A Case Series of Devastating Intracranial Hemorrhage During Venovenous Extracorporeal Membrane Oxygenation for COVID-19

Abstract

Objective: Anticoagulation may be a challenge in coronavirus disease 2019 (COVID-19) extracorporeal membrane oxygenation due to endothelial injury and dysregulation of coagulation, which may increase the risk of thrombotic and bleeding complications. This report was created to describe the authors' single institutional experience, with emphasis on the high rate of intracranial hemorrhage for the first 10 patients with COVID-19 placed on venovenous extracorporeal membrane oxygenation (VV ECMO). Design: Case series, retrospective analysis. Setting: Single institution. Participants: Ten patients. Interventions: None. Measurements and Main Results: Patient characteristics, mortality, stroke rate, and length of stay data were collected in all patients. In addition, laboratory values of D-dimer and C-reactive protein and standard measurements of prothrombin and activated partial thromboplastin time were collected on all patients. Ten patients, each confirmed with COVID-19 via reverse transcription-polymerase chain reaction, were supported on VV ECMO for acute respiratory distress syndrome (ARDS) for a mean duration of 9.4 § 7 days. Four of 10 patients had hemorrhagic strokes, 3 of which resulted in death. At 30 days after initiation of VV ECMO, a total of 7 survivors included 6 patients discharged from the hospital and 1 patient who remained in the intensive care unit. Conclusions: In this small study of 10 patients, intracranial hemorrhage was a common complication, resulting in a high rate of death. The authors urge caution in the anticoagulation management of VV ECMO for patients with severe ARDS and COVID-19 patients. Close monitoring of all hematologic parameters is recommended during ECMO support while awaiting larger, multicenter studies to examine the best practice.

Intracerebral Hemorrhage in COVID-19 Patients with Pulmonary Failure: A Propensity Score-Matched Registry Study

“…Whereas pulmonary embolism and deep vein thrombosis have repeatedly been documented in hospitalized COVID-19 patients [ 3 , 10 ], no study to date has examined the rate of major bleeding events. Only single-case reports [ 11 , 12 ] of massive intracerebral hemorrhage (ICH) in COVID-19 and a case series of COVID-19 patients on veno-venous extracorporeal membrane oxygenation (VV-ECMO) with 4 out of 10 patients suffering from ICH have been published [ 13 ].…”

The role of rotational thromboelastometry during the COVID-19 pandemic: a narrative review

“…Accordingly, the risk of ICH should be considered when developing an anticoagulation regimen for patients with COVID-19. Usman et al [ 83 ] reported a case series of COVID-19 patients treated with veno-venous extracorporeal membrane oxygenation (ECMO). Four of ten patients had hemorrhagic stroke, three of whom died.…”

Intracerebral hemorrhage in COVID-19: A narrative review

“…History of arterial HTN was reported in 89 (54%) out of 164 patients with intracranial hemorrhage, [2] , [18] , [19] , [21] – [24] , [26] , [27] , [30] – [34] , [36] , [41] , [42] , [44] – [47] , [49] , [51] and in 45 (52%) out of 87 patients with ICH. [2] , [18] , [22] , [24] , [26] , [31] – [34] , [36] , [41] , [42] , [44] – [47] , [49] , [51]…”

“…Of all 188 ICHs, 149 (79%) were primary, [2] , [18] – [28] , [30] – [38] , [41] , [43] – [48] , [50] including those with or without known risk factors such as arterial HTN, prior use of anticoagulants or extracorporeal membrane oxygenation (ECMO); 29 ICHs were secondary to hemorrhagic transformation of ischemic stroke, [18] , [39] , [42] , [49] 7 to cerebral vein thrombosis, [29] , [31] and 3 to encephalitis/encephalopathy. [40] , [51] , [52] …”