 As frequently reported in the literature, anticoagulant-related ICH occurs predominantly in a lobar and/or cortico-subcortical location. 154,155 In line with it, a greater prevalence of hemorrhagic transformation of ischemic strokes was reported in SARS-CoV-2-positive patients.…”

“…69 According to Kvernland et al, 89.5% of the patients with hemorrhagic stroke were on anticoagulation. 70 In this context, an underlying COVID-19-induced endotheliopathy is discussed, complicating anticoagulation decision, as clinicians have to balance risk of thrombosis with risk of ICH.…”

COVID-19 and cerebrovascular diseases: a comprehensive overview

“…A higher mortality rate was observed in COVID-19 patients compared to both contemporary and historical negative controls with ICH. 58 In another cohort, all COVID-19 patients with hemorrhagic lesions on brain MRI suffered from acute respiratory distress syndrome and were hospitalized in intensive care units. 88 A total of 20% patients with hemorrhagic lesions died during hospitalization, compared with 6% of COVID-19 patients with other non-hemorrhagic lesions.…”

Pragmatic Recommendations for the Management of Anticoagulation and Venous Thrombotic Disease for Hospitalized Patients with COVID-19 in Low- and Middle-Income Countries

“…31 Another study from the United States found that 19 (0.5%) patients developed hemorrhagic stroke, in which therapeutic anticoagulation was prescribed in 89.5% of these patients. 55 Full anticoagulation is now being provided for hospitalized COVID-19 patients in many centers. However, rates of bleeding in such patients appear to be high.…”