Intracerebral hemorrhage in COVID-19 patients with pulmonary failure – a propensity score matched registry study

Abstract

Background: Hypercoagulopathy in coronavirus disease 2019 (COVID-19) causing deep vein thrombosis and pulmonary artery embolism necessitate systemic anticoagulation. Case reports of intracerebral hemorrhages in ventilated COVID-19 patients warrant precaution. It is unclear however, if COVID-19 patients with acute respiratory distress syndrome (ARDS) with and without extracorporeal membrane oxygenation therapy (ECMO) have more intracerebral hemorrhages (ICH) compared to other ARDS patients.Methods: We conducted a retrospective observational single center study enrolling all patients with ARDS from 01/2018-05/2020. Patients with ARDS positive for SARS-CoV2 PCR were allocated to the COVID-19 group. Propensity score matching was performed for age, ECMO and risk of bleeding according to HAS-BLED score.Results: A total of 163, mostly severe ARDS patients were identified, 116 (71.2%) without COVID-19 and 47 (28.8%) positive for SARS-CoV-2. The two groups were comparable concerning the main confounders of ICH including age, HAS-BLED score, need for ECMO-therapy as well as anticoagulation levels reported. In 63/163 cases (38.7%), veno-venous ECMO therapy was required and ICU survival was 52.8%. Although HAS-BLED-score on admission was generally low (1.6±1.3), intracerebral hemorrhage was detected in 22 patients (13.5%) with no statistical difference between the groups (11.2 vs. 19.1% with and without SARS-CoV-2, respectively, p=0.21). Propensity score matching confirmed similar intracerebral bleeding rates in both groups (12.8 vs. 19.1% with and without SARS-CoV-2, respectively, p=0.57). Conclusions: Intracerebral hemorrhage was detectable in every tenth patient with ARDS. We found no statistically significant increased bleeding rate in patients with ARDS due to COVID-19 compared to other causes of ARDS.

Intracranial Hemorrhages on Extracorporeal Membrane Oxygenation: Differences Between COVID-19 and Other Viral Acute Respiratory Distress Syndrome

“…The high incidence of hemorrhage may be triggered by severe acute respiratory syndrome coronavirus 2 effects or by iatrogenic factors associated with strict anticoagulation strategies to prevent thromboembolic events. Spontaneous ICH in COVID-19 patients with ARDS not receiving ECMO support are not uncommon (10%) but was similar to non-COVID-19 ARDS (32). Of note, in our cohort, the overall rate of thromboembolic events was increased in COVID-19, in line with the existing literature, but were not a risk factor for the occurrence of ICH.…”

Intensive Care Resources and 60-Day Survival of Critically-Ill COVID-19 Patients

“…All other patients seemed to have overcome respiratory failure but died from overwhelming complications or multiorgan-failure. Interestingly, three patients died from intracerebral hemorrhage and were studied in a subsequent analysis [ 14 ]. ICU therapy withdrawal was due to DNR orders in two patients (no re-intubation preferred) - not decisively influencing the high mortality in our opinion.…”

Extracorporeal Membrane Oxygenation for COVID-19: A Systematic Review

“…As per emerging results, COVID-19 tends to be connected to a high rate of venous and arterial thromboembolic events, with a reported cumulative incidence of 20% [34][35][36]. After reports of thrombotic issues in COVID-19, the anticoagulation target has been modified from aPTT (activated partial thromboplastin time) 40-50 s to aPTT 50-70 s [37].…”