Intracranial hemorrhage in a patient with severe COVID-19 acute respiratory distress syndrome on Veno-venous extra corporeal membrane oxygenation: A case report.

introduction and importanceCOVID-19 can lead to severe acute respiratory distress syndrome (ARDS) where Veno-Venous Extra Corporeal Membrane Oxygenation (V-V ECMO) may be utilized for patients with severe respiratory failure. Our case report highlights a life threatening complication of V-V ECMO - intracranial hemorrhage (ICH), in a patient being treated for severe COVID-19 ARDS. CASE PRESENTATION: A 41-year-old male of Indian ethnicity with no known comorbidities presented with an 8 day history of fever and dyspnoea. The patient was diagnosed with COVID-19 through a positive RT PCR test and his clinical condition progressively deteriorated requiring mechanical ventilation. Inspite of lung protective ventilation strategies and prone ventilation, there was no improvement in oxygenation. Therefore, the patient was placed on extra corporeal life support. On day three of V-V ECMO, the patient developed anisocoria and his GCS dropped to E1VTM1. A non-contrast CT brain scan revealed a large intraparenchymal hemorrhage in the right frontoparietal lobe with an extension into the right lateral and third ventricles leading to an emergency decompressive craniectomy with lax duroplasty.Post intracranial hemorrhage,ECMO support was continued without systemic anticoagulation. Despite a transient improvement in his GCS post surgery, the patient eventually succumbed to refractory septic shock with multi organ dysfunction syndrome. CLINICAL DISCUSSION AND

conclusionBalancing anticoagulation therapy is one of the biggest challenges in managing ECMO support for COVID-19 ARDS. ICH is a rare and potentially fatal complication of V-V ECMO with an apparently higher incidence among COVID-19 patients. Neurosurgical procedures may be considered in such patients when no other possible management strategies are available (and the risk of death is imminent).