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. 2022 Jan 29;12(2):207. doi: 10.3390/life12020207

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© 2022 by the authors.

Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).

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Proposed pathomechanisms of intracerebral hemorrhage (ICH) in COVID-19 infection: direct and indirect pathways involving endothelial dysfunction. (A) Direct pathway: SARS-CoV-2 invasion of endothelial cells through ACE2 receptors may lead to endothelial cell death, vessel dysfunction, and rupture. Downregulation of ACE2 receptors may increase angiotensin II levels, resulting in hypertension and increased ICH risk. (B) Indirect pathway: SARS-CoV-2 interaction with endothelial ACE2 receptors leads to cytokine and chemokine release. This inflammatory response can interrupt tight junctions within the blood–brain barrier, increasing ICH risk. In addition to the direct and indirect pathways, ICH risk is increased by other risk factors such as anticoagulation, ICU admission, consumptive coagulopathy, and preexisting comorbidities. Created with BioRender.com (accessed on 20 January 2022).