Spontaneous intracerebral hemorrhage after anticoagulation therapy in a 57-year-old man with SARS-COV-2 infection: A case report

Fakhrurrazy, Fakhrurrazy; Pambudi, Pagan; Khatimah, Husnul; Runtuwene, Lily; Gunawan, Steven; Wibowo, Among; Dafif, Muhammad

Background and aims: Anticoagulation regimens are now being considered for COVID-19. Anticoagulation is known to increase the risk for adverse bleeding events, of which intracerebral hemorrhage (ICH). Methods: Case Report. Results: We report a 57-year-old man was admitted to hospital due decreased oxygen saturation, increased blood glucose levels and RT-PCR of oropharyngeal swab confirmed COVID-19. The patient had a previous history of type 2 DM and ischemic stroke. The first 5 days, the patient was receiving a prophylactic dose of low molecular weight heparin, enoxaparin, then continued with unfractionated heparin. The patient also received antiplatelet clopidogrel and convalescent plasma. The laboratory results are leucocyte 18.9 K/μL, ureum 79 mg/dL, creatinine 2.0 mg/dL, D-Dimer 0.22 μg/mL, INR 1.03, NLR 15.82, ALC 547, HbA1C 9.2, blood glucose level 336 mg/dL, CRP 41.2 mg/dL. On day ten of hospitalization, the patient had sudden right-sided hemiplegia and Broca's aphasia. A CT head demonstrated an ICH in the left basal ganglia with a volume approximately 77cc. Three days later the patient's condition had decreased consciousness and a craniotomy was performed. After being intubated for 4 days post craniotomy, because his condition improved, he was extubated. On day nine after surgery, the patient's condition decreased to coma, a repeat chest X-ray showed a worsening of the bilateral infiltrates and pleural effusion. His oxygen requirement was progressively increasing, so he was shifted to mechanical ventilation again. Conclusions: The risk of intracerebral hemorrhage in patients with COVID-19 is of paramount importance to inform the risk-benefit assessment of the use of anticoagulation in this patient.