Missed cerebrovascular events during prolonged sedation for COVID-19 pneumonia

Abstract

Cerebrovascular complications among critically ill patients with COVID-19 have yet to be fully characterized. In this retrospective case series from a single academic tertiary care referral center in New York City, we present 12 patients with ischemic or hemorrhagic strokes that were found on imaging after a period of prolonged sedation in the setting of COVID-19 pneumonia. This series demonstrates a pattern of cerebrovascular events clinically masked by deep sedation required for management of COVID-19 related acute respiratory distress syndrome (ARDS). Of the 12 patients included, 10 had ischemic stroke, 4 of which had hemorrhagic conversion, and 2 had primary intracerebral hemorrhage. Ten patients were on therapeutic anticoagulation prior to discovery of their stroke, and the remainder received intermediate dose anticoagulation (in a range between prophylactic and therapeutic levels). Additional studies are needed to further characterize the counterbalancing risks of ischemic and hemorrhagic stroke, as well as the optimal management of this patient population.

Keywords: ARDS; Anticoagulation; COVID-19; Intracerebral hemorrhage; Sedation; Stroke.

Fig. 1

A and B: Axial CT images of patient with subacute posterior circulation infarct. C: Axial CT image of subacute left middle and right parieto-occipital infarction with hemorrhagic conversion. D: Axial CT image of large left cerebral intraparenchymal hematoma with intraventricular extension.