Thrombotic and Hemorrhagic Neurological Complications in Critically Ill COVID-19 Patients
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Thrombotic and Hemorrhagic Neurological Complications in Critically Ill COVID‑19 Patients Bruno Gonçalves, Cassia Righy and Pedro Kurtz* © 2020 Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society
We report a series of three cases admitted to the intensive care unit (ICU) of Paulo Niemeyer State Brain Institute due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), all developing acute respiratory distress syndrome (ARDS) and acute renal failure, and later in the course of the disease, catastrophic intracerebral hemorrhages. Clinical characteristics of the patients are described in Table 1.
Patient 1 A 56-year-old woman presented with fever and flu syndrome on March 29th, prompting her to seek medical attention in the emergency department. After 2 days, she developed dyspnea and oxygen desaturation with need of O2 support by face mask. On April 5th, her symptoms worsened and she was intubated, started on empirical therapy with ceftriaxone, oseltamivir, and azithromycin. A chest computed tomography (CT) scan showed diffuse infiltrates with ground-glass pattern. Severe SARS-CoV-2 was diagnosed through reverse transcription polymerase chain reaction (RT-PCR) of her tracheal aspirate. She had no prior knowledge of other medical conditions. She was transferred to our ICU on April 7th and was admitted in septic shock and ARDS, requiring high levels of FiO2 and vasoactive drug support (norepinephrine). Her initial PaO2/FiO2 ratio was 149, and her chest CT scan showed diffuse ground-glass opacities in both lungs. Antibiotic was changed to piperacillin + tazobactam and hydroxychloroquine was started. Renal function progressively worsened (urea of 254 mg/L), and dialysis was started the following day. *Correspondence: [email protected] Department of Neurointensive Care, Instituto Estadual do Cérebro Paulo Niemeyer, Rua do Resende 156, Centro, Rio de Janeiro 20231092, Brazil
During the first 3 days, she stabilized with a low dose of norepinephrine and daily prolonged hemodialysis. She remained under continuous analgosedation (midazolam and fentanyl) and neuromuscular blockade (cisatracurium) with a PaO2/FiO2 ratio of 150-200. Her initial D-dimer was 59,960 mcg/L. On the fourth day, her pulmonary function worsened and she underwent prone positioning, with limited improvement in gas exchange. Her D-dimer was 53,460 mcg/L. On the following days, she was not able to undergo prone position or dialysis due to hemodynamic instability. Her PaO2/FiO2 ratio was still 150–200. Fibrinogen level was 575 mg/dl, and D-dimer levels remained elevated throughout her ICU stay with subsequent values of 42,132 mcg/L and 31,610 mcg/L. Prothrombin time and partial thromboplastin time, which were assessed every day, were within normal range and platelet counts progressively reduced after the fifth day in the ICU (114, 99, 74 and finally 59 thousand per milliliter). She was kept on continuous sedation, analgesia and neuromuscular blockade due to the severity of lung inj
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