Ali Daneshmand, MD, Thanh Nguyen, MD, Kushak Suchdev, MD
A subarachnoid hemorrhage (SAH) is abrupt bleeding into the subarachnoid space. The most common cause of spontaneous hemorrhage is a ruptured saccular aneurysm.
Incidence and Presentation:
Unknown risk of SAH in COVID-19 patients, no cases found at last literature search.
In a report from Wuhan, of 221 patients with COVID-19, eleven developed acute ischemic stroke, one cerebral venous sinus thrombosis, and one intracerebral hemorrhage . Cerebrovascular disease has been confirmed in the infection of other coronaviruses such as in SARS-CoV  and Middle East respiratory syndrome coronavirus (MER-CoV) .
In general, half of the patients with SAH present with “thunderclap headache” . Other signs and symptoms include impairment of consciousness, neck stiffness, nausea, vomiting, elevated blood pressure, and Valsalva preceding headache.
Intracranial saccular aneurysms are acquired lesions, and their pathogenesis is multifactorial . Hemodynamic stress causes the breakdown of the internal elastic lamina. Hypertension, cigarette smoking, and connective tissue disease can contribute to this process . There is some evidence that inflammation plays a role in the pathogenesis and growth of intracranial aneurysms.
Potential Direct CNS involvement by the coronavirus, possibly via hematogenous or lymphatic dissemination or through the invasion of peripheral nerve terminals with subsequent trans-synaptic transfer, has been previously reported. It is unclear whether such spread can put patients at higher risk of SAH .
Head CT obtained within 6 hours of symptom onset; for patients with a supportive history but negative CT, given the risk of exposure, decision regarding lumbar puncture should be discussed with attending physician and withheld unless high clinical suspicion in patients with COVID-19 . MRI is also a consideration for diagnosis, but contamination issues are present with this as well.
Once SAH is confirmed, CT angiogram of head and neck unless conventional catheter angiography is immediately available.
General principles of management of SAH patients remains the same in COVID-19 patients with a few additional considerations:
Consolidate neurological assessments to minimize the risk associated with exposure. Telecommunication can also be used to monitor patients.
Defer daily TCDs especially in asymptomatic patients. Alternate day TCDs can be performed if needed. Discuss with neurocritical care attending whether TCDs are needed on a given day.
TTE should also be deferred in patients who are hemodynamically stable.
Minimize lab draws as much as possible.
Consider early intubation/tracheostomy for high-grade SAH patients given the aerosolization risk associated with non-invasive ventilation.
Invasive lines (Arterial, central venous) should preferentially be placed at the same time
Discuss the need for any aerosolizing procedure (i.e., NG tube placement) with Neurocritical care attending
Maintain strict euvolemia given the respiratory risks associated with volume overload in ARDS.
In patients with urinary retention requiring straight catheterization, insert indwelling catheter
If blood pressure augmentation is indicated from neurological standpoint, would recommend initiation of vasopressors (given the risks associated with volume overload using fluid boluses).
Consider early EVD clamp trial to shorten duration of ICU stay (should be discussed between NCC and neurosurgery attendings) . Patients at high risk for vasospasm should not undergo early EVD wean.
Given the high prevalence of fever in COVID-19 patients, decision regarding CSF collection should be discussed between NCC and Neurosurgery attending physician and withheld unless high clinical suspicion of EVD associated meningoventriculitis
Patients with COVID-19 with cerebrovascular disease had a more severe inflammatory response and higher coagulability. As such, prompt initiation of DVT chemoprophylaxis given the reported cases of increased VTE risk in COVID-19 patients .
Patients who are not intubated and do not have EVD may be transferred to stepdown early, in discussion with neurocritical care attending.
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