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.

Keywords: COVID-19; SARS-CoV-2; anticoagulation; extracorporeal membrane oxygenation; intraparenchymal hemorrhage; stroke.

Fig 1

Representative images of CTH. Patient A-D represented as columns in Table 2. (A) Multicompartment intracranial hemorrhage with intraparenchymal, subarachnoid, and subdural components with marked diffuse edema and secondary infarction of the left anterior and posterior cerebral artery territories owing to vascular compression. (B) Large left hemispheric intracerebral hemorrhage with fluid level consistent with coagulopathic hemorrhage. (C) Multifocal intracerebral hemorrhage with left hemispheric lobar hemorrhage and separate right cerebellar hemorrhage. (D) Small left frontal cortical subarachnoid hemorrhage.