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

Abstract

Background The COVID-19 pandemic is an ongoing public health emergency. While most cases end in asymptomatic or minor illness, there is growing evidence that some COVID-19 infections result in non-conventional dire consequences. Objective To describe the characteristics of intracranial hemorrhage (ICH) patients who were infected with SARS-CoV-2. Also, with the existing literature, we raise the idea of a possible association between SARS-CoV-2 infection and ICH and propose possible pathophysiological mechanisms connecting the two. Methods We retrospectively collected and analyzed intracranial hemorrhage cases who were also positive for SARS-CoV-2 from four tertiary-care cerebrovascular centers. Results We identified a total of nineteen patients consisting of eleven males (58%) and eight females (42%). Mean age was 52.2 with 95% being less than 75 years of age. With respect to COVID-19 illness, 50% had mild-moderate disease, 21% had severe disease, and 20% had critical disease requiring intubation. Of the nineteen cases, twelve patients had intraparenchymal hemorrhage (63%), six had subarachnoid hemorrhage (32%), and one patient had a subdural hematoma (5%). Intracerebral hemorrhage score of 0 – 2 were in 43% and 3 – 6 in 57%. Modified Rankin Scale cores at discharge were 0-2 in 23% and 3-6 in 77%. The mortality rate was 59%. Conclusion Our series shed light on a distinct pattern of intracerebral hemorrhage in COVID-19 positive cases compared to typical non-COVID cases, namely the severity of hemorrhage, high mortality rate, and the young age of patients. Further research is warranted to delineate a potential association between SARS-CoV-2 infection and intracranial hemorrhage.

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

“…Some patients with COVID-19 may initially present with nonspecific neurological symptoms including headache and dizziness while others develop more specific neurological complications. There are reports of meningoencephalitis, encephalopathy, cerebrovascular disease and intracranial hemorrhage, 9 - 11 olfactory and gustatory disorders, and few with Guillain-Barré syndrome in adult patients. 12 In pediatric patients, 2 previous studies with children who tested positive for COVID-19 in Wuhan, China, reported no neurological symptoms.…”

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

“…52% of Covid -19 patients present SAH, while 95% of them have a history of hypertension and 60% have a history of diabetes Mellitus, 40% have cardio embolism and 5% have vessel disease, and 35% cryptogenic [19]. Hypertension (HTN) and chronic heart disease were the two most common vascular comorbidities, as documented in various studies on ICH in COVID-19 patients [13]. Ventricular Tachycardia (VT) in the form of Torsade de pointes (TdP) [20].…”

“…SARS-COV-2 infects host cells by entering via angiotensin-converting enzyme-2 receptors (ACE-2). ACE-2 receptors are omnipresent within the human body, particularly overexpressed on intestinal epithelial cells, endothelial and smooth cells of blood vessels, heart, lung, renal tubular epithelial cells [12], and in cerebrovascular endothelium which interacts with the viral "s" protein (homotrimer spike glycoprotein) [13]. A potential risk factor that causes intracranial hemorrhage (ICH) is intracerebral capillaries bursting as a result of direct endothelial toxicity.…”

“…As a result, the autoregulation of cerebral blood flow is compromised, and the local endothelium accumulates high amounts of angiotensin II. This subsequently results in uncontrolled hypertension, significantly raising the risk of subarachnoid hemorrhage (SAH) and ICH [13].…”

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

“…In patients with COVID-19 and aneurysmal SAH, the rupture of the aneurysm was assumed to be produced due to endothelial dysfunction. In addition, as the SARS-CoV-2 downregulates the expression of the ACE-2 receptors, the disruption of the renin-angiotensin-aldosterone system may cause an uncontrolled elevation in blood pressure, which is exacerbated by preexisting hypertension; thereby, the risk of bleeding is substantially increased [ 31 ]. Some authors proposed that the hyperinflammatory state also seen in COVID-19, with hypercytokinemia and inflammation, could contribute to vascular degeneration that will lead to aneurysm formation and size or morphology change, consequently resulting in rupture and bleeding [ 32 ].…”