Comparison of High-Risk Pulmonary Embolism Patients with and without COVID-19

Objectives: There has been a significant increase in pulmonary embolism (PE) cases during the coronavirus disease of 2019 (COVID-19) pandemic. In this study, we aimed to compare the effects of COVID-19 positivity on morbidity and mortality in patients treated with a diagnosis of high-risk PE. Method(s): In this single-center and observational study, patients who were referred to our center with the diagnosis of PE between January 1, 2019 and 2021 were retrospectively evaluated. Patients with moderate- and low-risk PE according to the European Society of Cardiology PE guidelines, those who did not undergo computed tomography pulmonary angiography (CTPA) or the ones who did not accept treatment were excluded from the study. The patients included in the study were divided into two groups, as those with and without COVID-19, and compared in terms of demographic data, comorbidities, symptoms, thromboembolism in vessels other than the pulmonary artery, laboratory parameters, treatments, and prognosis. Result(s): A total of 384 PE cases were identified during the study period. Among them, 322 cases that were in the intermediate or low-risk category, 21 cases who did not undergo CTPA, and one case who did not accept thrombolytic therapy were excluded from the study. A total of 40 cases were included in the study. The groups with and without COVID-19 consisted of 23 and 17 patients, respectively. In the group of patients with COVID-19, inflammatory markers were higher, Wells score was lower, and thromboembolism was seen in vessels other than the pulmonary artery. The two groups were similar in terms of other laboratory parameters, demographic data, comorbidities, symptoms, treatment, and prognosis. Conclusion(s): While the involvement of COVID-19 in PE etiology does not change mortality, it may cause more thrombosis development in both venous and arterial systems outside the pulmonary area by significantly increasing inflammation. However, the lower Wells scores in COVID-19 PE cases in our study indicate that new clinical assessment tools are needed to detect PE risk in COVID-19 patients.©Copyright 2022 by The Cardiovascular Thoracic Anaesthesia and Intensive Care.

Discussion on the causes of thrombolysis failure in a patient with STEMI: a case report.

BACKGROUND: Spontaneous coronary artery dissection (SCAD) has emerged as an increasingly diagnosed cause of ST-segment elevation myocardial infarction (STEMI), which is easily missed or delayed. The effective use of coronary angiography (CAG) and advanced intracoronary imaging examinations in STEMI patients has led to increased detection of SCAD. CASE PRESENTATION: A 59-year-old woman with acute angina pectoris was diagnosed with STEMI detected by electrocardiography combined with measurement of myocardial enzymes. Due to the ongoing pandemic of coronavirus disease 2019 (COVID-19) in Wuhan, she was first given thrombolytic therapy after excluding contraindications according to the requirements of the current consensus statement; however, subsequently, both the symptoms of ongoing chest pain and the electrocardiographic results indicated the failure of thrombolytic therapy, so the intervention team administered rescue percutaneous coronary intervention treatment under third-grade protection. CAG confirmed total occlusion in the distal left anterior descending (LAD) artery, with thrombolysis in myocardial infarction (TIMI) 0 flow, whereas the left circumflex and right coronary arteries appeared normal, with TIMI 3 flow. Intravenous ultrasound (IVUS) was further performed to investigate the causes of occlusion, which verified the absence of atherosclerosis but detected SCAD with intramural haematoma. During the operation, the guidewire reached the distal end of the LAD artery smoothly, the balloon was dilated slightly, and the reflow of TIMI blood could be seen by repeated CAG. During the follow-up period of one and a half years, the patient complained of occasional, slight chest tightness. The repeated CAG showed that the spontaneous dissection in the LAD artery had healed well, with TIMI 3 flow. The repeated IVUS confirmed that the SCAD and intramural haematoma had been mostly resorbed and repaired. CONCLUSION: This was a case of failed STEMI thrombolysis in our hospital during the outbreak of COVID-19. This case indicates that doctors need to consider the cause of the disease when treating STEMI patients, especially patients without traditional cardiovascular risk factors. Moreover, CAG and intracoronary imaging examinations should be actively performed to identify the aetiology and improve the treatment success rate.

The mucormycosis and stroke: The learning curve during the second COVID-19 pandemic.

BACKGROUND: The Angio-invasive Rhino-orbito-cerebral mucormycosis (ROCM) producing strokes is a less explored entity. Our hospital, a stroke-ready one, had an opportunity to manage mucormycosis when it was identified as the nodal center for mucormycosis management. We are sharing our experiences and mistakes in managing the cerebrovascular manifestations of ROCM. METHODS: We conducted a prospective observational study during the second wave of the COVID-19 pandemic from 1st May 2021 to 30th September 2021, where consecutive patients aged more than 18 years with microbiologically confirmed cases of ROCM were included. Clinical details (timing of stroke onset after ROCM symptoms, GCS, NIHSS), imaging findings (ASPECTS, the territory of stroke, the pattern of infarct, hemorrhagic transformation, cavernous sinus thrombosis), angiogram findings, management details (IV thrombolysis), and outcomes (mRS at discharge and duration of hospital stay) were documented. We also compared the demographics, clinical features (NIHSS), radiological findings, treatment details, duration of hospital stay, and functional outcome at the discharge of the ROCM stroke patients with stroke patients without ROCM. RESULTS: Stroke developed in 42% of patients with ROCM, predominantly anterior circulation border zone ischemic infarcts. Strokes occurred after a median of five days from the onset of ROCM symptoms. The most common vessel involved was the ophthalmic artery, followed by the cavernous ICA. We could not thrombolyse ROCM stroke patients. ROCM patients who developed stroke compared with patients without stroke had a more infiltrative fungal infection and higher inflammatory markers. Mucormycosis associated stroke patients had higher in-hospital mortality and poor functional outcomes. T CONCLUSION: Due to delayed recognition of stroke symptoms, none received reperfusion strategies, leading to poor functional outcomes. For early stroke detection, ROCM cases need frequent monitoring and education of patients and their relatives about the ALS acronym (loss of ambulation, limb weakness, and loss of speech).

Electrical Impedance Tomography As a Bedside Diagnostic Tool for Pulmonary Embolism.

Electrical impedance tomography (EIT) has been shown to be of value in evaluating the distribution of ventilation. In addition, several studies, particularly case reports, have demonstrated the use of EIT in the assessment of lung perfusion. EIT may be a potential diagnostic bedside tool in the diagnosis and follow-up of acute pulmonary embolism. CASE SUMMARY: We present one case of a patient with COVID-19 who likely had pulmonary thromboembolism where perfusion scans were made before and after thrombolytic therapy. Perfusion scans showed improvement after thrombolytic therapy. This article should therefore be seen as a first step in proving the validity of EIT-derived perfusion scans as a diagnostic for pulmonary embolism. CONCLUSION: The hypertonic saline bolus EIT method as a diagnostic tool for pulmonary embolism is a promising new technique, which can be particularly meaningful for critically ill patients. Further study is required to evaluate the sensitivity and specificity of this technique and the impact on decision-making and outcomes of critically ill patients.

Systemic thrombolytics as rescue therapy for COVID-19 patients with acute respiratory distress syndrome: A retrospective observational study.

Background: Coronavirus disease 2019 (COVID-19) pneumonia with severe acute respiratory distress syndrome (ARDS) is often associated with a progressive respiratory failure that is refractory to maximal ventilatory support and other ARDS strategies. Studies show evidence of a hypercoagulable state in COVID-19 patients, including capillary thrombosis and alveolar fibrin deposits which impede normal gas exchange. In this context, thrombolysis is considered as a salvage therapy to rescue critically hypoxemic patients. Methods: In this retrospective observational study, the efficacy of thrombolysis on outcome of COVID-19 ARDS with respiratory failure was analyzed. Patients with severe ARDS and d-dimer levels of 5 µg/ml or above were initiated on alteplase, as a 25 mg bolus followed by a 25 mg infusion over 22 h. Primary outcome was intensive care unit (ICU) mortality and secondary outcomes were change in PaO2/FiO2 24 h after thrombolysis, avoidance of intubation, ventilator free days (VFD), and ICU and hospital length-of-stay (LOS). Results: Thirteen out of 34 patients with severe COVID ARDS underwent thrombolysis. They had lower ICU mortality than non-thrombolysed patients (23.1% vs. 71.4%, P = 0.006), greater percentage improvement in PaO2/FiO2 (116% vs. 31.5%, P = 0.002), more VFDs (13 days vs. 0 day, P = 0.004), and lesser requirement for intubation (23.1% vs. 76.2%, P = 0.004). ICU and hospital LOS were similar. Conclusion: Thrombolysis can be considered as a rescue therapy for nonintubated COVID-19 ARDS patients with severe hypoxemic respiratory failure, who show evidence of a procoagulant state. Larger studies are needed before inclusion into the regular treatment protocol for COVID-19 patients.

FEATURES OF COAGULOPATHY AND SYSTEMIC INFLAMMATION IN PATIENTS AFTER COVID-19 INFECTION.

OBJECTIVE: The aim: To determine the peculiarities of laboratory data concerning blood coagulation and systemic inflammation in COVID-19 patients in three months after discharge and recovery. The state of coagulation, anticoagulation, and fibrinolytic systems, as well as their prognostic value having been well studied in hospitalized COVID-19 patients, their state three months after hospitalization, are not yet well understood. PATIENTS AND METHODS: Materials and methods: Methods of randomization, anthropometry, ECG, standard clinical blood testing, immunoenzymometry, immunoanalysis, and primary statistical analysis were used in the study. Anthropometric measurements of patients (n=20), blood samples, blood serum samples, urine samples, and statistical data were the materials of the study. RESULTS: Results: Indices of coagulation and systemic inflammation in studied patients after COVID-19 were obtained (PTT, s ; PATPT, s; Fibrinogen, g/L; Platelets ×109 /L; PCT, ng/mL; DD, µg/L; СRP, mg/L; IL -6, pg/mL; IL -10, pg/mL; Cortisol (nM/L); CIC (IU/mL); Ig A (g/L). CONCLUSION: Conclusions: Summing up the results obtained, it is possible to assert micro- and macro-vascular thromboses to be common in COVID-19 cases; they are associated with poor prognosis for diseased patients and are not completely investigated; the role of thromboses in COVID-19 course and complications are to be studied as well as the strategies of fibrinolytic therapies for such condition are to be justified. The presence of specific rheological and serological changes in patients even three months after surviving COVID-19 needs further study to understand the necessity of anti-thrombolytic drug uptake for a relatively long time.

The effects of the coronavirus disease pandemic on intravenous thrombolytic therapy among patients with acute ischemic stroke in Dalian, China.

BACKGROUND: We investigated the influence of the coronavirus disease 2019 (COVID-19) pandemic on the number of patients with acute ischemic stroke who received intravenous thrombolytic therapy (ITT) in Dalian, China, in 2020. METHODS: This retrospective descriptive study, conducted from February 1, 2020, to August 31, 2020, examined 13 hospitals in Dalian that participated in the "stroke emergency map". To use this "stroke emergency map" of China, patients followed the official "Stroke Map" WeChat account and dialed 120 for emergency medical services. We analyzed the number of patients with acute ischemic stroke who underwent ITT. In particular, we examined the onset-to-door time (ODT), door-to-needle time (DNT), onset-to-needle time (ONT), mode of transportation to the hospital, and National Institutes of Health Stroke Scale (NIHSS) scores before and after ITT. Data were collected for the aforementioned period and compared with the 2021 baseline data from the same time of year. The Mann‒Whitney U test was performed for data analysis. RESULTS: Compared with the data from 2020, the number of patients with acute ischemic stroke who underwent ITT increased (from 735 to 1719 cases) in 2021, but the DNT decreased (from 59 to 45 min; P = 0.002). Moreover, 83.9% of patients in 2020 presented to the hospital without ambulance transport, compared to 81.1% of patients in the 2021 non-COVID-19 pandemic period. Patients with NIHSS scores of 6-14 were more likely to call an ambulance for transport to the hospital than to transport themselves to the emergency department. CONCLUSIONS: During the 2020 COVID-19 pandemic, the DNT was prolonged as a result of strengthened fever surveillance. In 2021, the number of patients with acute ischemic stroke who underwent ITT increased compared to the previous year. Notably, the growth in the number of patients with acute ischemic stroke who underwent ITT benefited from both the "stroke emergency map" of China and the "green channel," a novel treatment approach that focuses on the rational design of the rescue process. TRIAL REGISTRATION: Our study was a retrospective descriptive study, not a clinical trial, thus we did not have to register for clinical trials.

Successful thrombolysis with low dose thrombolytic agent in a patient with acute life-threatening massive pulmonary thromboembolism: A case report.

Introduction: and importance: Acute massive pulmonary thromboembolism is a potentially life-threatening condition requiring urgent management to decrease mortality. Although the standard dose of systemic thrombolysis with alteplase is 100 mg, half the dose of alteplase can be used to break up clots successfully, especially if bleeding is a concern. Case presentation: We report a case of massive pulmonary thromboembolism presenting with cardiopulmonary arrest, successfully managed with advanced cardiac life support, anticoagulants, and low-dose thrombolytics. Clinical discussion: Management of massive pulmonary thromboembolism includes medical thrombolysis along with maintenance of hemodynamic stability. Our patient was successfully managed with low-dose thrombolytics and was continued with standard oral anticoagulants for 6 months. Conclusion: In patients of acute massive pulmonary thromboembolism, a low dose of the thrombolytic agent can achieve complete resolution of the thrombus with less bleeding risk.

Pharmacotherapy consideration of thrombolytic medications in COVID-19-associated ARDS.

BACKGROUND: In late 2019, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which is responsible for coronavirus disease (COVID-19), was identified as the new pathogen to lead pneumonia in Wuhan, China, which has spread all over the world and developed into a pandemic. Despite the over 1 year of pandemic, due to the lack of an effective treatment plan, the morbidity and mortality of COVID-19 remains high. Efforts are underway to find the optimal management for this viral disease. MAIN BODY: SARS-CoV-2 could simultaneously affect multiple organs with variable degrees of severity, from mild to critical disease. Overproduction of pro-inflammatory mediators, exacerbated cellular and humoral immune responses, and coagulopathy such as Pulmonary Intravascular Coagulopathy (PIC) contributes to cell injuries. Considering the pathophysiology of the disease and multiple microthrombi developments in COVID-19, thrombolytic medications seem to play a role in the management of the disease. Beyond the anticoagulation, the exact role of thrombolytic medications in the management of patients with COVID-19-associated acute respiratory distress syndrome (ARDS) is not explicit. This review focuses on current progress in underlying mechanisms of COVID-19-associated pulmonary intravascular coagulopathy, the historical use of thrombolytic drugs in the management of ARDS, and pharmacotherapy considerations of thrombolytic therapy, their possible benefits, and pitfalls in COVID-19-associated ARDS. CONCLUSIONS: Inhaled or intravenous administration of thrombolytics appears to be a salvage therapy for severe ARDS associated with COVID-19 by prompt attenuation of lung injury. Considering the pathogenesis of COVID-19-related ARDS and mechanism of action of thrombolytic agents, thrombolytics appear attractive options in stable patients without contraindications.

The Effects of the SARS-CoV-2 Virus on the Cardiovascular System and Coagulation State Leading to Cardiovascular Diseases: A Narrative Review.

The novel coronavirus pandemic has led to morbidity and mortality throughout the world. Until now, it is a highly virulent contagion attacking the respiratory system in humans, especially people with chronic diseases and the elderly who are most vulnerable. A majority of afflicted are those suffering from cardiovascular and coronary diseases. In this review article, an attempt has been made to discuss and thoroughly review the mode of therapies that alleviate cardiac complications and complications due to hypercoagulation in patients infected with the SARS-CoV-2 virus. Presently a host of thrombolytic drugs are in use like Prourokinase, Retelapse, RhTNK-tPA and Urokinase. However, thrombolytic therapy, especially if given intravenously, is associated with a serious risk of intracranial haemorrhage, systemic haemorrhage, immunologic complications, hypotension and myocardial rupture. The effects of the SARS-CoV-2 virus upon the cardiovascular system and coagulation state of the body are being closely studied. In connection to the same, clinical prognosis and complications of thrombolytic therapy are being scrutinized. It is noteworthy to mention that myocardial oxygen supply/demand mismatch, direct myocardial cells injury and acute plaque rupture are the multiple mechanisms responsible for acute coronary syndrome and cardiac complications in Covid-19 infection. However, this review has limitations as data available in this context is limited, scattered and heterogenous that questions the reliability of the same. So, more multi-centric studies involving representative populations, carried out meticulously, could further assist in responding better to cardiac complications among Covid-19 patients.

Successful use of ultraslow thrombolytic therapy in stuck mechanical aortic valve in a patient with COVID-19; a case report.

INTRODUCTION AND IMPORTANCE: COVID-19 represents a new challenge for patients with prosthetic valve, through increasing the risk of thrombosis and reducing the frequency of anticoagulation follow up visits. CASE PRESENTATION: A 37-year-old male patient on aspirin and warfarin for a mechanical aortic valve (AV, St Jude size 21 mm), presented with generalized fatigue and loss one of the mechanical heart sounds for 10 days. Urgent fluoroscopy showed stuck one of the AV leaflets in a closed and opening positions. Echocardiography showed high peak and mean AV gradients. The patient was confirmed with COVID-19 with fever on the day of admission. Cardiac CT with contrast showed stuck right (posterior) disc with a 6 × 4 mm thrombus surrounded by pannus formation. The patient was started on ultraslow thrombolytic therapy (alteplase 1 mg, every hour for 25 h, followed by 6 h of unfractionated heparin). Repeated fluoroscopy showed normal opening and closure of both discs. Repeated echocardiography showed a significant reduction in the peak and mean AV gradients back to baselines. The patient was discharged after 7 days with INR 3.0 for two consecutive days. The patient was asymptomatic with stable INR in three- and six-month follow-up visits. Transthoracic ultrasound demonstrated normally functioning mechanical AV. CLINICAL DISCUSSION: Accurate and timely diagnosis of stuck mechanical AV requires high suspicion and timely diagnostic aids. CONCLUSION: Full recovery can be achieved after one cycle of ultraslow thrombolytic therapy. Further supportive data are still needed before recommending thrombolytic therapy as a successful alternative to surgery in COVID-19 patients.

Time Metrics in Acute Ischemic Stroke Care During the Second and First Wave of COVID 19 Pandemic: A Tertiary Care Center Experience from South India.

BACKGROUND: During the first wave of the pandemic, stroke care suffered globally and there were reduced stroke admissions and delays in time metrics. Stroke care was reorganized during the second wave learning from the experience of previous wave. This study shares our experience in stroke time metrics during the second wave of pandemic compared to the first wave. METHODS: We did a single-center prospective study, where consecutive acute ischemic stroke patients within 24 hours of the onset of symptoms and aged more than 18 years, who presented to Stroke Unit, Department of Neurology, Government Medical College, Thiruvananthapuram from June 1st to 31st August, 2020 and June 1st to 31st August in 2021 were included. In-hospital time metrics (door to CT time and door to Needle time) were compared during the two time periods. We also compared functional outcomes at discharge and in-hospital mortality during the two periods. Functional outcome at discharge was assessed by modified Rankin scale (mRS). RESULTS: From June to August 2021 (second wave of the COVID 19 pandemic), compared to the same months during the first wave (2020), our study demonstrated better in-hospital time metrics (door to CT time and door to needle time). We also found lower admission systolic blood pressure and higher baseline CT early ischemic changes during the second wave. There was no difference in functional outcome at discharge and in-hospital mortality. Intravenous thrombolysis rates also remained the same during the two periods. CONCLUSION: Our study has confirmed that time metrics in stroke care can be improved through system rearrangement even during the pandemic. Acute stroke treatments are time-dependent and hospital administrators must stick to the maxim "Time is Brain" while restructuring stroke workflows during future challenges.

SYSTEMIC THROMBOLYSIS AND ECPR FOR FATAL MIS-C WITH EXTENSIVE CORONARY THROMBOSIS AND CARDIAC ARREST

Extracorporeal cardiopulmonary resuscitation (ECPR) and thrombolytic therapy were utilized to re-establish myocardial perfusion and prevent death. Herein, we report a case of fatal MIS-C with giant coronary artery aneurysms complicated myocardial infraction and extensive thrombosis, despite intravenous immunoglobulin (IVIG), steroids, and immunomodulators. [Extracted from the article] Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Acute myocardial infarction with ST-segment elevation. / Infarto agudo al miocardio con elevación del segmento ST en época de COVID-19.

Coronavirus disease 19 (COVID-19) is the infection caused by the SARS-CoV-2 virus and it has become a global emergency. The disease has a hughe impact on cardiopaths. Under regular conditions, patients entering the emergency room with a ST-segment elevation myocardial infarction (STEMI) must be urgently treated with reperfusion strategy. However, due to the scarce knowledge about COVID-19, there have not being yet established the guidelines for management of patients with STEMI and COVID-19. In this review we expose the main conclusions of relevant articles published about STEMI management during this pandemic. We aim to provide a review to guide the decisions about the management of STEMI during the COVID-19 emergency.

La infección por coronavirus SARS-CoV-2 es una emergencia sanitaria global que puede afectar gravemente a las personas cardiópatas. En condiciones normales, los pacientes que se presentan en las unidades médicas con diagnóstico de infarto agudo al miocardio con elevación del segmento ST (IAM-CEST) deben ser atendidos con estrategia de reperfusión coronaria de manera urgente. Sin embargo, no existen lineamientos bien establecidos sobre el tratamiento de los pacientes con IAM-CEST y COVID-19 debido a la aún escasa información al respecto, dada la súbita aparición de la enfermedad. En este artículo se exponen los principales aspectos de los artículos más relevantes sobre el manejo del IAM-CEST en el contexto de esta pandemia. El objetivo de esta publicación es apoyar en la toma de decisiones para el manejo del IAM-CEST en el contexto de la emergencia por COVID-19.

Overview of Acute Ischemic Stroke Evaluation and Management.

Stroke is a major contributor to death and disability worldwide. Prior to modern therapy, post-stroke mortality was approximately 10% in the acute period, with nearly one-half of the patients developing moderate-to-severe disability. The most fundamental aspect of acute stroke management is "time is brain". In acute ischemic stroke, the primary therapeutic goal of reperfusion therapy, including intravenous recombinant tissue plasminogen activator (IV TPA) and/or endovascular thrombectomy, is the rapid restoration of cerebral blood flow to the salvageable ischemic brain tissue at risk for cerebral infarction. Several landmark endovascular thrombectomy trials were found to be of benefit in select patients with acute stroke caused by occlusion of the proximal anterior circulation, which has led to a paradigm shift in the management of acute ischemic strokes. In this modern era of acute stroke care, more patients will survive with varying degrees of disability post-stroke. A comprehensive stroke rehabilitation program is critical to optimize post-stroke outcomes. Understanding the natural history of stroke recovery, and adapting a multidisciplinary approach, will lead to improved chances for successful rehabilitation. In this article, we provide an overview on the evaluation and the current advances in the management of acute ischemic stroke, starting in the prehospital setting and in the emergency department, followed by post-acute stroke hospital management and rehabilitation.

Thrombolytic Therapy for ST-Elevation Myocardial Infarction Presenting to non-Percutaneous Coronary Intervention Centers During the COVID-19 Crisis.

PURPOSE OF REVIEW: The purpose of this review is to offer a discussion on the existing data for the use of thrombolytic therapy for the treatment of ST-elevation myocardial infarction (STEMI) as well to present an evidence-based approach regarding the treatment for STEMI patients presenting to non-percutaneous coronary intervention (PCI)-capable hospitals during the ongoing COVID-19 pandemic. RECENT FINDINGS: There have been tremendous advances in the care of STEMI patients over the past two decades with primary (PCI) being the standard of care. However, many hospitals do not have interventional cardiology services available, and either have to expeditiously transfer patients for primary PCI, or use the strategy of fibrinolysis therapy with facilitated or rescue PCI. The current COVID-19 crisis has created an unprecedented paradigm shift with regard to the decision-making algorithm for STEMI patients especially in non-PCI-capable hospitals. Depending on regional transfer systems and potential delay in primary PCI, a strategy of thrombolysis first could be entertained at certain regional systems of care. The COVID-19 pandemic has caused a dramatic decline in the number of patient seeking care for myocardial infarction as well as a reduction in the accessibility of cardiac catheterization services. Regardless, professional societies continue to recommend PCI as the primary means of treatment for STEMI through the COVID-19 pandemic, and early multicenter data suggests the benefit of this therapy remains. Future research will be necessary and holds the key to proving this benefit persists beyond the immediate hospitalization time period both in the current era and in the context of possible future pandemics.

Safety and Outcomes of Intravenous Thrombolytic Therapy in Ischemic Stroke Patients with COVID-19: CASCADE Initiative.

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.

[Ischemic stroke in coronavirus disease 2019]. / Ischämische Hirninfarkte bei Coronavirus-19-Erkrankung.

This article reports two cases of patients with coronavirus disease 2019 (COVID-19) in which occlusion of large cerebral arteries occurred. These occurred in a female patient in the early stage of COVID-19 and in the second case in the late stage. One female patient could be successfully treated with i.v. thrombolysis and mechanical thrombectomy. Coagulopathy in the course of COVID-19 can result in severe stroke with poor outcome even in younger patients. With respect to the etiology of arterial occlusions (COVID-19-induced hypercoagulopathy, cardiomyopathy, vasculitis) there is a necessity for further research.

A Case of Failure of EkoSonic™ Endovascular System in the Treatment of Submassive Pulmonary Embolism.

Submassive pulmonary embolism (SPE) is characterized by the presence of right ventricular (RV) strain as visualized on echocardiogram or CT scan with brain natriuretic peptide (BNP) and/or troponin elevation. The condition accounts for 20-25% of all pulmonary embolism (PE) cases. In cases of SPE, catheter-directed thrombolysis (CDT) is generally considered in the presence of severe hypoxemia, worsening RV dysfunction, patients with increasing tachycardia and elevated troponins, free-floating thrombus in the right atrium or RV, and presence of extensive clot burden. EkoSonic™ Endovascular System (EKOS; Boston Scientific, Marlborough, MA) has been successfully used to treat cases of PE even where systemic thrombolytic therapy has failed. However, in this article, we describe a unique case of the failure of EKOS in treating a 71-year-old African American man who presented to the hospital with progressively worsening chest pain, shortness of breath, and fatigue. He was suspected to have SPE; however, a CT pulmonary angiogram could not be performed to estimate the clot burden due to an acute kidney injury. He was diagnosed with coronavirus disease 2019 (COVID-19) pneumonia during the hospitalization and had a delayed EKOS procedure with minimal improvement in oxygenation and clot burden. He subsequently underwent half-dose systemic thrombolytic therapy with complete resolution of his symptoms. Given our success with half-dose systemic therapy, we propose that it may be considered as a "rescue therapy" in cases where EKOS fails to deliver results.

Acute high-risk pulmonary embolism requiring thrombolytic therapy in a COVID-19 pneumonia patient despite intermediate dosing deep vein thromboprophylaxis.

Cytokine storm induced by the coronavirus 19 (COVID-19) profoundly activates the coagulation cascade causing venous thromboembolism (VTE). Initial studies from Wuhan, China showed increased incidence of VTE in patients with no standard deep vein thrombosis (DVT) prophylaxis in COVID-19 pneumonia patients. Few have argued for high intensity or intermediate DVT prophylaxis in COVID-19 patients with the incidence of VTE ranging from 16 to 27% despite standard DVT prophylaxis. However, no guideline recommendations presently exist to prescribe augmented DVT prophylaxis in these patients due to lack of evidence although the risk of VTE was clearly demonstrated. While there are ongoing trials to demonstrate the efficacy of intermediate dosing against standard DVT prophylaxis in the prevention of VTE, we present a 36-year-old male admitted with COVID-19 pneumonia who developed acute high-risk pulmonary embolism (PE) requiring emergent thrombolytic therapy despite intermediate dosing DVT prophylaxis.