Etiopathogenetic factors and the course of hemorrhagic stroke associated with COVID-19

Background. Acute stroke is a highly specific neurological symptom in the acute phase of COVID-19. Hemorrhagic stroke (HS) is an infrequent, but life-threatening complication of COVID-19.

Objective. To analyze etiopathogenetic factors and the course of HS associated with COVID-19.

Design and methods. A retrospective analysis of 27 medical histories of patients with HS associated with COVID-19 (the main group) and 14 medical histories of patients with HS not related to COVID-19 (the control group) was performed. In the main group, COVID-19 was confirmed by the positive polymerase chain reaction method. HS developed before COVID-19 symptoms in 10 (37,04%) patients and after 4–16 days of COVID-19 symptoms onset in 17 (62,96%) patients.

Results. Our study indicates significant differences in blood pressure (BP), respiratory system parameters, laboratory data, neuroimaging data in patients of the main and control groups. Coagulopathy, thrombocytopenia, hypoxia, and the renal and hepatic failure play a significant role in the development of HS associated with COVID-19 compared to the classic HS (without COVID-19), where hypertension seems to be the important. At the same time BP is significantly lower in the main group.

Conclusions. The etiopathogenetic factors and the course of HS associated with COVID-19 require pathogenetically different therapy compared to HS without COVID-19.

1. Stakhovskaya LV, Kotov SV. Stroke. A guide for doctors. MIA Moscow 2018. 488 p. In Russian.

2. Mao L, Jin H, Wang M, Hu Y, Chen S, He Q et al. Neurologic manifestations of hospitalized patients with coronavirus disease 2019 in Wuhan, China. JAMA Neurol. 2020;77(6):683–690. doi:10.1001/jamaneurol.2020.1127

3. Margos N, Meintanopoulos A, Filioglou D, Ellul J. Intracerebral hemorrhage in COVID-19: a narrative review. J Clin Neurosci. 2021;89:271–278. doi.org/10.1016/j.jocn.2021.05.019

4. Melmed K, Cao M, Dogra S, Zhang R, Yaghi S, Lewis A et al. Risk factors for intracerebral hemorrhage in patients with COVID-19. J Thromb Thrombolysis. 2021;51(4):953–960. doi:10.1007/s11239-020-02288-0

5. Cheruiyot I, Sehmi P, Ominde B, Bundi P, Mislani M, Ngure B et al. Intracranial hemorrhage in coronavirus disease 2019 (COVID-19) patients. Neurol Sci. 2021;42(1):25–33. doi:10.1007/s10072-020-04870-z

6. Altschul D, Unda S, de La Garza Ramos R, Zampolin R, Benton J, Holland R et al. Hemorrhagic presentations of COVID-19: risk factors for mortality. Clin Neurol Neurosurg. 2020;198:106112. doi:10.1016/j.clineuro.2020.106112

7. Kvernland A, Kumar A, Yaghi S, Raz E, Frontera J, Lewis A et al. Anticoagulation use and hemorrhagic stroke in SARS-CoV-2 patients treated at a New York Healthcare system. Neurocrit Care. 2021;34(3):748–759. doi.org/10.1007/s12028-020-01077-0

8. Beyrouti R, Best JG, Chandratheva A, Perry RJ, Werring DJ. Characteristics of intracerebral haemorrhage associated with COVID-19: a systematic review and pooled analysis of individual patient and aggregate data. J Neurol. 2021:268(9):3105–3115. doi:10.1007/s00415-021-10425-9

9. Conklin J, Frosch M, Mukerji S, Rapalino O, Maher M, Schaefer P et al. Cerebral microvascular injury in severe COVID-19. medRxiv. 2020;2020.07.21.20159376. doi:10.1101/2020.07.21.20159376

10. Wang H, Tang X, Fan H, Luo Y, Song Y, Xu Y et al. Potential mechanisms of hemorrhagic stroke in elderly COVID-19 patients. Aging (Albany NY). 2020;12(11):10022–10034. doi:10.18632/aging.103335

11. Lattanzi S, Brigo F, Trinka E, Cagnetti C, Di Napoli M, Silvestrini M. Neutrophil-to-lymphocyte ratio in acute cerebral hemorrhage: a system review. Transl Stroke Res. 2019;10(2):137–145. doi:10.1007/s12975-018-0649-4

12. Benger M, Williams O, Siddiqui J, Sztriha L. Intracerebral haemorrhage and COVID-19: Clinical characteristics from a case series. Brain Behav Immun. 2020;88:940–944. doi:10.1016/j.bbi.2020.06.005

13. Dastur C, Yu W. Current management of spontaneous intracerebral haemorrhage. Stroke Vasc Neurol. 2017;2(1):21–29. doi:10.1136/svn-2016-000047

14. Katz JM, Libman RB, Wang JJ, Filippi CG, Sanelli P, Zlochower A et al. COVID-19 severity and stroke: correlation of imaging and laboratory markers. AJNR Am J Neuroradiol. 2021;42(2):257–261. doi:10.3174/ajnr.A6920

15. Johansson K, Jansson JH, Johansson L, Wiklund PG, Nilsson TK, Lind M. D-dimer is associated with first-ever intracerebral hemorrhage. Stroke. 2018;49(9):2034–2039. doi:10.1161/STROKEAHA.118.021751

16. Muhammad S, Petridis A, Cornelius JF, Hänggi D. Letter to editor: severe brain haemorrhage and concomitant COVID-19 Infection: a neurovascular complication of COVID-19. Brain Behav Immun. 2020;87:150–151. doi.org/10.1016/j.bbi.2020.05.015