Abstract
COVID-19, or coronavirus infection, is an acute respiratory illness caused by the corona virus that can develop into a life-threatening form of ARDS. Extracorporeal membrane oxygenation (ECMO) is a highly effective treatment for life-threatening instances. One of the many complications associated with ECMO was bleeding. COVID patients are at risk for intracerebral bleeding due to several factors, including the drug's action on ACE2 receptors, leading to hypertension, as well as hypercoagulability, dysregulated immune response, DIC, and the use of anticoagulants.
Keywords: COVID-19, ECMO, ICB, Hypercoagulability, Dysregulated immune response
Letter to the editor:
We read the article by J. Finsterer et al. with great interest [1] about some issues with our case report about a 53-year-old man with severe COVID-19 who needed mechanical ventilation for acute respiratory distress syndrome (ARDS) and extra-corporal membrane oxygenation (ECMO) treatment for low oxygenation [2].
In response to the concerns which was allied by Finsterer J et al. [1]. The MRI brain was not done to the patient as he was critically ill, hypotensive, and there was no mobile MRI unit at our facility.
Other causes of bleeding like hemorrhagic encephalitis were excluded clinically (as no history of suspected encephalitis) and CT brain picture not like our case. As hemorrhagic encephalitis CT brain may showed multifocal non hemorrhagic white matter lesions in both cerebral hemispheres and the brainstem [3], or may show extensive bilateral hemispheric white matter hypoattenuation [4], or may demonstrate symmetric low attenuation within the bilateral medial thalami [5].
No CTA or MRA (computed tomography angiography or magnetic resonance angiography) was performed because of the patient critical condition.
Other causes of ICB like aneurysmal ICH or ruptured AVM not seemed to be like our case as they had special imaging characteristics.
As according to their location to the AVM nidus, aneurysms and aneurysm-like dilations are classified as either extranidal or intranidal [6]. Also, there was no symptoms from the history suspect sinus thrombosis and there was no history of thromboembolic events like pulmonary embolism or DVT.
The lumbar puncture for cerebrospinal fluid (CSF) investigations were not done as there was clinical signs of increased intracranial pressure (ICP), impending brain herniation and dilated pupils. Thus, LP should be avoided when any signs of increased ICP [7].
Dysregulated immune responses in COVID cases can contribute to the production of immune-mediated processes via activation of different inflammation-related cells and production of cytokines, resulting in a wide range of clinical manifestations, such as Guillain-Barré Syndrome (GBS) [8]. Also, those processes can lead to ICB as a result of dysfunctional thrombocytes [9]. In our case [2] the patient D-dimer was high (14 μg/ml) with thrombocytopenia which improved through hospital stay. Also, the patient was confirmed COVID-19 positive by PCR test.
Conclusion
Patients with COVID-19 typically do not experience ICB. Patients with COVID-19 may exhibit symptoms of ICB following any one of several conditions, including post-stroke, encephalitis, or sinus thrombosis. Extracorporeal membrane oxygenation (ECMO) is a potential contributing factor in such scenarios.
Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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