Intracranial Hemorrhage in COVID-19 Patients

Abstract

Objective: To describe the clinical, laboratory, temporal, radiographic, and outcome features of acute Intracranial Hemorrhage (ICH) in COVID-19 patients.

Methods: Retrospective, observational, consecutive case series of patients admitted with ICH to Maimonides Medical Center from March 1 through July 31, 2020, who had confirmed or highly suspected COVID-19. Demographic, clinical, laboratory, imaging, and outcome data were analyzed. ICH rates among all strokes were compared to the same time period in 2019 in two-week time intervals. Correlation of systolic blood pressure variability (SBPV) and neutrophil-to-lymphocyte ratio (NLR) to clinical outcomes were performed.

Results: Of 324 patients who presented with stroke, 65 (20%) were diagnosed with non-traumatic ICH: 8 had confirmed and 3 had highly suspected COVID-19. Nine (82%) had at least one associated risk factor for ICH. Three ICHs occurred during inpatient anticoagulation. More than half (6) suffered either deep or cerebellar hemorrhages; only 2 were lobar hemorrhages. Two of 8 patients with severe pneumonia survived. During the NYC COVID-19 peak period in April, ICH comprised the highest percentage of all strokes (40%), and then steadily decreased week-after-week (p = 0.02). SBPV and NLR were moderately and weakly positively correlated to discharge modified Rankin Scale, respectively.

Conclusions: COVID-19 associated ICH is often associated with at least one known ICH risk factor and severe pneumonia. There was a suggestive relative surge in ICH among all stroke types during the first peak of the NYC pandemic. It is important to be vigilant of ICH as a possible and important manifestation of COVID-19.

Keywords: COVID-19; Hemorrhagic Stroke; Intracerebral Hemorrhage; Intracranial Hemorrhage; Subarachnoid hemorrhage.

Fig. 1

Cochran-Armitage Test For ICH from March - July 2019 versus March - July 2020. X axis = approximate 2-week time periods from 3/1/2020 to 7/31/2020 Y axis = percentage of ICH patients among all strokes during March - July in 2019 (orange) versus March - July in 2020 (blue).

Fig. 2

Axial CT head without contrast for all patients. (A) Patient 1 – Left basal ganglia hemorrhage. (B) Patient 2 – Bilateral subcortical hemorrhages and right perimesencephalic cistern subarachnoid hemorrhage (not visualized on this cut). (C) Patient 3 – Right thalamic hemorrhage. (D) Patient 4 – Left occipital and intraventricular hemorrhage. (E) Patient 5 – Left frontoparietal, bilateral occipital and intraventricular hemorrhage, left frontoparietal subarachnoid hemorrhage. (F) Patient 6 – Bilateral frontotemporoparietal subarachnoid hemorrhage, intraventricular hemorrhage and hydrocephalus. (G) Patient 7 – Left basal ganglia and intraventricular hemorrhage, diffuse subarachnoid hemorrhage. (H) Patient 8 – Left cerebellar hemorrhage, quadrigeminal cistern subarachnoid hemorrhage (not visualized on this cut), chronic right frontal subdural hematoma (not visualized on this cut). (I) Patient 9  – Left basal ganglia and intraventricular hemorrhage, 2 cm left to right midline shift, left uncal herniation (not visualized on this cut). (J) Patient 10 – Diffuse intraventricular hemorrhage and mild hydrocephalus. (K) Patient 11 – Left frontal SAH.