Risk factors for intracerebral hemorrhage in patients with COVID-19

Abstract

Intracerebral hemorrhage (ICH) can be a devastating complication of coronavirus disease (COVID-19). We aimed to assess risk factors associated with ICH in this population. We performed a retrospective cohort study of adult patients admitted to NYU Langone Health system between March 1 and April 27 2020 with a positive nasopharyngeal swab polymerase chain reaction test result and presence of primary nontraumatic intracranial hemorrhage or hemorrhagic conversion of ischemic stroke on neuroimaging. Patients with intracranial procedures, malignancy, or vascular malformation were excluded. We used regression models to estimate odds ratios and 95% confidence intervals (OR, 95% CI) of the association between ICH and covariates. We also used regression models to determine association between ICH and mortality. Among 3824 patients admitted with COVID-19, 755 patients had neuroimaging and 416 patients were identified after exclusion criteria were applied. The mean (standard deviation) age was 69.3 (16.2), 35.8% were women, and 34.9% were on therapeutic anticoagulation. ICH occurred in 33 (7.9%) patients. Older age, non-Caucasian race, respiratory failure requiring mechanical ventilation, and therapeutic anticoagulation were associated with ICH on univariate analysis (p < 0.01 for each variable). In adjusted regression models, anticoagulation use was associated with a five-fold increased risk of ICH (OR 5.26, 95% CI 2.33–12.24, p < 0.001). ICH was associated with increased mortality (adjusted OR 2.6, 95 % CI 1.2–5.9). Anticoagulation use is associated with increased risk of ICH in patients with COVID-19. Further investigation is required to elucidate underlying mechanisms and prevention strategies in this population. Electronic supplementary material The online version of this article (10.1007/s11239-020-02288-0) contains supplementary material, which is available to authorized users.

Acute haemorrhagic leukoencephalitis (Hurst disease) in severe COVID- 19 infection

“…It has been shown that ICH in COVID-19 could be linked with anticoagulation treatment. More than half of these patients were on anticoagulation due to significantly high D-dimer levels, and a larger number of ICH patients were on heparin (treatment dose) ( Melmed et al., 2020 ). It is speculated that could be rather a sign of severity of the illness than the increased risk of ICH while on heparin infusion ( Melmed et al., 2020 ).…”

Toxic Metabolic Encephalopathy in Hospitalized Patients with COVID-19

“…5 New York University Langone Hospitals, New York, NY, USA. 6 Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA.…”

“…Multiple studies have identified neurological events in the context of recent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection [1][2][3][4][5][6][7][8]. Many of these complications are sequelae of severe illness or represent secondary effects of multisystem organ failure.…”

Ischemic stroke in COVID-19-positive patients: an overview of SARS-CoV-2 and thrombotic mechanisms for the neurointerventionalist

“…43 This is not to say that anticoagulation is appropriate for all stroke patients, particularly given that anticoagulation was identified as an independent risk factor for intracranial hemorrhage in patients with COVID-19. 51 Instead, it highlights the need to direct future studies at evaluating the role of anticoagulants in treating acute ischemic strokes in COVID-19-positive patients who are not eligible for currently recommended therapies (eg, recombinant tissue plasminogen activator (rtPA) or thrombectomy). Gavioli et al have published a proposed clinical treatment pathway for hospitalized COVID-19 patients which guides treatment with prophylactic versus therapeutic heparin and enoxaparin as well as rtPA in hospitalized patients with COVID-19.…”