Diagnostic and Therapeutic Challenges of Concurrent Intracranial Hemorrhage and Cerebral Venous Thrombosis in a Patient With Acute Lymphoblastic Leukemia: A Case Report and Literature Review.

Cerebral venous sinus thrombosis (CVST) is a cerebrovascular condition due to the thrombosis of cerebral venous sinuses, leading to intracranial hemorrhage, increased intracranial pressure, focal deficit, seizure, toxic edema, encephalopathy, and death. The diagnosis and therapeutic approach of CVST remain challenging because of its highly nonspecific clinical presentation including headaches, seizures, focal neurologic deficits, and altered mental status, etc. Anticoagulation is the mainstay of CVST treatment and should be started as soon as the diagnosis is confirmed. Here, we present the case of a 34-year-old male construction worker who presented to the emergency department with a complaint of right chest wall pain and swelling. He was admitted to the hospital following a diagnosis of anterior chest wall abscess and mediastinitis. During hospitalization, his complete blood count revealed pancytopenia with blast cells, and bone marrow biopsy revealed 78.5% lymphoid blasts by aspirate differential count and hypercellular marrow (100%) with decreased hematopoiesis. He developed concurrent CVST and intracranial hemorrhage while receiving CALGB10403 (vincristine, daunorubicin, pegaspargase, prednisone) with intrathecal cytarabine induction chemotherapy for acute lymphoblastic leukemia (ALL). The patient failed two standard chemotherapy for ALL and achieved remission while on third-line chemotherapy with an anti-CD19 monoclonal antibody, blinatumomab. Although this patient had an MRI scan of the brain with multiple follow-up non-contrast CT scans, it was CT angiography that revealed CVST. This showed the diagnostic challenge in CVST, with CT and MRI venography having excellent sensitivity in diagnosing CVST. Risk factors for CVST in our patient were ALL and its intensive induction chemotherapy with pegaspargase.

Neuropathogenesis and Neurological Manifestations of SARS-CoV-2

Neurological complications of COVID-19 contribute significantly to mortality in the intensive care unit (ICU). Preventive therapy, though discussed in literature, is limited for COVID-19 neurological manifestations and treatment algorithms continue to rely on evidence from previous pandemics. Thus, in this chapter we evaluate current in vitro, in vitro, histopathological studies to ascertain the most likely mechanisms of SARS-CoV-2 central nervous system entry. From this understanding, we determine probable mechanisms for neurological compilations observed in COVID-19 as relevant to the clinician. SARS-CoV-2 infection of nasal epithelium and the respiratory tract may allow for a systemic inflammatory response that results in neuroinflammation. While most neurological complications are inflammatory in etiology, rarely, SARS-CoV-2 may enter into the central nervous system and mediate neuronal damage. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.

COVID-19 and stroke: A review.

COVID-19 patients have presented with a wide range of neurological disorders, among which stroke is the most devastating. We have reviewed current studies, case series, and case reports with a focus on COVID-19 patients complicated with stroke, and presented the current understanding of stroke in this patient population. As evidenced by increased D-dimer, fibrinogen, factor VIII and von Willebrand factor, SARS-CoV-2 infection induces coagulopathy, disrupts endothelial function, and promotes hypercoagulative state. Collectively, it predisposes patients to cerebrovascular events. Additionally, due to the unprecedented strain on the healthcare system, stroke care has been inevitably compromised. The underlying mechanism between COVID-19 and stroke warrants further study, so does the development of an effective therapeutic or preventive intervention.

Intracranial Hemorrhage After Pfizer-BioNTech (BNT162b2) mRNA COVID-19 Vaccination: A Case Report.

The Coronavirus 2019 (COVID-19) pandemic has affected over 700 million people worldwide and caused nearly 7 million deaths. Vaccines currently developed or in development are the most effective tools for curbing the pandemic and mitigating its impacts. In Turkey, inoculation with the Pfizer-BioNTech COVID-19 vaccine (BNT162b2, also known as tozinameran) has been approved. We report a 56-year-old female patient with underlying essential hypertension who experienced intracranial hemorrhage after receiving her first dose of tozinameran. The patient underwent immediate surgical evacuation of the hematoma, during which a left middle cerebral artery bifurcation aneurysm was macroscopically identified and clipped. The patient was pronounced deceased on the second postoperative day. This is the second case of intracranial hemorrhage following tozinameran administration caused by a ruptured middle cerebral artery bifurcation aneurysm. Upon analyzing the case, there might be a connection between the vaccine's potential immune-triggering effect on hemodynamic patterns and the rupture of the previously unknown cerebral aneurysm. However, these severe complications do not justify avoiding vaccines; further studies are needed. This study emphasizes the need for increased vigilance in patients with underlying systemic comorbidities who have recently been vaccinated and to share our insights into the potential relationship between tozinameran and intracranial hemorrhage.

Intracranial hemorrhage in patients treated for SARS-CoV-2 with extracorporeal membrane oxygenation: A systematic review and meta-analysis.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is routinely used in patients with severe respiratory failure and has been increasingly needed during the COVID-19 pandemic. In patients treated with ECMO, significant intracranial hemorrhage (ICH) risk exists due to circuit characteristics, anticoagulation, and disease characteristics. ICH risk may be substantially higher in COVID-19 patients than patients treated with ECMO for other indications. METHODS: We systematically reviewed current literature regarding ICH during ECMO treatment of COVID-19. We utilized Embase, MEDLINE, and Cochrane Library databases. Meta-analysis was performed for included comparative studies. Quality assessment was performed using MINORS criteria. RESULTS: A total of 54 studies with 4000 ECMO patients were included, all retrospective. Risk of bias was increased via MINORS score primarily due to retrospective designs. ICH was more likely in COVID-19 patients (RR 1.72, 95% CI 1.23, 2.42). Mortality among COVID patients on ECMO with ICH was 64.0%, compared with 41% in patients without ICH (RR1.9, 95% 1.44, 2.51). CONCLUSION: This study suggests increased hemorrhage rates in COVID-19 patients on ECMO compared to similar controls. Hemorrhage reduction strategies may include atypical anticoagulants, conservative anticoagulation strategies, or biotechnology advances in circuit design and surface coatings.

Evaluation of organ donation process and affecting factors in COVID-19 pandemic

Objectives: More than six million people worldwide are affected by end-stage organ failure and the COVID- 19 pandemic has dramatically changed organ and tissue donation. Methods: The data of patients diagnosed with brain death between July 2018-March 2020 (pre-pandemic period) and April 2020-December 2021 (pandemic period) were analyzed retrospectively. Donor characteristics, laboratory levels, time from intensive care admission to determination of brain death, time to family approval, family approval rates and organ types were analyzed. Results: The mean age of 56 patients with pre-pandemic diagnosis of brain death was 61.82 ± 21.39 years, 37 (63%) patients were donors and 53 organs were obtained. Mean age of 39 patients diagnosed with brain death during the pandemic was 58.26 ± 18.02 years and 38 organs were obtained from 21 (52.5%) donors. Between the two periods, there was a decrease of 30.35% in the diagnosis of brain death, 43.24% in the number of donors and 26.41% in the number of organs supplied. The most common cause of brain death was intracranial hemorrhage during both periods. While the time elapsed between family interview and surgery was 9.33 ± 2.19 hours before the pandemic, it was 15.29 ± 4.28 hours during the pandemic period (p = 0.01). There was a significant difference between C-reactive protein levels at the time of diagnosis of brain death (p < 0.05). Staphylococcus haemolyticus was most frequently seen in blood culture. Conclusions: Brain death and organ donation have decreased significantly during the pandemic period compared to previous years, similar to research conducted in different countries and regions. Due to COVID- 19, prolonged stays in the intensive care unit (ICU) may pose a risk of infection in ICU donors, and care should be taken in terms of donor loss. [ FROM AUTHOR] Copyright of European Research Journal is the property of Prusa Medical Publishing and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

SARS-CoV-2 infection increases risk of intracranial hemorrhage.

Introduction: SARS-CoV-2 virus infection causes a dysbalanced and severe inflammatory response, including hypercytokinemia and immunodepression. Systemic inflammation triggered by a viral infection can potentially cause vascular damage, which may lead to cardiovascular and neurovascular events. Research question: The aim was to investigate whether CNS complications are related to COVID-19. Materials and methods: We examined 21 patients suffering from stroke and intracranial hemorrhage (ICH) and 9 (43%) of them were male. We compared relative frequencies using Fisher's exact test. As we had few observations and many variables, we used principal component analysis (PCA) to reduce data dimensionality. We trained a linear support vector machine (SVM) on the first two PCs of the laboratory data to predict COVID-19. Results: Patients suffering from stroke had either hypertension or SARS-CoV-2 infection, but seldom both (OR = 0.05, p = 0.0075). The presence of SARS-CoV-2 infection was strongly associated with the logarithm of CRP (p = 1.4e-07) and with D-DIMER (p = 1.6e-05) and moderately with PT (p = 0.0024). SARS-CoV-2 infection was not related to any other factor. CRP, D-DIMER, PT, and INR were all related to each other (R 2 ranging from 0.19 to 0.52, p ranging from 0.012 to < 0.0001). The first two PCs covered 96% of the variance in the four variables. Using them, perfect linear discrimination between patients suffering from COVID-19 and other patients could be achieved. Discussion and conclusion: SARS-CoV-2 infection causes systemic inflammation, which is suggested as a predictor of the severe course of ICH. SARS-CoV-2 infection is an additional risk factor for vascular complications.

Outcome of COVID-19-Associated Acute Stroke: A Study from South India.

Background and Objective: Coronavirus 2019 (COVID-19) infection is prevalent worldwide. COVID-19 infection can lead to various neurological disorders including acute stroke. We investigated the functional outcome and its determinants among our patients with acute stroke associated with COVID-19 infection in the present setup. Materials and Methods: This study is a prospective study in which we recruited acute stroke patients with COVID-19 positivity. Data on duration of COVID-19 symptoms and type of acute stroke were recorded. All patients underwent stroke subtype workup and measurement of D-dimer, C-reactive protein (CRP), lactate-dehydrogenase (LDH), procalcitonin, interleukin-6, and ferritin levels. Poor functional outcome was defined by modified Rankin score (mRS) ≥3 at 90 days. Results: During the study period, 610 patients were admitted for acute stroke, of whom 110 (18%) tested positive for COVID-19 infection. Majority (72.7%) were men with a mean age of 56.5 years and mean duration of COVID-19 symptoms for 6.9 days. Acute ischemic and hemorrhagic strokes were observed in 85.5% and 14.5% patients, respectively. Poor outcome was observed in 52.7%, including in-hospital mortality in 24.5% patients. COVID-19 symptoms ≤5 days (odds ratio [OR]: 1.41, 95% confidence interval [CI]: 1.20-2.99), CRP positivity (OR: 1.97, 95% CI: 1.41-4.87), elevated levels of D-dimer (OR: 2.11, 95% CI: 1.51-5.61), interleukin-6 (OR: 1.92, 95% CI: 1.04-4.74), and serum ferritin (OR: 2.4, 95% CI: 1.02-6.07), and cycle threshold (Ct) value ≤25 (OR: 8.8, 95% CI: 6.52-12.21) were independent predictors of poor outcome. Conclusion: Poor outcomes were relatively higher among acute stroke patients with concomitant COVID-19 infection. In the present study, we established the independent predictors of poor outcome to be onset of COVID-19 symptoms (<5 days) and elevated levels of CRP, D-dimer, interleukin-6, ferritin, and Ct value ≤25 in acute stroke.

A 14-year-old boy with multiple trauma and bilateral basal ganglia hemorrhage due to coronavirus disease 2019: a case report.

BACKGROUND: In December 2019, coronavirus disease 2019 spread worldwide, causing acute respiratory distress syndrome. Coronavirus disease 2019 presents from an asymptomatic infection to severe disease causing multiorgan failure. Neurological manifestations were observed in some patients, including intracerebral hemorrhage. Bilateral basal ganglia hemorrhage is rare due to trauma. CASE PRESENTATION: Our patient was a 14-year-old Iranian boy with multiple trauma and loss of consciousness who tested positive for coronavirus disease 2019. The brain computed tomography scan reported bilateral basal ganglia hemorrhage. Bilateral ground glass opacity was reported through a chest computed tomography scan. DISCUSSION AND CONCLUSIONS: In this study, we reported a 14-year-old boy referred to the emergency room due to multiple trauma. Through the medical interventions, bilateral basal ganglia hemorrhage was discovered incidentally. Coronavirus disease 2019 was detected in this patient on the basis of findings in chest computed tomography scan and positive real reverse transcription polymerase chain reaction test. Several clinical reports and series exploring the relationship between coronavirus disease 2019 and ischemic strokes have been published. Coronavirus disease 2019, like other acute respiratory syndromes, can invade the central nervous system through hematogenous and neuronal dissemination or it can be an immune response to the cytokine storm. In conclusion, it is vital to know the pathophysiology of the neurological manifestations of coronavirus disease 2019 and prevent the mild neurological manifestations leading to severe conditions.

Patterns of acute ischemic stroke and intracranial hemorrhage in patients with COVID-19 : Results of a retrospective multicenter neuroimaging-based study from three central European countries.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is an infection which can affect the central nervous system. In this study, we sought to investigate associations between neuroimaging findings with clinical, demographic, blood and cerebrospinal fluid (CSF) parameters, pre-existing conditions and the severity of acute COVID-19. MATERIALS AND METHODS: Retrospective multicenter data retrieval from 10 university medical centers in Germany, Switzerland and Austria between February 2020 and September 2021. We included patients with COVID-19, acute neurological symptoms and cranial imaging. We collected demographics, neurological symptoms, COVID-19 severity, results of cranial imaging, blood and CSF parameters during the hospital stay. RESULTS: 442 patients could be included. COVID-19 severity was mild in 124 (28.1%) patients (moderate n = 134/30.3%, severe n = 43/9.7%, critical n = 141/31.9%). 220 patients (49.8%) presented with respiratory symptoms, 167 (37.8%) presented with neurological symptoms first. Acute ischemic stroke (AIS) was detected in 70 (15.8%), intracranial hemorrhage (IH) in 48 (10.9%) patients. Typical risk factors were associated with AIS; extracorporeal membrane oxygenation therapy and invasive ventilation with IH. No association was found between the severity of COVID-19 or blood/CSF parameters and the occurrence of AIS or IH. DISCUSSION: AIS was the most common finding on cranial imaging. IH was more prevalent than expected but a less common finding than AIS. Patients with IH had a distinct clinical profile compared to patients with AIS. There was no association between AIS or IH and the severity of COVID-19. A considerable proportion of patients presented with neurological symptoms first. Laboratory parameters have limited value as a screening tool.

A Non-traumatic Non-aneurysmal Subarachnoid Hemorrhage in a Mild COVID-19 Infection: A Case Report.

Both subarachnoid hemorrhage and intraparenchymal hemorrhage have been reported in patients with coronavirus disease 2019 (COVID-19) infection. We report a 38-year-old male patient who was initially admitted for alcoholic hepatitis and had a mild COVID-19 infection that was confirmed 10 days prior to presentation. During his hospitalization, he reported worsening of his occipital headache that started when he tested positive for COVID-19. Neurological examination was intact and no history of trauma, hypertension, illicit drug use, or family history of brain aneurysm was reported. Investigating his worsening headache revealed a tiny, right-sided, posterior subarachnoid hemorrhage. No coagulopathy was evident. No aneurysm was seen on the cerebral angiogram. The patient was managed conservatively. This case raises the point of the importance of investigating headaches even in mild COVID-19 infection, as it may herald intracranial bleeding.

Global Impact of the COVID-19 Pandemic on Stroke Volumes and Cerebrovascular Events: One-Year Follow-up.

BACKGROUND AND OBJECTIVES: Declines in stroke admission, intravenous thrombolysis, and mechanical thrombectomy volumes were reported during the first wave of the COVID-19 pandemic. There is a paucity of data on the longer-term effect of the pandemic on stroke volumes over the course of a year and through the second wave of the pandemic. We sought to measure the impact of the COVID-19 pandemic on the volumes of stroke admissions, intracranial hemorrhage (ICH), intravenous thrombolysis (IVT), and mechanical thrombectomy over a one-year period at the onset of the pandemic (March 1, 2020, to February 28, 2021) compared with the immediately preceding year (March 1, 2019, to February 29, 2020). METHODS: We conducted a longitudinal retrospective study across 6 continents, 56 countries, and 275 stroke centers. We collected volume data for COVID-19 admissions and 4 stroke metrics: ischemic stroke admissions, ICH admissions, intravenous thrombolysis treatments, and mechanical thrombectomy procedures. Diagnoses were identified by their ICD-10 codes or classifications in stroke databases. RESULTS: There were 148,895 stroke admissions in the one-year immediately before compared to 138,453 admissions during the one-year pandemic, representing a 7% decline (95% confidence interval [95% CI 7.1, 6.9]; p<0.0001). ICH volumes declined from 29,585 to 28,156 (4.8%, [5.1, 4.6]; p<0.0001) and IVT volume from 24,584 to 23,077 (6.1%, [6.4, 5.8]; p<0.0001). Larger declines were observed at high volume compared to low volume centers (all p<0.0001). There was no significant change in mechanical thrombectomy volumes (0.7%, [0.6,0.9]; p=0.49). Stroke was diagnosed in 1.3% [1.31,1.38] of 406,792 COVID-19 hospitalizations. SARS-CoV-2 infection was present in 2.9% ([2.82,2.97], 5,656/195,539) of all stroke hospitalizations. DISCUSSION: There was a global decline and shift to lower volume centers of stroke admission volumes, ICH volumes, and IVT volumes during the 1st year of the COVID-19 pandemic compared to the prior year. Mechanical thrombectomy volumes were preserved. These results suggest preservation in the stroke care of higher severity of disease through the first pandemic year. TRIAL REGISTRATION INFORMATION: This study is registered under NCT04934020.

Impact of COVID-19 on neurocritical care delivery and outcomes in patients with severe acute brain injury - Assessing the initial response in the first US epicenter.

To investigate the pandemic's impact on critically ill patients with neurological emergencies, we compared care metrics and outcomes of patients with severe acute brain injury (SABI) before and during the initial COVID-19 surge at our institution. We included adult patients with SABI during two separate three-month time periods: 'pre-COVID vs COVID'. We further stratified the COVID cohort to characterize outcomes in patients requiring COVID-19 precautions (Patient Under Investigation, 'PUI'). The primary endpoint was in-hospital mortality; secondary endpoints included length of stay (LOS), diagnostic studies performed, time to emergent decompressive craniectomies (DCHC), ventilator management, and end-of-life care. We included 394 patients and found the overall number of admissions for SABI declined by 29 % during COVID (pre-COVID n = 231 vs COVID, n = 163). Our primary outcome of mortality and most secondary outcomes were similar between study periods. There were more frequent extubation attempts (72.1 % vs 76 %) and the mean time to extubation was shorter during COVID (55.5 h vs 38.2 h). The ICU LOS (6.10 days vs 4.69 days) and hospital LOS (15.32 days vs 11.74 days) was shorter during COVID. More PUIs died than non-PUIs (51.7 % vs 11.2 %), but when adjusted for markers of illness severity, this was not significant. We demonstrate the ability to maintain a consistent care delivery for patients with SABI during the pandemic at our institution. PUIs represent a population with higher illness severity at risk for delays in care. Multicenter, longitudinal studies are needed to explore the impact of the pandemic on patients with acute neurological emergencies.

Ischemic stroke and intracranial hemorrhage in extracorporeal membrane oxygenation for COVID-19: A systematic review and meta-analysis.

PURPOSE: Extracorporeal membrane oxygenation (ECMO) is employed to support critically ill COVD-19 patients. The occurrence of ischemic stroke and intracranial hemorrhage (ICH), as well as the implementation of anticoagulation strategies under the dual influence of ECMO and COVID-19 remain unclear. We conducted a systematic review and meta-analysis to describe the ischemic stroke, ICH and overall in-hospital mortality in COVID-19 patients receiving ECMO and summarize the anticoagulation regimens. METHODS: EMBASE, PubMed, Cochrane, and Scopus were searched for studies examining ischemic stroke, ICH, and mortality in COVID-19 patients supported with ECMO. The outcomes were incidences of ischemic stroke, ICH, overall in-hospital mortality and anticoagulation regimens. We calculated the pooled proportions and 95% confidence intervals (CIs) to summarize the results. RESULTS: We analyzed 12 peer-reviewed studies involving 6039 COVID-19 patients. The incidence of ischemic stroke had a pooled estimate of 2.2% (95% CI: 1.2%-3.2%). The pooled prevalence of ICH was 8.0% (95% CI: 6.3%-9.6%). The pooled estimate of overall in-hospital mortality was 40.3% (95% CI: 33.1%-47.5%). The occurrence of ICH was significantly higher in COVID-19 patients supported with ECMO than in other respiratory ECMO [relative risk=1.75 (95% CI: 1.00-3.07)]. Unfractionated heparin was the most commonly used anticoagulant, and anticoagulation monitoring practice varied among centers. CONCLUSIONS: Ischemic stroke and ICH were common under the double "hit" of COVID-19 and ECMO. The prevalence of ICH was significantly higher in COVID-19 patients supported with ECMO than non-COVID-19 patients requiring ECMO. Individualized anticoagulation regimens may be a good choice to balance thrombosis and bleeding. More detailed research and further exploration are needed to clarify the underlying mechanism and clinical management decisions.

Ad26.COV2.S Vaccine-Induced Thrombocytopenia Leading to Dural Sinus Thrombosis and Intracranial Hemorrhage Requiring Hemicraniectomy: A Case Report and Systematic Review.

The coronavirus disease 2019 (COVID-19) pandemic has claimed nearly 5.5 million lives worldwide. Adenovirus-based vaccines are safe and effective, but they are rarely associated with vaccine-induced thrombosis and thrombocytopenia (VITT) as well as cerebral venous sinus thrombosis (CVST). We conducted a systematic literature search of intracerebral hemorrhage (ICH) secondary to CVST associated with VITT from the Ad26.COV2.S vaccine, and we present the first case of this pathology in the reviewed literature of a patient who required neurosurgical decompression. The systematic literature review was completed on December 19, 2021, by searching PubMed and Ovid for articles with primary data on CVST associated with VITT following the Ad26.COV2.S vaccine. We also specifically searched for cases that required neurosurgical intervention. Articles were independently screened by two authors, and both secondary and tertiary searches were done as well. Descriptive statistics were collected and presented in table form. Nine studies were identified that met inclusion criteria. There were no cases identified of patients who underwent neurosurgical decompression after developing this pathology. We thus present the first case in the reviewed literature of a patient who developed ICH after receiving the Ad26.COV2.S vaccine and underwent decompressive hemicraniectomy. Despite severe thrombocytopenia and prolonged intensive care, the patient was discharged to neurorehabilitation. There is a much greater risk of CVST and ICH during COVID-19 infections than from the vaccines. However, as booster vaccines are approved and widely distributed, it is critical to make prompt, accurate diagnoses of this vaccine-related complication and consider neurosurgical decompression.

Intracranial hemorrhage in a patient with severe COVID-19 acute respiratory distress syndrome on Veno-venous extra corporeal membrane oxygenation: A case report.

INTRODUCTION AND IMPORTANCE: COVID-19 can lead to severe acute respiratory distress syndrome (ARDS) where Veno-Venous Extra Corporeal Membrane Oxygenation (V-V ECMO) may be utilized for patients with severe respiratory failure. Our case report highlights a life threatening complication of V-V ECMO - intracranial hemorrhage (ICH), in a patient being treated for severe COVID-19 ARDS. CASE PRESENTATION: A 41-year-old male of Indian ethnicity with no known comorbidities presented with an 8 day history of fever and dyspnoea. The patient was diagnosed with COVID-19 through a positive RT PCR test and his clinical condition progressively deteriorated requiring mechanical ventilation. Inspite of lung protective ventilation strategies and prone ventilation, there was no improvement in oxygenation. Therefore, the patient was placed on extra corporeal life support. On day three of V-V ECMO, the patient developed anisocoria and his GCS dropped to E1VTM1. A non-contrast CT brain scan revealed a large intraparenchymal hemorrhage in the right frontoparietal lobe with an extension into the right lateral and third ventricles leading to an emergency decompressive craniectomy with lax duroplasty.Post intracranial hemorrhage,ECMO support was continued without systemic anticoagulation. Despite a transient improvement in his GCS post surgery, the patient eventually succumbed to refractory septic shock with multi organ dysfunction syndrome. CLINICAL DISCUSSION AND CONCLUSION: Balancing anticoagulation therapy is one of the biggest challenges in managing ECMO support for COVID-19 ARDS. ICH is a rare and potentially fatal complication of V-V ECMO with an apparently higher incidence among COVID-19 patients. Neurosurgical procedures may be considered in such patients when no other possible management strategies are available (and the risk of death is imminent).

Intracranial Hemorrhage Due to Potential Rupture of an Arteriovenous Malformation after BNT162b2 COVID-19 mRNA Vaccination in a Young Korean Woman: Case Report.

Inoculation with the Pfizer-BioNTech coronavirus infection-19 (COVID-19) vaccine (BNT162b2) has been approved in Korea. Although it is generally safe, several possible side effects have been reported. The present report describes a 28-year-old woman who developed an intracerebral hemorrhage in her right temporal lobe after the first dose of the Pfizer-BioNTech COVID-19 vaccine. The patient complained of a persistent headache for four days after the first dose, along with right third nerve palsy and drowsiness. Non-enhanced brain computed tomography confirmed a 5.0 × 3.7 × 5.0 cm3-sized intracranial hemorrhage in the right temporal lobe due to the rupture of an arteriovenous malformation (AVM). Transfemoral cerebral angiography revealed that blood was supplied to the AVM by the right middle cerebral artery branch and drained into the right transverse sinus. The patient underwent surgical treatment for AVM nidus removal with hematoma evacuation on the day of admission. Her condition stabilized 10 days postoperatively. These findings indicate that clinicians should be aware that cerebral hemorrhage caused by AVM rupture may be a side effect of inoculation with the BNT162b2 mRNA COVID-19 vaccine.

COVID-19 and Intracranial Hemorrhage: A Multicenter Case Series, Systematic Review and Pooled Analysis.

INTRODUCTION: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) profoundly impacts hemostasis and microvasculature. In the light of the dilemma between thromboembolic and hemorrhagic complications, in the present paper, we systematically investigate the prevalence, mortality, radiological subtypes, and clinical characteristics of intracranial hemorrhage (ICH) in coronavirus disease (COVID-19) patients. METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we performed a systematic review of the literature by screening the PubMed database and included patients diagnosed with COVID-19 and concomitant ICH. We performed a pooled analysis, including a prospectively collected cohort of critically ill COVID-19 patients with ICH, as part of the PANDEMIC registry (Pooled Analysis of Neurologic Disorders Manifesting in Intensive Care of COVID-19). RESULTS: Our literature review revealed a total of 217 citations. After the selection process, 79 studies and a total of 477 patients were included. The median age was 58.8 years. A total of 23.3% of patients experienced the critical stage of COVID-19, 62.7% of patients were on anticoagulation and 27.5% of the patients received ECMO. The prevalence of ICH was at 0.85% and the mortality at 52.18%, respectively. CONCLUSION: ICH in COVID-19 patients is rare, but it has a very poor prognosis. Different subtypes of ICH seen in COVID-19, support the assumption of heterogeneous and multifaceted pathomechanisms contributing to ICH in COVID-19. Further clinical and pathophysiological investigations are warranted to resolve the conflict between thromboembolic and hemorrhagic complications in the future.

INTRACRANIAL HEMORRHAGE DURING THE USE OF VENOVENOUS ECMO IN COVID 19: A CASE SERIES

Despite ECMO being a valid option there have been reported complications possibly due to viral pathophysiology posing unique perturbations not seen in other cases of acute respiratory distress syndrome (ARDS). Deliberation of risks, benefits, and neurologic assessments prior to initiation of VVECMO in patients with COVID-19 ARDS needs to be taken. B Introduction/Hypothesis: b The COVID-19 outbreak was declared a pandemic by the World Health Organization on March 11, 2020. [Extracted from the article] Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)