Primary spontaneous intracerebral hemorrhage in COVID-19 patients: differences among presentation patterns – A systematic review

Gustavo Parra-Romero, Department of Neurosurgery, Mexico General Hospital, Mexico City, Mexico
José L. Navarro-Olvera, Department of Neurosurgery, Mexico General Hospital, Mexico City, Mexico
Jesús Q. Beltrán-Mendoza, Department of Neurosurgery, Hospital General de Mexico, Mexico City; Functional Neurosurgery, Stereotactic and Radiosurgery Department, Hospital General de Mexico, Mexico City; Mexico
José L. Ruiz-Sandoval, Department of Neurology, Hospital Civil Fray Antonio Alcalde, Guadalajara, Jalisco, México
Ariatne Mar-Álvarez, Department of Neurosurgery, Hospital General de Mexico, Mexico City, México
Gustavo Aguado-Carrillo, Unidad Médica de Alta Especialidad, Hospital de Traumatología y Ortopedia de Puebla, Centro Médico Nacional Gral. de Div. Manuel Ávila Camacho, Instituto Mexicano del Seguro Social (IMSS), Puebla, México
Nicolas Teyes-Calva, Department of Neurosurgery, Hospital General de Mexico, Mexico City, Mexico
Jahir Rodriguez-Morales, Department of Neurosurgery, Hospital General de Mexico, Mexico City, Mexico
Ariam A. Martínez-Luna, Department of Neurosurgery, Hospital General de Mexico, Mexico City, Mexico
Aldo F. Hernández-Valencia, Department of Neurosurgery, Hospital General de Mexico, Mexico City, Mexico
José D. Carrillo-Ruiz, Department of Neurosurgery, Mexico General Hospital; Research Direction, Mexico General Hospital; Faculty of Health Sciences, Anahuac University North Campus. Mexico City, Mexico

Objective: The objective of this study was to determine if there are differences between the presentation patterns of hemorrhagic stroke (HS) associated to COVID-19. Methods: It was performed a systematic search based on PRISMA guidelines of the cases reported in PUBMED of HS associated to SARS-CoV-2 infection and we added to this sample cases from our own hospital cohort. Patients in the database were separated by groups according to presentation symptoms: if they debuted with neurological symptoms or debuted with pulmonary symptoms. Results: Seventy cases were included in the study. Patients that debuted with pulmonary symptoms accounted for 68.6% of the cases with an interval between the development of symptoms and the presentation of HS of 15.6 days. We found that the use of anticoagulants during hospitalization, multifocal image pattern, and the elevation of D-dimer, Ferritin, and lactate dehydrogenase levels were significantly associated with the group of pulmonary presentation, whereas the presence of hypertension during hospitalization, and a lower hemoglobin level was associated with the group of neurologic symptoms. Conclusion: Although HS associated with COVID-19 is a clinical entity with increasing evidence, it is necessary to establish that there are two forms of presentation with their own characteristics.

Keywords: Cerebrovascular disease. Coagulopathy. COVID-19. Hemorrhagic stroke. SARS-CoV-2 infection.