Potential Mechanisms of COVID-19-related Intracranial Hemorrhage Due to Temporary Depletion of Vitamin K-dependent Coagulation Factors: An Illustrative Case.

Coronavirus disease 2019 (COVID-19)-related intracranial hemorrhage (ICH) is believed to be associated with at least one known risk factor for ICH, such as hypertension, hyperlipidemia, diabetes mellitus, severe pneumonia, or anticoagulation therapy. However, in this study, we report a case of ICH in a 14-year-old boy with mild COVID-19 infection without pneumonia who had no such risk factors. The only abnormal laboratory finding was temporary depletion of vitamin K-dependent coagulation factors. This case indicates that COVID-19 infection may cause simultaneous asymptomatic intracranial microhemorrhages and temporary depletion of vitamin K-dependent coagulation factors. This temporary depletion might transform the intracranial microhemorrhages into symptomatic ICH.

Risk of Recurrent Ischemic Stroke with Unintended Low-Dose Oral Anticoagulant Therapy and Optimal Timing of Review.

BACKGROUND: Direct oral anticoagulant (DOAC) dose is adjusted according to manufacturer's recommendations when introduced. However, subsequent changes from appropriate DOAC doses to "unintended" inappropriate low-dose DOAC (ILD) due to increased body weight (BW) or decreased serum creatinine concentration might be overlooked. We investigated outcomes in patients receiving appropriate DOAC, "intended" ILD, or unintended ILD, to determine the optimal review time for DOAC doses and associated factors. METHODS: This single-center, retrospective cohort study included inpatients receiving apixaban for stroke prevention between August 2015 and July 2017. Primary outcome was whether starting DOAC dose was selected according to manufacturer's recommendations and whether that dose remained appropriate thereafter. Secondary outcome was the incidence of recurrent ischemic stroke and intracranial bleeding during therapy. Average rates of change in BW, creatinine, and creatinine clearance (CrCl) were evaluated after hospitalization every 10 ± 3 days. RESULTS: During the study period, 120 patients received apixaban; 112 (93.3%) commenced appropriate DOAC doses, and 8 (6.7%) commenced intended ILD doses. Of the 112 patients on appropriate DOAC doses, 7 (6.3%) changed to unintended ILD doses because of increased BW (n = 4) or decreased creatinine (n = 3). The rate of recurrent ischemic stroke differed significantly between the appropriate DOAC dose and the intended or unintended ILD dose group (1.9% [2 of 105] versus 20.0% [3 of 15], P = .014). BW and renal function had stabilized after 20 ± 3 days posthospitalization. CONCLUSIONS: Receiving ILD doses, especially unintended, might be a risk factor for recurrent ischemic stroke and DOAC dose should be reviewed around 20 ± 3 days posthospitalization.

Intracerebral pneumocephalus and hemiparesis as a complication of a halo vest in a patient with multiple myeloma. Case report.

A halo orthosis is often used to immobilize the cervical spine after severe injury in patients who cannot tolerate surgery. Although complications such as pin loosening or brain abscess have been reported, there are no reported cases of hemiparesis following pneumocephalus associated with halo use. The authors report the case of a 77-year-old man with multiple myeloma who, after undergoing halo vest therapy and chemotherapy, suddenly developed hemiparesis and speech disturbance. Diagnostic neuroimaging demonstrated penetration of the inner table at the right posterior pin site and intracerebral pneumocephalus at the parietal lobe. Intraoperative inspection revealed only air and no purulent materials or cerebrospinal fluid in the cystic lesion. When a halo device is used, attention to detail in pin application, maintenance, and proper pin-site care must be undertaken to minimize complications. The tightening of the pin in cases in which late-onset loosening has occurred should not be performed. Additionally, because late loosening of the pin and pin-site infection increase the risks of complications, a halo vest should be used only as a short-term treatment, and the clinician should be aware of the possible increased risk of serious complications such as pneumocephalus or subdural abscess formation.