Intracranial Hemorrhage in Patients with Coronavirus Disease 2019 (COVID-19): A Case Series

Abstract

Background: The coronavirus disease 2019 (COVID-19) pandemic is an ongoing public health emergency. While most cases end in asymptomatic or minor illness, there is growing evidence that some COVID-19 infections result in nonconventional dire consequences. We sought to describe the characteristics of patients with intracranial hemorrhage who were infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Also, with the existing literature, we raise the idea of a possible association between SARS-CoV-2 infection and intracranial hemorrhage and propose possible pathophysiological mechanisms connecting the two.

Methods: We retrospectively collected and analyzed intracranial hemorrhage cases who were also positive for SARS-CoV-2 from 4 tertiary-care cerebrovascular centers.

Results: We identified a total of 19 patients consisting of 11 males (58%) and 8 females (42%). Mean age was 52.2, with 95% younger than 75 years of age. With respect to COVID-19 illness, 50% had mild-to-moderate disease, 21% had severe disease, and 20% had critical disease requiring intubation. Of the 19 cases, 12 patients had intraparenchymal hemorrhage (63%), 6 had subarachnoid hemorrhage (32%), and 1 patient had a subdural hematoma (5%). A total of 43% had an intracerebral hemorrhage score of 0-2 and 57% a score of 3-6. Modified Rankin Scale cores at discharge were 0-2 in 23% and 3-6 in 77%. The mortality rate was 59%.

Conclusions: Our series sheds light on a distinct pattern of intracerebral hemorrhage in COVID-19-positive cases compared with typical non-COVID-19 cases, namely the severity of hemorrhage, high mortality rate, and the young age of patients. Further research is warranted to delineate a potential association between SARS-CoV-2 infection and intracranial hemorrhage.

Keywords: COVID-19; Intracranial hemorrhage; Neurotropism; Neurovascular disease; SARS-CoV-2.

Figure 1

(A–C) Axial, coronal, and sagittal noncontrasted computed tomography (CT) images of the head of a previously healthy 24-year-old male patient who presented after a syncopal episode at home followed by unresponsiveness. On arrival, he had no extremity movements, pupils were fixed, dilated, and nonreactive, and he had no brainstem reflexes. CT of the head (pictured here) demonstrated a large posterior fossa hemorrhage centered in the left cerebellar hemisphere with intraventricular extension into the third and fourth ventricles, herniation, and significant brainstem compression. CT angiography did not show any vascular abnormality. The patient tested positive for coronavirus disease 2019 (COVID-19) and ultimately succumbed to severe neurologic damage and died. (D) The patient’s CT image of the chest (axial) showing diffuse ground-glass opacities and consolidative airspace disease bilaterally.