SARS-CoV-2 triggered seizure complicated by fatal subdural hematoma under edoxaban and clopidogrel

SARS-CoV-2 associated coagulopathy may manifest as hypocoagulability with a propensity for bleeding. Here we report a COVID-19 patient with fatal subdural hematoma (SDH) shortly after thrombendarteriectomy (TEA), and anticoagulation together with anti-thrombotic treatment. A 83-year-old male developed sudden-onset fever triggering a first ever tonic-clonic seizure. His previous history was positive for diabetes, hypertension, hyperlipidemia, aorto-coronary bypass grafting, percutaneous, transluminal coronary angioplasty with stent implantation, peripheral occlusive artery disease with percutaneous, transluminal angioplasty of the left popliteal artery, hypoacusis, and atrial fibrillation. He had undergone TEA 10 days prior to admission because of a non-symptomatic, right-sided 70% common carotid artery stenosis. He was on clopidogrel and edoxaban on admission. He presented with coma, non-reacting, unrounded pupils, stretch synergisms, reduced tendon reflexes, and positive pyramidal signs. Cerebral CT revealed an extensive SDH over the left hemisphere with edema and mass effect and a midline shift to the right. After acute decompression surgery had been declined, the patient expired a few hours after admission. Fatal SDH may occur under clopidogrel and edoxaban during a mild COVID-19 disease after a seizure triggered by fever. Whether hypocoagulation due to COVID-19 increased the bleeding risk and thus contributed to the fatal bleeding remains speculative, but is conceivable.