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1.
Interv Neuroradiol ; : 15910199221093896, 2022 Apr 11.
Article in English | MEDLINE | ID: covidwho-1785091

ABSTRACT

BACKGROUND: The neutrophil-lymphocyte ratio (NLR) is emerging as an important biomarker of acute physiologic stress in a myriad of medical conditions, and is a confirmed poor prognostic indicator in COVID-19. OBJECTIVE: We sought to describe the role of NLR in predicting poor outcome in COVID-19 patients undergoing mechanical thrombectomy for acute ischemic stroke. METHODS: We analyzed NLR in COVID-19 patients with large vessel occlusion (LVO) strokes enrolled into an international 12-center retrospective study of laboratory-confirmed COVID-19, consecutively admitted between March 1, 2020 and May 1, 2020. Increased NLR was defined as ≥7.2. Logistic regression models were generated. RESULTS: Incidence of LVO stroke was 38/6698 (.57%). Mean age of patients was 62 years (range 27-87), and mortality rate was 30%. Age, sex, and ethnicity were not predictive of mortality. Elevated NLR and poor vessel recanalization (Thrombolysis in Cerebral Infarction (TICI) score of 1 or 2a) synergistically predicted poor outcome (likelihood ratio 11.65, p = .003). Patients with NLR > 7.2 were 6.8 times more likely to die (OR 6.8, CI95% 1.2-38.6, p = .03) and almost 8 times more likely to require prolonged invasive mechanical ventilation (OR 7.8, CI95% 1.2-52.4, p = .03). In a multivariate analysis, NLR > 7.2 predicted poor outcome even when controlling for the effect of low TICI score on poor outcome (NLR p = .043, TICI p = .070). CONCLUSIONS: We show elevated NLR in LVO patients with COVID-19 portends significantly worse outcomes and increased mortality regardless of recanalization status. Severe neuro-inflammatory stress response related to COVID-19 may negate the potential benefits of successful thrombectomy.

2.
J Stroke Cerebrovasc Dis ; 30(12): 106121, 2021 Dec.
Article in English | MEDLINE | ID: covidwho-1415617

ABSTRACT

BACKGROUND: There is little information regarding the safety of intravenous tissue plasminogen activator (IV-tPA) in patients with stroke and COVID-19. METHODS: This multicenter study included consecutive stroke patients with and without COVID-19 treated with IV-tPA between February 18, 2019, to December 31, 2020, at 9 centers participating in the CASCADE initiative. Clinical outcomes included modified Rankin Scale (mRS) at hospital discharge, in-hospital mortality, the rate of hemorrhagic transformation. Using Bayesian multiple regression and after adjusting for variables with significant value in univariable analysis, we reported the posterior adjusted odds ratio (OR, with 95% Credible Intervals [CrI]) of the main outcomes. RESULTS: A total of 545 stroke patients, including 101 patients with COVID-19 were evaluated. Patients with COVID-19 had a more severe stroke at admission. In the study cohort, 85 (15.9%) patients had a hemorrhagic transformation, and 72 (13.1%) died in the hospital. After adjustment for confounding variables, discharge mRS score ≥2 (OR: 0.73, 95% CrI: 0.16, 3.05), in-hospital mortality (OR: 2.06, 95% CrI: 0.76, 5.53), and hemorrhagic transformation (OR: 1.514, 95% CrI: 0.66, 3.31) were similar in COVID-19 and non COVID-19 patients. High-sensitivity C reactive protein level was a predictor of hemorrhagic transformation in all cases (OR:1.01, 95%CI: 1.0026, 1.018), including those with COVID-19 (OR:1.024, 95%CI:1.002, 1.054). CONCLUSION: IV-tPA treatment in patients with acute ischemic stroke and COVID-19 was not associated with an increased risk of disability, mortality, and hemorrhagic transformation compared to those without COVID-19. IV-tPA should continue to be considered as the standard of care in patients with hyper acute stroke and COVID-19.


Subject(s)
COVID-19/complications , Fibrinolytic Agents/administration & dosage , Ischemic Stroke/drug therapy , Thrombolytic Therapy , Aged , Aged, 80 and over , COVID-19/diagnosis , COVID-19/mortality , Disability Evaluation , Europe , Female , Fibrinolytic Agents/adverse effects , Hospital Mortality , Humans , Infusions, Intravenous , Intracranial Hemorrhages/chemically induced , Iran , Ischemic Stroke/complications , Ischemic Stroke/diagnosis , Ischemic Stroke/mortality , Male , Middle Aged , Risk Assessment , Risk Factors , Thrombolytic Therapy/adverse effects , Thrombolytic Therapy/mortality , Time Factors , Treatment Outcome
3.
J Stroke Cerebrovasc Dis ; 30(1): 105434, 2021 Jan.
Article in English | MEDLINE | ID: covidwho-941358

ABSTRACT

SARS-CoV-2, the virus responsible for novel Coronavirus (COVID-19) infection, has recently been associated with a myriad of hematologic derangements; in particular, an unusually high incidence of venous thromboembolism has been reported in patients with COVID-19 infection. It is postulated that either the cytokine storm induced by the viral infection or endothelial damage caused by viral binding to the ACE-2 receptor may activate a cascade leading to a hypercoaguable state. Although pulmonary embolism and deep venous thrombosis have been well described in patients with COVID-19 infection, there is a paucity of literature on cerebral venous sinus thrombosis (cVST) associated with COVID-19 infection. cVST is an uncommon etiology of stroke and has a higher occurrence in women and young people. We report a series of three patients at our institution with confirmed COVID-19 infection and venous sinus thrombosis, two of whom were male and one female. These cases fall outside the typical demographic of patients with cVST, potentially attributable to COVID-19 induced hypercoaguability. This illustrates the importance of maintaining a high index of suspicion for cVST in patients with COVID-19 infection, particularly those with unexplained cerebral hemorrhage, or infarcts with an atypical pattern for arterial occlusive disease.


Subject(s)
COVID-19/complications , Sinus Thrombosis, Intracranial/etiology , Stroke/etiology , Thromboembolism/etiology , Venous Thrombosis/etiology , Adolescent , Adult , Aged , COVID-19/diagnosis , COVID-19/therapy , Fatal Outcome , Female , Humans , Male , Sinus Thrombosis, Intracranial/diagnostic imaging , Sinus Thrombosis, Intracranial/therapy , Stroke/diagnostic imaging , Stroke/therapy , Thromboembolism/diagnostic imaging , Thromboembolism/therapy , Treatment Outcome , Venous Thrombosis/diagnostic imaging , Venous Thrombosis/therapy
4.
J Stroke Cerebrovasc Dis ; 30(2): 105429, 2021 Feb.
Article in English | MEDLINE | ID: covidwho-899244

ABSTRACT

The current Coronavirus pandemic due to the novel SARS-Cov-2 virus has proven to have systemic and multi-organ involvement with high acuity neurological conditions including acute ischemic strokes. We present a case series of consecutive COVID-19 patients with cerebrovascular disease treated at our institution including 3 cases of cerebral artery dissection including subarachnoid hemorrhage. Knowledge of the varied presentations including dissections will help treating clinicians at the bedside monitor and manage these complications preemptively.


Subject(s)
Aneurysm, Dissecting/mortality , COVID-19/mortality , Hemorrhagic Stroke/mortality , Hospital Mortality , Intensive Care Units , Intracranial Aneurysm/mortality , Ischemic Stroke/mortality , Patient Admission , Adult , Aged , Aged, 80 and over , Aneurysm, Dissecting/diagnosis , Aneurysm, Dissecting/therapy , COVID-19/diagnosis , COVID-19/therapy , Female , Hemorrhagic Stroke/diagnosis , Hemorrhagic Stroke/therapy , Humans , Intracranial Aneurysm/diagnosis , Intracranial Aneurysm/therapy , Ischemic Stroke/diagnosis , Ischemic Stroke/therapy , Male , Middle Aged , New York City/epidemiology , Prospective Studies , Risk Assessment , Risk Factors
5.
J Stroke Cerebrovasc Dis ; 29(12): 105397, 2020 Dec.
Article in English | MEDLINE | ID: covidwho-886527

ABSTRACT

SARS-CoV-2 infection has been associated with ischemic stroke as well as systemic complications such as acute respiratory failure; cytotoxic edema is a well-known sequelae of acute ischemic stroke and can be worsened by the presence of hypercarbia induced by respiratory failure. We present the case of a very rapid neurologic and radiographic decline of a patient with an acute ischemic stroke who developed rapid fulminant cerebral edema leading to herniation in the setting of hypercarbic respiratory failure attributed to SARS-CoV-2 infection. Given the elevated incidence of cerebrovascular complications in patients with COVID-19, it is imperative for clinicians to be aware of the risk of rapidly progressive cerebral edema in patients who develop COVID-19 associated acute respiratory distress syndrome.


Subject(s)
Brain Edema/etiology , Breast Neoplasms/complications , COVID-19/complications , Encephalocele/etiology , Intracranial Hemorrhages/etiology , Stroke/etiology , Aged , Brain Edema/diagnostic imaging , Breast Neoplasms/diagnosis , Breast Neoplasms/drug therapy , COVID-19/diagnosis , Disease Progression , Encephalocele/diagnostic imaging , Female , Humans , Intracranial Hemorrhages/diagnostic imaging , Risk Factors , Stroke/diagnostic imaging
6.
J Stroke Cerebrovasc Dis ; 29(12): 105321, 2020 Dec.
Article in English | MEDLINE | ID: covidwho-872317

ABSTRACT

BACKGROUND: The emergence of the COVID-19 pandemic has significantly impacted global healthcare systems and this may affect stroke care and outcomes. This study examines the changes in stroke epidemiology and care during the COVID-19 pandemic in Zanjan Province, Iran. METHODS: This study is part of the CASCADE international initiative. From February 18, 2019, to July 18, 2020, we followed ischemic and hemorrhagic stroke hospitalization rates and outcomes in Valiasr Hospital, Zanjan, Iran. We used a Bayesian hierarchical model and an interrupted time series analysis (ITS) to identify changes in stroke hospitalization rate, baseline stroke severity [measured by the National Institutes of Health Stroke Scale (NIHSS)], disability [measured by the modified Rankin Scale (mRS)], presentation time (last seen normal to hospital presentation), thrombolytic therapy rate, median door-to-needle time, length of hospital stay, and in-hospital mortality. We compared in-hospital mortality between study periods using Cox-regression model. RESULTS: During the study period, 1,026 stroke patients were hospitalized. Stroke hospitalization rates per 100,000 population decreased from 68.09 before the pandemic to 44.50 during the pandemic, with a significant decline in both Bayesian [Beta: -1.034; Standard Error (SE): 0.22, 95% CrI: -1.48, -0.59] and ITS analysis (estimate: -1.03, SE = 0.24, p < 0.0001). Furthermore, we observed lower admission rates for patients with mild (NIHSS < 5) ischemic stroke (p < 0.0001). Although, the presentation time and door-to-needle time did not change during the pandemic, a lower proportion of patients received thrombolysis (-10.1%; p = 0.004). We did not see significant changes in admission rate to the stroke unit and in-hospital mortality rate; however, disability at discharge increased (p < 0.0001). CONCLUSION: In Zanjan, Iran, the COVID-19 pandemic has significantly impacted stroke outcomes and altered the delivery of stroke care. Observed lower admission rates for milder stroke may possibly be due to fear of exposure related to COVID-19. The decrease in patients treated with thrombolysis and the increased disability at discharge may indicate changes in the delivery of stroke care and increased pressure on existing stroke acute and subacute services. The results of this research will contribute to a similar analysis of the larger CASCADE dataset in order to confirm findings at a global scale and improve measures to ensure the best quality of care for stroke patients during the COVID-19 pandemic.


Subject(s)
Brain Ischemia/therapy , COVID-19 , Hospitalization/trends , Intracranial Hemorrhages/therapy , Outcome and Process Assessment, Health Care/trends , Stroke/therapy , Thrombolytic Therapy/trends , Time-to-Treatment/trends , Aged , Aged, 80 and over , Bayes Theorem , Brain Ischemia/diagnosis , Brain Ischemia/mortality , COVID-19/epidemiology , Female , Hospital Mortality/trends , Humans , Interrupted Time Series Analysis , Intracranial Hemorrhages/diagnosis , Intracranial Hemorrhages/mortality , Iran/epidemiology , Length of Stay/trends , Male , Middle Aged , Recovery of Function , Stroke/diagnosis , Stroke/mortality , Time Factors , Treatment Outcome
7.
J Stroke Cerebrovasc Dis ; 29(9): 105011, 2020 Sep.
Article in English | MEDLINE | ID: covidwho-548355

ABSTRACT

The current COVID-19 pandemic has recently brought to attention the myriad of neuro- logic sequelae associated with Coronavirus infection including the predilection for stroke, particularly in young patients. Reversible cerebral vasoconstriction syndrome (RCVS) is a well-described clinical syndrome leading to vasoconstriction in the intracra- nial vessels, and has been associated with convexity subarachnoid hemorrhage and oc- casionally cervical artery dissection. It is usually reported in the context of a trigger such as medications, recreational drugs, or the postpartum state; however, it has not been described in COVID-19 infection. We report a case of both cervical vertebral ar- tery dissection as well as convexity subarachnoid hemorrhage due to RCVS, in a pa- tient with COVID-19 infection and no other triggers.


Subject(s)
Betacoronavirus/pathogenicity , Cerebral Arteries/physiopathology , Coronavirus Infections/complications , Pneumonia, Viral/complications , Subarachnoid Hemorrhage/complications , Vasoconstriction , Vertebral Artery Dissection/complications , Adult , COVID-19 , Cerebral Arteries/diagnostic imaging , Cerebral Arteries/drug effects , Coronavirus Infections/diagnosis , Coronavirus Infections/virology , Female , Headache Disorders, Primary/etiology , Headache Disorders, Primary/physiopathology , Host-Pathogen Interactions , Humans , Pandemics , Pneumonia, Viral/diagnosis , Pneumonia, Viral/virology , Risk Factors , SARS-CoV-2 , Subarachnoid Hemorrhage/diagnostic imaging , Subarachnoid Hemorrhage/drug therapy , Subarachnoid Hemorrhage/physiopathology , Syndrome , Vasoconstriction/drug effects , Vasodilation , Vertebral Artery Dissection/diagnostic imaging , Vertebral Artery Dissection/drug therapy , Vertebral Artery Dissection/physiopathology
9.
J Stroke Cerebrovasc Dis ; 29(8): 104941, 2020 Aug.
Article in English | MEDLINE | ID: covidwho-380483

ABSTRACT

Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a global health threat. Some COVID-19 patients have exhibited widespread neurological manifestations including stroke. Acute ischemic stroke, intracerebral hemorrhage, and cerebral venous sinus thrombosis have been reported in patients with COVID-19. COVID-19-associated coagulopathy is increasingly recognized as a result of acute infection and is likely caused by inflammation, including inflammatory cytokine storm. Recent studies suggest that axonal transport of SARS-CoV-2 to the brain can occur via the cribriform plate adjacent to the olfactory bulb that may lead to symptomatic anosmia. The internalization of SARS-CoV-2 is mediated by the binding of the spike glycoprotein of the virus to the angiotensin-converting enzyme 2 (ACE2) on cellular membranes. ACE2 is expressed in several tissues including lung alveolar cells, gastrointestinal tissue, and brain. The aim of this review is to provide insights into the clinical manifestations and pathophysiological mechanisms of stroke in COVID-19 patients. SARS-CoV-2 can down-regulate ACE2 and, in turn, overactivate the classical renin-angiotensin system (RAS) axis and decrease the activation of the alternative RAS pathway in the brain. The consequent imbalance in vasodilation, neuroinflammation, oxidative stress, and thrombotic response may contribute to the pathophysiology of stroke during SARS-CoV-2 infection.


Subject(s)
Betacoronavirus/pathogenicity , Brain/physiopathology , Coronavirus Infections/physiopathology , Encephalitis, Viral/physiopathology , Pneumonia, Viral/physiopathology , Stroke/physiopathology , Angiotensin-Converting Enzyme 2 , Betacoronavirus/metabolism , Blood Coagulation , Brain/metabolism , Brain/virology , COVID-19 , Coronavirus Infections/epidemiology , Coronavirus Infections/metabolism , Coronavirus Infections/virology , Encephalitis, Viral/epidemiology , Encephalitis, Viral/metabolism , Encephalitis, Viral/virology , Host Microbial Interactions , Humans , Inflammation Mediators/metabolism , Oxidative Stress , Pandemics , Peptidyl-Dipeptidase A/metabolism , Pneumonia, Viral/epidemiology , Pneumonia, Viral/metabolism , Pneumonia, Viral/virology , Renin-Angiotensin System , SARS-CoV-2 , Signal Transduction , Spike Glycoprotein, Coronavirus/metabolism , Stroke/epidemiology , Stroke/metabolism , Stroke/virology , Vasodilation , Virulence
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