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Hemorrhagic presentations of COVID-19: Risk factors for mortality
David J Altschul1, Santiago R Unda1, Rafael de La Garza Ramos1
1Department of Neurosurgery, Montefiore Medical Center, Bronx, NY, USA.
Insights
Hemorrhage in COVID-19 patients is rare but deadly, with a 45.7% mortality rate. Mechanical ventilation, elevated INR, and spontaneous hemorrhage significantly increase mortality risk in these patients.
Area of Science:
- Neurology
- Infectious Diseases
- Critical Care Medicine
Background:
- COVID-19 has been associated with various neurological complications.
- Hemorrhagic presentations in COVID-19 patients are not well-characterized.
Purpose of the Study:
- To determine the incidence and mortality risk of hemorrhage in COVID-19 patients.
- To identify risk factors for mortality in this patient population.
Main Methods:
- Retrospective cohort study of patients with COVID-19 and neuroaxis imaging.
- Classified hemorrhage into 5 subtypes: SDH, SAH, MCH, MFH, and fICH.
- Recorded demographics, comorbidities, biomarkers, vital signs, and mechanical ventilation status.
Main Results:
- 35 out of 5227 COVID-19 patients (0.67%) presented with hemorrhage.
- Overall mortality was 45.7%.
- Mechanical ventilation (OR 10.24), INR > 1.2 (OR 14.36), and spontaneous hemorrhage (OR 6.11) were associated with increased mortality risk.
Conclusions:
- Hemorrhagic manifestations of COVID-19 are infrequent but carry a high mortality rate.
- Neurosurgeons should be aware of these presentations, which can occur without primary pulmonary symptoms.
- Severe pulmonary disease, elevated INR, and spontaneous hemorrhage are critical risk factors for mortality.
Objective:
We aim to characterize the incidence, risk for mortality, and identify risk factors for mortality in patients presenting with hemorrhage and COVID-19.
Methods:
This retrospective cohort study included a cohort of patients admitted to one of three major hospitals of our healthcare network including, an academic medical center and comprehensive stroke center, which accepts transfers for complex cases from eight community hospitals, during March 1 to May 1, 2020. All patients that received imaging of the neuroaxis and had positive PCR testing for COVID-19 were identified and reviewed by an attending neuroradiologist. Demographics and comorbidities were recorded. Biomarkers were recorded from the day of the hemorrhagic event. Vital signs from the day of the hemorrhagic event mechanical ventilation orders at admission were recorded. Imaging findings were divided into 5 subtypes; acute subdural hematoma (SDH), subarachnoid hemorrhage (SAH), multi-compartmental hemorrhage (MCH), multi-focal intracerebral hemorrhage (MFH), and focal intracerebral hemorrhage (fICH). Outcomes were recorded as non-routine discharge and mortality.
Results:
We found a total of 35 out of 5227 patients with COVID-19 that had hemorrhage of some kind. Mortality for the entire cohort was 45.7 % (n = 16). SDH patients had a mortality rate of 35.3 % (n = 6), SAH had a mortality of 50 % (n = 1), MCH patients had a mortality of 71.4 % (n = 5), MFH patients had a mortality of 50 % (n = 2), fICH patients had a mortality of 40 % (n = 2). Patients with severe pulmonary COVID requiring mechanical ventilation (OR 10.24 [.43-243.12] p = 0.015), with INR > 1.2 on the day of the hemorrhagic event (OR 14.36 [1.69-122.14] p = 0.015], and patients presenting with spontaneous vs. traumatic hemorrhage (OR 6.11 [.31-118.89] p = 0.023) had significantly higher risk for mortality.
Conclusions:
Hemorrhagic presentations with COVID-19 are a rare but serious way in which the illness can manifest. It is important for neurosurgeons to realize that patients can present with these findings without primary pulmonary symptoms, and that severe pulmonary symptoms, elevated INR, and spontaneous hemorrhagic presentations is associated with increased risk for mortality.
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