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.

Keywords: Anticoagulation; COVID-19; Hemorrhagic stroke; Intracerebral hemorrhage; Mechanical ventilation.

Fig. 1

3824 patients were admitted with COVID-19. Of these, 755 had brain imaging available for review, of which 416 met our inclusion criteria. We identified 37 patients with ICH, and further excluded 4 patients for recent trauma (2), intracranial neoplasm (2) and thus 33 were included for analysis.

Fig. 2

ROC curve for occurrence of ICH predicted by coagulation parameters. ROC curve analysis indicated that the area under the curve of INR, aPTT, platelet nadir and peak D-dimer in patients with ICH was 0.64, 0.73, 0.45 and 0.67, respectively (p = 0.01, p < 0.01, p = 0.4 and p < 0.01; respectively). aPTT: activated partial thromboplastin time; ICH: intracerebral hemorrhage cerebral microbleeds; ROC: receiver operating characteristic