Hemorrhagic transformation in SARS-CoV-2 infected patients: case reports from Indonesia

Introduction: While initially suggested as a primary respiratory infection, there has been increasing proof that the novel coronavirus disease (COVID-19) also leads to severe neurological manifestation particularly ischemic stroke. The hypercoagulable state observed in COVID-19 patients is thought to contribute to this phenomenon although the exact pathophysiology is still unclear. Case: We are reporting two cases of hemorrhagic transformation after ischemic stroke in COVID-19 patients. Both patients were women presenting with ischemic stroke and bronchopneumonia due to COVID-19. They both experienced prolonged coagulation studies before sudden neurological deterioration. Evaluation CT scan demonstrated the hemorrhagic transformation of infarction. It is still unknown whether the coagulation disruption is primarily caused due to viral activity or secondary due to the inflammatory response. Hemorrhagic transformation is a complication of ischemic stroke, particularly in post-thrombolysis patients. However COVID-19 coagulopathy was thought to induce such event in COVID-19 patients presented with ischemic stroke. Conclusion: Although ischemic stroke has been widely reported in COVID-19 patients, there have been a few reports of hemorrhagic transformation events. This may lead to an increased understanding regarding COVID-19 pathophysiology and cerebrovascular disease.