Spontaneous Intraparenchymal Hemorrhage in Patients with COVID-19: A Prospective Study and Literature Review

Introduction Coronavirus disease 2019 (COVID-19) is a devastating pandemic that may also affect the nervous system. One of its neurological manifestations is intracerebral hemorrhage (ICH). Data about pure spontaneous intraparenchymal hemorrhage related to COVID-19 is scarce. In this study, we present some patients with COVID-19 disease who also had spontaneous intraparenchymal hemorrhage along with a review of the literature. Methods This single-center prospective study was done among 2,862 patients with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) between March 1 and November 1, 2020. Out of 2,862 patients with SARS-CoV-2, 14 patients with neurological manifestations were assessed with a noncontrast brain computed tomography scan. Seven patients with spontaneous intraparenchymal hemorrhage were enrolled. Results All seven patients were male, with a mean age of 60.8 years old. Six patients (85.7%) only had minimal symptoms of COVID-19 without significant respiratory distress. The level of consciousness in two patients (28.5%) was less than eight, according to the Glasgow Coma Scale (GCS). Hypertension (71.4%) was the most common risk factor in their past medical history. The mean volume of hematoma was 41cc. Four patients died during hospitalization, and the others were discharged with a mean hospital stay of 42.6 days. All patients with GCS less than 11 died. Conclusion It concluded that ICH patients with COVID-19 are related to higher blood volume, cortical and subcortical location of hemorrhage, higher fatality rate, and younger age that is different to spontaneous ICH in general population. We recommend more specific neuroimaging in patients with COVID 19 such as brain magnetic resonance imaging concomitant with vascular studies in future. The impact of COVID-19 on mortality rate is not clear because of limited epidemiologic studies, but identifying the causal relationship between COVID-19 and ICH requires further clinical and laboratory studies.

Evaluation and Feasibility of a Head Positioning Intervention in Patients with Intraparenchymal Hemorrhage

Stroke caused by intraparenchymal hemorrhage (IPH) is most commonly the result of hypertension-induced blood vessel rupture in the brain and is associated with devastating disability and high rates of death. To date, no intervention has improved outcomes in IPH stroke patients; however, head elevation may be one of the most important first steps to promote clinical stability in the hyperacute stage of IPH stroke because of the risk of increased intracranial pressure (ICP) in these patients. Nursing research completed in the late 1970s and early 1980s in patients with increased ICP due to traumatic brain injury showed that elevating the head of bed (HOB) increased gravity drainage of venous blood and cerebrospinal fluid, lowering ICP, However, no study has yet been completed in a generalizable sample of hyperacute IPH stroke patients to examine serial changes in clinical stability in relation to HOB positioning. Recently, the Head Position in Stroke Trial (HeadPoST), which enrolled a highly heterogeneous sample of subacute stroke patients, found that head position does not affect 3-month outcome; however, the study was heavily criticized by international stroke experts due to significant internal validity concerns. HeadPoST findings have created significant confusion within the acute stroke practice community about whether there is a role for head positioning in hyperacute IPH stroke management. The focus of our research was to build knowledge of key clinical methods that will support future definitive HOB research in hyperacute IPH stroke patients. We established 1) the clinical knowledge and skill set supporting nurses’ ability to localize stroke disability within vascular territories in the brain and 2) use of the National Institutes of Health Stroke Scale as a valid assessment tool for serial monitoring of clinical change in hyperacute IPH patients. We also 3) examined the degree of acceptance of HeadPoST findings internationally among nurse and physician clinicians caring for IPH stroke patients and 4) evaluated elements tied to the feasibility of conducting hyperacute IPH HOB research at a large, comprehensive stroke center in the Midsouth. Collectively, the chapters in this dissertation create a foundation for future IPH head-positioning research, providing direction for our next steps in understanding the contribution of HOB positioning to hyperacute IPH patient management. Patients with hypertensive IPH stroke suffer significantly higher rates of disability and death compared to other forms of stroke, yet despite a great deal of inquiry into interventions to improve outcomes, none have been successful. Positioning the patient’s HOB at 30-degrees may be one of the most important early interventions that nurses can employ to impart stability in hypertensive IPH patients. Our research and conclusions position nurse scientists to further their examination of the effect of this simple HOB-positioning intervention in this highly vulnerable patient population.

Anticoagulation after Spontaneous Intraparenchymal Hemorrhage in Patients with Mechanical Heart Valves and Concomitant Atrial Fibrillation

Aim Patients with mechanical heart valves and coexisting atrial fibrillation (AFib-MHV) who suffer an intraparenchymal hemorrhage (IPH, defined as bleeding solely within the brain parenchyma and/or ventricle) are at a high risk of thromboembolism without anticoagulation. Data are lacking regarding the safety of early re-initiation of anticoagulation in these patients. Patients and Methods We performed a descriptive, single-institution retrospective analysis of patients with AFib-MHV who suffered a non-traumatic, supratentorial IPH between July 2013 and June 2017. We analyzed the patients and IPH characteristics, anticoagulation and antiplatelet use, the occurrence of thrombotic and hemorrhage complications, and discharge disposition. We described the timing of initiation of anticoagulation and outcomes after IPH while in-patient. Results Six patients with AFib-MHV suffered a spontaneous IPH. Four were initiated on anticoagulation prior to discharge, of whom two were initiated within 3 days post-hemorrhage. These patients suffered no bleeding complications and were discharged home with a modified Rankin Scale of 1. Conclusion Patients with AFib-MHV who suffer a spontaneous IPH are a rare population to study. Further studies to guide the management of restarting anticoagulation in this select population are warranted.

Hepatic Compartment Syndrome Treated with Damage Control Surgery and Transarterial Embolization: A Case Report

Background: Hepatic compartment syndrome (HCS) is a complication of nonoperative management in patients with blunt hepatic injury. Although decompression of elevated intrahepatic pressure through surgical exploration or drainage and hemorrhage control are required to manage this condition, evidence for such a management for this complication is insufficient. Herein, we report a pediatric patient treated with a planned combination strategy of surgical decompression with perihepatic packing to reduce intrahepatic pressure and subcapsular hemorrhage control as well as angioembolization to control intraparenchymal hemorrhage. Case presentation: A 12-year-old boy was referred to our emergency department 5 h after sustaining severe bruising in the upper abdomen in a traffic accident. Computed tomography (CT) showed an intraparenchymal hematoma in the right lobe of the liver; nonoperative management was selected based on stable hemodynamic status. Two days after the injury, he complained of severe abdominal pain and shock. CT showed an intraparenchymal and large subcapsular hematoma with right branch compression of the portal vein and extravasation of contrast material. Laboratory data showed progression of hepatocellular damage. We successfully managed this patient with a planned combination strategy of surgical decompression with perihepatic packing for reduction of intrahepatic pressure and subcapsular hemorrhage control, followed by angioembolization for control of intraparenchymal hemorrhage. Conclusion: Our study suggests that for the management of HCS, a planned combination strategy of damage control surgery and angioembolization is a therapeutic option.

Intraparenchymal hemorrhage after serial ventricular reservoir taps in neonates with hydrocephalus and association with neurodevelopmental outcome at 2 years of age

OBJECTIVE Decompressing the ventricles with a temporary device is often the initial neurosurgical intervention for preterm infants with hydrocephalus. The authors observed a subgroup of infants who developed intraparenchymal hemorrhage (IPH) after serial ventricular reservoir taps and sought to describe the characteristics of IPH and its association with neurodevelopmental outcome. METHODS In this multicenter, case-control study, for each neonate with periventricular and/or subcortical IPH, a gestational age-matched control with reservoir who did not develop IPH was selected. Digital cranial ultrasound (cUS) scans and term-equivalent age (TEA)–MRI (TEA-MRI) studies were assessed. Ventricular measurements were recorded prior to and 3 days and 7 days after reservoir insertion. Changes in ventricular volumes were calculated. Neurodevelopmental outcome was assessed at 2 years corrected age using standardized tests. RESULTS Eighteen infants with IPH (mean gestational age 30.0 ± 4.3 weeks) and 18 matched controls were included. Reduction of the ventricular volumes relative to occipitofrontal head circumference after 7 days of reservoir taps was greater in infants with IPH (mean difference −0.19 [95% CI −0.37 to −0.004], p = 0.04). Cognitive and motor Z-scores were similar in infants with and those without IPH (mean difference 0.42 [95% CI −0.17 to 1.01] and 0.58 [95% CI −0.03 to 1.2]; p = 0.2 and 0.06, respectively). Multifocal IPH was negatively associated with cognitive score (coefficient −0.51 [95% CI −0.88 to −0.14], p = 0.009) and ventriculoperitoneal shunt with motor score (coefficient −0.50 [95% CI −1.6 to −0.14], p = 0.02) after adjusting for age at the time of assessment. CONCLUSIONS This study reports for the first time that IPH can occur after a rapid reduction of the ventricular volume during the 1st week after the initiation of serial reservoir taps in neonates with hydrocephalus. Further studies on the use of cUS to guide the amount of cerebrospinal fluid removal are warranted.