Electroencephalography at the height of a pandemic: EEG findings in patients with COVID-19.

OBJECTIVE: To characterize continuous video electroencephalogram (VEEG) findings of hospitalized COVID-19 patients. METHODS: We performed a retrospective chart review of patients admitted at three New York City hospitals who underwent VEEG at the peak of the COVID-19 pandemic. Demographics, comorbidities, neuroimaging, VEEG indications and findings, treatment, and outcomes were collected. RESULTS: Of 93 patients monitored, 77% had severe COVID-19 and 40% died. Acute ischemic or hemorrhagic stroke was present in 26% and 15%, respectively. Most common VEEG indications were encephalopathy/coma (60%) and seizure-like movements (38%). Most common VEEG findings were generalized slowing (97%), generalized attenuation (31%), generalized periodic discharges (17%) and generalized sharp waves (15%). Epileptiform abnormalities were present in 43% and seizures in 8% of patients, all of whom had seizure risk factors. Factors associated with an epileptiform VEEG included increasing age (OR 1.07, p = 0.001) and hepatic/renal failure (OR 2.99, p = 0.03). CONCLUSIONS: Most COVID-19 patients who underwent VEEG monitoring had severe COVID-19 and over one-third had acute cerebral injury (e.g., stroke, anoxia). Seizures were uncommon. VEEG findings were nonspecific. SIGNIFICANCE: VEEG findings in this cohort of hospitalized COVID-19 patients were those often seen in critical illness. Seizures were uncommon and occurred in the setting of common seizure risk factors.

The emerging association between COVID-19 and acute stroke.

Prior to COVID-19, only two human-tropic coronaviruses resulted in epidemics and cerebrovascular disease was rarely reported. Evidence now suggests that 1-6% of hospitalized COVID-19 patients develop stroke. According to some reports, stroke risk is more than sevenfold greater in patients with COVID-19 than influenza. Concerningly, outcomes of COVID-19-related stroke are often worse than in stroke patients without COVID-19 from the same cohorts. In this review, we highlight the emerging association between COVID-19 and stroke and discuss putative pathogenetic mechanisms. Etiology of stroke in COVID-19 patients is likely multifactorial, related to coagulopathy, inflammation, platelet activation, and alterations to the vascular endothelium. Significant work remains to be done to better understand the pathogenesis of COVID-19-related stroke and for designing optimal primary and secondary prevention strategies.

Acute Cerebrovascular Events With COVID-19 Infection.

BACKGROUND AND PURPOSE: Coronavirus disease 2019 (COVID-19) has been associated with an increased incidence of thrombotic events, including stroke. However, characteristics and outcomes of COVID-19 patients with stroke are not well known. METHODS: We conducted a retrospective observational study of risk factors, stroke characteristics, and short-term outcomes in a large health system in New York City. We included consecutively admitted patients with acute cerebrovascular events from March 1, 2020 through April 30, 2020. Data were stratified by COVID-19 status, and demographic variables, medical comorbidities, stroke characteristics, imaging results, and in-hospital outcomes were examined. Among COVID-19-positive patients, we also summarized laboratory test results. RESULTS: Of 277 patients with stroke, 105 (38.0%) were COVID-19-positive. Compared with COVID-19-negative patients, COVID-19-positive patients were more likely to have a cryptogenic (51.8% versus 22.3%, P<0.0001) stroke cause and were more likely to suffer ischemic stroke in the temporal (P=0.02), parietal (P=0.002), occipital (P=0.002), and cerebellar (P=0.028) regions. In COVID-19-positive patients, mean coagulation markers were slightly elevated (prothrombin time 15.4±3.6 seconds, partial thromboplastin time 38.6±24.5 seconds, and international normalized ratio 1.4±1.3). Outcomes were worse among COVID-19-positive patients, including longer length of stay (P<0.0001), greater percentage requiring intensive care unit care (P=0.017), and greater rate of neurological worsening during admission (P<0.0001); additionally, more COVID-19-positive patients suffered in-hospital death (33% versus 12.9%, P<0.0001). CONCLUSIONS: Baseline characteristics in patients with stroke were similar comparing those with and without COVID-19. However, COVID-19-positive patients were more likely to experience stroke in a lobar location, more commonly had a cryptogenic cause, and had worse outcomes.

History of Stroke Is Independently Associated With In-Hospital Death in Patients With COVID-19.

BACKGROUND AND PURPOSE: In December 2019, an outbreak of severe acute respiratory syndrome coronavirus causing coronavirus disease 2019 (COVID-19) occurred in China, and evolved into a worldwide pandemic. It remains unclear whether the history of cerebrovascular disease is associated with in-hospital death in patients with COVID-19. METHODS: We conducted a retrospective, multicenter cohort study at Mount Sinai Health System in New York City. Using our institutional data warehouse, we identified all adult patients who were admitted to the hospital between March 1, 2020 and May 1, 2020 and had a positive nasopharyngeal swab polymerase chain reaction test for severe acute respiratory syndrome coronavirus in the emergency department. Using our institutional electronic health record, we extracted clinical characteristics of the cohort, including age, sex, and comorbidities. Using multivariable logistic regression to control for medical comorbidities, we modeled the relationship between history of stroke and all-cause, in-hospital death. RESULTS: We identified 3248 patients, of whom 387 (11.9%) had a history of stroke. Compared with patients without history of stroke, patients with a history of stroke were significantly older, and were significantly more likely to have a history of all medical comorbidities except for obesity, which was more prevalent in patients without a history of stroke. Compared with patients without history of stroke, patients with a history of stroke had higher in-hospital death rates during the study period (48.6% versus 31.7%, P<0.001). In the multivariable analysis, history of stroke (adjusted odds ratio, 1.28 [95% CI, 1.01-1.63]) was significantly associated with in-hospital death. CONCLUSIONS: We found that history of stroke was associated with in-hospital death among hospitalized patients with COVID-19. Further studies should confirm these results.

Emergent Large Vessel Occlusion Stroke During New York City's COVID-19 Outbreak: Clinical Characteristics and Paraclinical Findings.

BACKGROUND AND PURPOSE: The 2019 novel coronavirus outbreak and its associated disease (coronavirus disease 2019 [COVID-19]) have created a worldwide pandemic. Early data suggest higher rate of ischemic stroke in severe COVID-19 infection. We evaluated whether a relationship exists between emergent large vessel occlusion (ELVO) and the ongoing COVID-19 outbreak. METHODS: This is a retrospective, observational case series. Data were collected from all patients who presented with ELVO to the Mount Sinai Health System Hospitals across New York City during the peak 3 weeks of hospitalization and death from COVID-19. Patients' demographic, comorbid conditions, cardiovascular risk factors, COVID-19 disease status, and clinical presentation were extracted from the electronic medical record. Comparison was made between COVID-19 positive and negative cohorts. The incidence of ELVO stroke was compared with the pre-COVID period. RESULTS: Forty-five consecutive ELVO patients presented during the observation period. Fifty-three percent of patients tested positive for COVID-19. Total patients' mean (±SD) age was 66 (±17). Patients with COVID-19 were significantly younger than patients without COVID-19, 59±13 versus 74±17 (odds ratio [95% CI], 0.94 [0.81-0.98]; P=0.004). Seventy-five percent of patients with COVID-19 were male compared with 43% of patients without COVID-19 (odds ratio [95% CI], 3.99 [1.12-14.17]; P=0.032). Patients with COVID-19 were less likely to be White (8% versus 38% [odds ratio (95% CI), 0.15 (0.04-0.81); P=0.027]). In comparison to a similar time duration before the COVID-19 outbreak, a 2-fold increase in the total number of ELVO was observed (estimate: 0.78 [95% CI, 0.47-1.08], P≤0.0001). CONCLUSIONS: More than half of the ELVO stroke patients during the peak time of the New York City's COVID-19 outbreak were COVID-19 positive, and those patients with COVID-19 were younger, more likely to be male, and less likely to be White. Our findings also suggest an increase in the incidence of ELVO stroke during the peak of the COVID-19 outbreak.

COVID-19 and Decompressive Hemicraniectomy for Acute Ischemic Stroke.

BACKGROUND AND PURPOSE: Young patients with malignant cerebral edema have been shown to benefit from early decompressive hemicraniectomy. The impact of concomitant infection with coronavirus disease 2019 (COVID-19) and how this should weigh in on the decision for surgery is unclear. METHODS: We retrospectively reviewed all COVID-19-positive patients admitted to the neuroscience intensive care unit for malignant edema monitoring. Patients with >50% of middle cerebral artery involvement on computed tomography imaging were considered at risk for malignant edema. RESULTS: Seven patients were admitted for monitoring of whom 4 died. Cause of death was related to COVID-19 complications, and these were either seen both very early and several days into the intensive care unit course after the typical window of malignant cerebral swelling. Three cases underwent surgery, and 1 patient died postoperatively from cardiac failure. A good outcome was attained in the other 2 cases. CONCLUSIONS: COVID-19-positive patients with large hemispheric stroke can have a good outcome with decompressive hemicraniectomy. A positive test for COVID-19 should not be used in isolation to exclude patients from a potentially lifesaving procedure.

Macrothrombosis and stroke in patients with mild Covid-19 infection.

Coronavirus disease 2019 (COVID-19) is a pandemic disease currently affecting millions of people worldwide. Its neurological implications are poorly understood, and further study is urgently required. A hypercoagulable state has been reported in patients with severe COVID-19, but nothing is known about coagulopathy in patients with milder disease. We describe cases of patients in New York City presenting with stroke secondary to large vessel thrombosis without occlusion, incidentally found to have COVID-19 with only mild respiratory symptoms. This is in contrast to the venous thrombosis and microangiopathy that has been reported in patients with severe COVID-19. Our cases suggest that even in the absence of severe disease, patients with COVID-19 may be at increased risk of thrombus formation leading to stroke, perhaps resulting from viral involvement of the endothelium. Further systematic study is needed because this may have implications for primary and secondary stroke prevention in patients with COVID-19.