Imaging features and ultraearly hematoma growth in intracerebral hemorrhage associated with COVID-19

Abstract

Purpose Intracerebral hemorrhage (ICH) is an uncommon but deadly event in patients with COVID-19 and its imaging features remain poorly characterized. We aimed to describe the clinical and imaging features of COVID-19-associated ICH. Methods Multicenter, retrospective, case–control analysis comparing ICH in COVID-19 patients (COV19 +) versus controls without COVID-19 (COV19 −). Clinical presentation, laboratory markers, and severity of COVID-19 disease were recorded. Non-contrast computed tomography (NCCT) markers (intrahematoma hypodensity, heterogeneous density, blend sign, irregular shape fluid level), ICH location, and hematoma volume (ABC/2 method) were analyzed. The outcome of interest was ultraearly hematoma growth (uHG) (defined as NCCT baseline ICH volume/onset-to-imaging time), whose predictors were explored with multivariable linear regression. Results A total of 33 COV19 + patients and 321 COV19 − controls with ICH were included. Demographic characteristics and vascular risk factors were similar in the two groups. Multifocal ICH and NCCT markers were significantly more common in the COV19 + population. uHG was significantly higher among COV19 + patients (median 6.2 mL/h vs 3.1 mL/h, p = 0.027), and this finding remained significant after adjustment for confounding factors (systolic blood pressure, antiplatelet and anticoagulant therapy), in linear regression ( B (SE) = 0.31 (0.11), p = 0.005). This association remained consistent also after the exclusion of patients under anticoagulant treatment ( B (SE) = 0.29 (0.13), p = 0.026). Conclusions ICH in COV19 + patients has distinct NCCT imaging features and a higher speed of bleeding. This association is not mediated by antithrombotic therapy and deserves further research to characterize the underlying biological mechanisms.

Neurologic Complications of Patients With COVID-19 Requiring Extracorporeal Membrane Oxygenation: A Systematic Review and Meta-Analysis

“…Intraparenchymal hemorrhage accounted for more than two-thirds of all ICHs, and there were frequent reports of fluid levels and multifocal ICH (31)(32)(33)(34)(35). Fluid levels are suggestive of impaired clot formation, either from pathologic coagulopathy or iatrogenic anticoagulation, and are associated with hematoma expansion (36)(37)(38). Similarly, multifocal hemorrhages are associated with coagulopathy, typically in the context of systemic anticoagulation (39).…”

Cerebrovascular Manifestations of SARS-CoV-2: A Comprehensive Review

“…Imaging typically involves non-contrast CT. Patients with ICH and COVID-19 have been observed via CT to have a higher bleeding speed, more haemorrhagic foci, and extension in a larger area than with a typical ICH, independent of vascular risk factors [ 81 ].…”

Ischemic strokes in COVID-19: risk factors, obesity paradox, and distinction between trigger and causal association

“…The most relevant features that have been highlighted in the literature are a higher proportion of large artery disease (LAD) ( 3 ) and multifocality ( 4 , 5 ), a younger age at onset ( 6 ), a higher rate of concurrent systemic thrombotic events ( 7 ), resistance to prophylactic and even therapeutic antithrombotic therapy ( 8–10 ), a higher NIHSS at onset, and a worse functional outcome ( 11 ). A lower number of reports described intracerebral hemorrhage (ICH) related to COVID-19 infection, pointing out the more inhomogeneous pattern of presentation at neuroimaging, the higher tendency to early hematoma expansion ( 12 ), the high mortality rate, COVID-19 severity as a risk factor, and the role of therapeutic anticoagulation as an independent risk factor for ICH ( 13 , 14 ).…”