Abstract
Introduction: One of the possible mechanisms by which the new coronavirus (SARS-Cov2) could induce brain damage is the impairment of cerebrovascular hemodynamics (CVH) and intracranial compliance (ICC) due to the elevation of intracranial pressure (ICP). The main objective of this study was to assess the presence of CVH and ICC alterations in patients with COVID-19 and evaluate their association with short-term clinical outcomes. Methods: Fifty consecutive critically ill COVID-19 patients were studied with transcranial Doppler (TCD) and non-invasive monitoring of ICC. Subjects were included upon ICU admission; CVH was evaluated using mean flow velocities in the middle cerebral arteries (mCBFV), pulsatility index (PI), and estimated cerebral perfusion pressure (eCPP), while ICC was assessed by using the P2/P1 ratio of the non-invasive ICP curve. A CVH/ICC score was computed using all these variables. The primary composite outcome was unsuccessful in weaning from respiratory support or death on day 7 (defined as UO). Results: At the first assessment (n = 50), only the P2/P1 ratio (median 1.20 [IQRs 1.00–1.28] vs. 1.00 [0.88–1.16]; p = 0.03) and eICP (14 [11–25] vs. 11 [7–15] mmHg; p = 0.01) were significantly higher among patients with an unfavorable outcome (UO) than others. Patients with UO had a significantly higher CVH/ICC score (9 [8–12] vs. 6 [5–7]; p < 0.001) than those with a favorable outcome; the area under the receiver operating curve (AUROC) for CVH/ICC score to predict UO was 0.86 (95% CIs 0.75–0.97); a score > 8.5 had 63 (46–77)% sensitivity and 87 (62–97)% specificity to predict UO. For those patients undergoing a second assessment (n = 29), after a median of 11 (5–31) days, all measured variables were similar between the two time-points. No differences in the measured variables between ICU non-survivors (n = 30) and survivors were observed. Conclusions: ICC impairment and CVH disturbances are often present in COVID-19 severe illness and could accurately predict an early poor outcome.
Highlights
The severity of the disease caused by the new coronavirus 2019 (COVID-19) is predominantly harbored in the occurrence of severe acute hypoxemic respiratory failure, which often requires ventilatory support
Exclusion criteria included the absence of a temporal acoustic window for transcranial Doppler (TCD) assessment, the absence of a dedicated operator for intracranial compliance (ICC) and cerebrovascular hemodynamics (CVH) assessment, patients unable to undergo ICC monitoring due to lesions and/or skin infections in the sensor application region, and patients with head circumference smaller than 47 cm
As the availability of personnel to perform TCD and B4C assessments was scarce, and considering the exploratory purpose of the study, a total of 50 patients were eventually included within 72 h of intensive care units (ICUs) admission
Summary
The severity of the disease caused by the new coronavirus 2019 (COVID-19) is predominantly harbored in the occurrence of severe acute hypoxemic respiratory failure, which often requires ventilatory support. As many COVID-19 patients experience neurological symptoms, such as headache, anosmia, paresthesia, nausea, vomiting, and alteration of consciousness [11], one hypothesis could be that intracranial compliance (ICC) and cerebrovascular hemodynamics (CVH) are impaired in the early course of the disease, either directly (i.e., encephalitis, brain edema, or focal ischemia) or indirectly (i.e., hypoxic distress, cytokine storm, and endothelial dysfunction) [12,13]. This would be even more frequent in critically ill patients, who often suffer from persistent somnolence, lethargy, and delirium [14,15]
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