Hemorrhagic transformation in SARS-CoV-2 infected patients: case reports from Indonesia

Retnaningsih Retnaningsih; Dodik Tugasworo; Yovita Andhitara; Rahmi Ardhini; Aditya Kurnianto; Jacob Bunyamin; Fatiha Sri Utami; Ida Ayu Sogata; Hairuzaman Hairuzaman

doi:10.15562/bmj.v10i3.2254

Hemorrhagic transformation in SARS-CoV-2 infected patients: case reports from Indonesia

Retnaningsih Retnaningsih ,

Dodik Tugasworo ,

Yovita Andhitara ,

Rahmi Ardhini ,

Aditya Kurnianto ,

Jacob Bunyamin ,

Fatiha Sri Utami ,

Ida Ayu Sogata ,

Hairuzaman Hairuzaman ,

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DOI: https://doi.org/10.15562/bmj.v10i3.2254 |
Published: 2021-12-27

Abstract

Introduction:While initially suggested as a primary respiratory infection, there has been increasing proof that the novel coronavirus disease (COVID-19) also leads to severe neurological manifestation particularly ischemic stroke. The hypercoagulable state observed in COVID-19 patients is thought to contribute to this phenomenon although the exact pathophysiology is still unclear.

Case: We are reporting two cases of hemorrhagic transformation after ischemic stroke in COVID-19 patients. Both patients were women presenting with ischemic stroke and bronchopneumonia due to COVID-19. They both experienced prolonged coagulation studies before sudden neurological deterioration. Evaluation CT scan demonstrated the hemorrhagic transformation of infarction. It is still unknown whether the coagulation disruption is primarily caused due to viral activity or secondary due to the inflammatory response. Hemorrhagic transformation is a complication of ischemic stroke, particularly in post-thrombolysis patients. However COVID-19 coagulopathy was thought to induce such event in COVID-19 patients presented with ischemic stroke.

Conclusion: Although ischemic stroke has been widely reported in COVID-19 patients, there have been a few reports of hemorrhagic transformation events. This may lead to an increased understanding regarding COVID-19 pathophysiology and cerebrovascular disease.

References

Mahase E. Covid-19: death rate is 0.66% and increases with age, study estimates. BMJ. 2020;369:m1327. doi: 10.1136/bmj.m1327.
Abou-Ismail MY, Diamond A, Kapoor S, Arafah Y, Nayak L. The hypercoagulable state in COVID-19: Incidence, pathophysiology, and management. Thromb Res. 2020;194:101-115. doi: 10.1016/j.thromres.2020.06.029.
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):683–90.
Ahmed MU, Hanif M, Ali MJ, Haider MA, Kherani D, Memon GM, et al. Neurological Manifestations of COVID-19 (SARS-CoV-2): A Review. Front Neurol. 2020;11:1–9.
Beyrouti R, Adams ME, Benjamin L, Cohen H, Farmer SF, Goh YY, et al. Characteristics of ischaemic stroke associated with COVID-19. J Neurol Neurosurg Psychiatry. 2020;0(0):8–11.
Saggese CE, Del Bianco C, Di Ruzza MR, Magarelli M, Gandini R, Plocco M. COVID-19 and Stroke: Casual or Causal Role? Cerebrovasc Dis. 2020;49(3):341-344. doi: 10.1159/000509453.
Szegedi I, Orbán-Kálmándi R, Csiba L, Bagoly Z. Stroke as a Potential Complication of COVID-19-Associated Coagulopathy: A Narrative and Systematic Review of the Literature. J Clin Med. 2020;9(10):3137.
Merkler AE, Parikh NS, Mir S, Gupta A, Kamel H, Lin E, Lantos J, Schenck EJ, Goyal P, Bruce SS, Kahan J, Lansdale KN, LeMoss NM, Murthy SB, Stieg PE, Fink ME, Iadecola C, Segal AZ, Cusick M, Campion TR Jr, Diaz I, Zhang C, Navi BB. Risk of Ischemic Stroke in Patients With Coronavirus Disease 2019 (COVID-19) vs Patients With Influenza. JAMA Neurol. 2020;77(11):1–7. doi: 10.1001/jamaneurol.2020.2730.
Aggarwal M, Dass J, Mahapatra M. Hemostatic Abnormalities in COVID-19: An Update. Indian J Hematol Blood Transfus. 2020;36(4):616–26. https://doi.org/10.1007/s12288-020-01328-2
Yi X, Wang L, Liang A, Gong Z. Severe Acute Respiratory Syndrome and Venous Thromboembolism in Multiple Organs To the Editor : The University of Nottingham Division of General Hospital of Guangzhou Military Region. Am J Respir Crit Care Med. 2010;182:436–7.
Spiezia L, Boscolo A, Poletto F, Cerruti L, Tiberio I, Campello E, et al. COVID-19-Related Severe Hypercoagulability in Patients Admitted to Intensive Care Unit for Acute Respiratory Failure. Thromb Haemost. 2020;120(6):998–1000.
Dogra S, Jain R, Cao M, Bilaloglu S, Zagzag D, Hochman S, et al. Hemorrhagic stroke and anticoagulation in COVID-19. J Stroke Cerebrovasc Dis. 2020;29(8):1–6.
Sharifi-Razavi A, Karimi N, Rouhani N. COVID-19 and intracerebral haemorrhage: causative or coincidental?. New Microbes New Infect. 2020;35:0–1.
Melmed KR, 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. 2020;(0123456789).
Jickling GC, Liu D, Stamova B, Ander BP, Zhan X, Lu A, et al. Hemorrhagic transformation after ischemic stroke in animals and humans. J Cereb Blood Flow Metab. 2014;34(2):185–99.
Bagoly Z, Szegedi I, Kálmándi R, Tóth NK, Csiba L. Markers of coagulation and fibrinolysis predicting the outcome of acute ischemic stroke thrombolysis treatment: A review of the literature. Front Neurol. 2019;10:1–13.
Trouillas P, Derex L, Philippeau F, Nighoghossian N, Honnorat J, Hanss M, et al. Early fibrinogen degradation coagulopathy is predictive of parenchymal hematomas in cerebral rt-PA thrombolysis: A study of 157 cases. Stroke. 2004;35(6):1323–8.
Dakay K, Kaur G, Mayer SA, Santarelli J, Gandhi C, Al-Mufti F. Cerebral Herniation Secondary to Stroke-Associated Hemorrhagic Transformation, Fulminant Cerebral Edema in Setting of COVID-19 Associated ARDS and Active Malignancy. J Stroke Cerebrovasc Dis. 2020;29(12):105397. https://doi.org/10.1016/j.jstrokecerebrovasdis.2020.105397.

[1] Mahase E. Covid-19: death rate is 0.66% and increases with age, study estimates. BMJ. 2020;369:m1327. doi: 10.1136/bmj.m1327.

[2] Abou-Ismail MY, Diamond A, Kapoor S, Arafah Y, Nayak L. The hypercoagulable state in COVID-19: Incidence, pathophysiology, and management. Thromb Res. 2020;194:101-115. doi: 10.1016/j.thromres.2020.06.029.

[3] 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):683–90.

[4] Ahmed MU, Hanif M, Ali MJ, Haider MA, Kherani D, Memon GM, et al. Neurological Manifestations of COVID-19 (SARS-CoV-2): A Review. Front Neurol. 2020;11:1–9.

[5] Beyrouti R, Adams ME, Benjamin L, Cohen H, Farmer SF, Goh YY, et al. Characteristics of ischaemic stroke associated with COVID-19. J Neurol Neurosurg Psychiatry. 2020;0(0):8–11.

[6] Saggese CE, Del Bianco C, Di Ruzza MR, Magarelli M, Gandini R, Plocco M. COVID-19 and Stroke: Casual or Causal Role? Cerebrovasc Dis. 2020;49(3):341-344. doi: 10.1159/000509453.

[7] Szegedi I, Orbán-Kálmándi R, Csiba L, Bagoly Z. Stroke as a Potential Complication of COVID-19-Associated Coagulopathy: A Narrative and Systematic Review of the Literature. J Clin Med. 2020;9(10):3137.

[8] Merkler AE, Parikh NS, Mir S, Gupta A, Kamel H, Lin E, Lantos J, Schenck EJ, Goyal P, Bruce SS, Kahan J, Lansdale KN, LeMoss NM, Murthy SB, Stieg PE, Fink ME, Iadecola C, Segal AZ, Cusick M, Campion TR Jr, Diaz I, Zhang C, Navi BB. Risk of Ischemic Stroke in Patients With Coronavirus Disease 2019 (COVID-19) vs Patients With Influenza. JAMA Neurol. 2020;77(11):1–7. doi: 10.1001/jamaneurol.2020.2730.

[9] Aggarwal M, Dass J, Mahapatra M. Hemostatic Abnormalities in COVID-19: An Update. Indian J Hematol Blood Transfus. 2020;36(4):616–26. https://doi.org/10.1007/s12288-020-01328-2

[10] Yi X, Wang L, Liang A, Gong Z. Severe Acute Respiratory Syndrome and Venous Thromboembolism in Multiple Organs To the Editor : The University of Nottingham Division of General Hospital of Guangzhou Military Region. Am J Respir Crit Care Med. 2010;182:436–7.

[11] Spiezia L, Boscolo A, Poletto F, Cerruti L, Tiberio I, Campello E, et al. COVID-19-Related Severe Hypercoagulability in Patients Admitted to Intensive Care Unit for Acute Respiratory Failure. Thromb Haemost. 2020;120(6):998–1000.

[12] Dogra S, Jain R, Cao M, Bilaloglu S, Zagzag D, Hochman S, et al. Hemorrhagic stroke and anticoagulation in COVID-19. J Stroke Cerebrovasc Dis. 2020;29(8):1–6.

[13] Sharifi-Razavi A, Karimi N, Rouhani N. COVID-19 and intracerebral haemorrhage: causative or coincidental?. New Microbes New Infect. 2020;35:0–1.

[14] Melmed KR, 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. 2020;(0123456789).

[15] Jickling GC, Liu D, Stamova B, Ander BP, Zhan X, Lu A, et al. Hemorrhagic transformation after ischemic stroke in animals and humans. J Cereb Blood Flow Metab. 2014;34(2):185–99.

[16] Bagoly Z, Szegedi I, Kálmándi R, Tóth NK, Csiba L. Markers of coagulation and fibrinolysis predicting the outcome of acute ischemic stroke thrombolysis treatment: A review of the literature. Front Neurol. 2019;10:1–13.

[17] Trouillas P, Derex L, Philippeau F, Nighoghossian N, Honnorat J, Hanss M, et al. Early fibrinogen degradation coagulopathy is predictive of parenchymal hematomas in cerebral rt-PA thrombolysis: A study of 157 cases. Stroke. 2004;35(6):1323–8.

[18] Dakay K, Kaur G, Mayer SA, Santarelli J, Gandhi C, Al-Mufti F. Cerebral Herniation Secondary to Stroke-Associated Hemorrhagic Transformation, Fulminant Cerebral Edema in Setting of COVID-19 Associated ARDS and Active Malignancy. J Stroke Cerebrovasc Dis. 2020;29(12):105397. https://doi.org/10.1016/j.jstrokecerebrovasdis.2020.105397.

Hemorrhagic transformation in SARS-CoV-2 infected patients: case reports from Indonesia

Abstract

References

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