Hemorrhagic presentations of COVID-19: Risk factors for mortality

Abstract

Objective We aim to characterize the incidence, risk for mortality, and identify risk factors for mortality in patients presenting with hemorrhage and COVID-19. Methods This retrospective cohort study included a cohort of patients admitted to one of three major hospitals of our healthcare network including, an academic medical center and comprehensive stroke center, which accepts transfers for complex cases from eight community hospitals, during March 1 to May 1, 2020. All patients that received imaging of the neuroaxis and had positive PCR testing for COVID-19 were identified and reviewed by an attending neuroradiologist. Demographics and comorbidities were recorded. Biomarkers were recorded from the day of the hemorrhagic event. Vital signs from the day of the hemorrhagic event mechanical ventilation orders at admission were recorded. Imaging findings were divided into 5 subtypes; acute subdural hematoma (SDH), subarachnoid hemorrhage (SAH), multi-compartmental hemorrhage (MCH), multi-focal intracerebral hemorrhage (MFH), and focal intracerebral hemorrhage (fICH). Outcomes were recorded as non-routine discharge and mortality. Results We found a total of 35 out of 5227 patients with COVID-19 that had hemorrhage of some kind. Mortality for the entire cohort was 45.7 % (n = 16). SDH patients had a mortality rate of 35.3 % (n = 6), SAH had a mortality of 50 % (n = 1), MCH patients had a mortality of 71.4 % (n = 5), MFH patients had a mortality of 50 % (n = 2), fICH patients had a mortality of 40 % (n = 2). Patients with severe pulmonary COVID requiring mechanical ventilation (OR 10.24 [.43−243.12] p = 0.015), with INR > 1.2 on the day of the hemorrhagic event (OR 14.36 [1.69−122.14] p = 0.015], and patients presenting with spontaneous vs. traumatic hemorrhage (OR 6.11 [.31−118.89] p = 0.023) had significantly higher risk for mortality. Conclusions Hemorrhagic presentations with COVID-19 are a rare but serious way in which the illness can manifest. It is important for neurosurgeons to realize that patients can present with these findings without primary pulmonary symptoms, and that severe pulmonary symptoms, elevated INR, and spontaneous hemorrhagic presentations is associated with increased risk for mortality.

Hemorrhagic and ischemic stroke in patients with coronavirus disease 2019: incidence, risk factors, and pathogenesis - a systematic review and meta-analysis

“…All 18 studies were included in the meta-analysis to calculate the global prevalence of hemorrhagic stroke in COVID-19 patients and the frequency of symptoms leading to hospital admission 32 – 49 . Data from nine studies were included to calculate the mortality rate of hemorrhagic stroke in COVID-19 patients 32 , 33 , 35 – 37 , 40 , 45 , 48 , 49 , while the other nine studies did not report relevant data. The 18 studies and the prevalence of hemorrhagic stroke reported in each of them are summarized in Table 1 .…”

COVID‐19: Neuroimaging Features of a Pandemic

“…Our review documented a total of 18 studies reporting about imaging features of 135 COVID-19 patients with ICH. 12,18,21,22,26,48,56,57,59,65,[71][72][73][74][75][76][77] Eight studies were presented as single case reports or as case series. 48,59,[71][72][73][74][75]77 Another eight studies were conducted as retrospective studies reporting on neuroimaging findings of ICH patients.…”

COVID-19 infection produces subarachnoid hemorrhage; acting now to understand its cause: A short communication

“…The novel coronavirus disease 2019 (COVID-19) is a global pandemic with international concern [ 1 ]. SAH is a devastating disease [ 2 ], which accounts for approximately 5–10 % of strokes [ 2 ] Several case report about the SAH and COVID-19 infection have been reported [ [3] , [4] , [5] , [6] ], but three reviews about the interaction between COVID-19 and the central nervous system have been recently published, but the occurrence of SAH in patients with Covid-19 infection has not been mentioned in these reviews [ [7] , [8] , [9] ]. There is limited knowledge on the SAH following COVID-19 at present.…”