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1.
J Stroke Cerebrovasc Dis ; 30(12): 106152, 2021 Dec.
Article in English | MEDLINE | ID: covidwho-1506161

ABSTRACT

Cerebrovascular diseases attributed to coronavirus disease 2019 (COVID-19) are uncommon but can result in devastating outcomes. Pediatric acute ischemic strokes are themselves rare and with very few large vessel occlusion related acute ischemic strokes attributed to COVID-19 described in the literature as of date. COVID-19 pandemic has contributed to acute stroke care delays across the world and with pediatric endovascular therapy still in its infancy, it poses a great challenge in facilitating good outcomes in children presenting with acute ischemic strokes in the setting of COVID-19. We present a pediatric patient who underwent endovascular therapy for an internal carotid artery occlusion related acute ischemic stroke in the setting of active COVID-19 and had an excellent outcome thanks to a streamlined stroke pathway involving the vascular neurology, neuro-interventional, neurocritical care, and anesthesiology teams.


Subject(s)
COVID-19/complications , Carotid Artery Thrombosis/therapy , Carotid Artery, Internal , Carotid Stenosis/therapy , Endovascular Procedures , Ischemic Stroke/therapy , Thrombectomy , COVID-19/diagnosis , Carotid Artery Thrombosis/diagnosis , Carotid Artery Thrombosis/etiology , Carotid Artery, Internal/diagnostic imaging , Carotid Stenosis/diagnosis , Carotid Stenosis/etiology , Child , Endovascular Procedures/instrumentation , Humans , Ischemic Stroke/diagnosis , Ischemic Stroke/etiology , Male , Stents , Treatment Outcome
2.
Sultan Qaboos Univ Med J ; 21(1): e116-e119, 2021 Feb.
Article in English | MEDLINE | ID: covidwho-1156224

ABSTRACT

OBJECTIVES: This study aimed to discuss the different challenges faced while managing emergency vascular surgery cases during the COVID-19 pandemic and how these challenges were overcome. METHODS: This study details 14 emergency cases that were managed during a period of one month from mid-March to mid-April at Sultan Qaboos University Hospital, Muscat, Oman. The cases included acute limb ischaemia, critical limb ischaemia, type B dissection of the thoracic aorta, thoraco-abdominal aneurysm, critical internal carotid artery stenosis, trauma, infected arteriovenous forearm loop graft and thrombosed arteriovenous fistulas. RESULTS: Only one patient was confirmed to have COVID-19. Five were negative for COVID-19 while the remaining eight were not tested. Various strategies on how the vascular surgical team accommodated changes in hospital protocols and nationwide lockdown are discussed in detail. CONCLUSIONS: With the judicious use of personal protective equipment and consumable surgical and endovascular devices, communication with support services and other hospitals and implementation of triage protocols, it was possible to manage vascular surgery emergencies effectively.


Subject(s)
COVID-19/diagnosis , Emergencies , Referral and Consultation , Vascular Diseases/therapy , Vascular Surgical Procedures/methods , Adult , Aged , Aged, 80 and over , Amputation/methods , Aneurysm, Dissecting/therapy , Angioplasty/methods , Aortic Aneurysm/therapy , Arteriovenous Shunt, Surgical , COVID-19/complications , Carotid Stenosis/therapy , Disease Management , Embolectomy/methods , Female , Graft Occlusion, Vascular/complications , Graft Occlusion, Vascular/therapy , Humans , Ischemia/therapy , Lower Extremity , Male , Middle Aged , Oman , SARS-CoV-2 , Tertiary Care Centers , Upper Extremity
3.
J Stroke Cerebrovasc Dis ; 29(12): 105362, 2020 Dec.
Article in English | MEDLINE | ID: covidwho-872318

ABSTRACT

INTRODUCTION: The COVID-19 pandemic has presented challenges to managing vascular risk factors with in-person follow-up of patients with asymptomatic carotid stenosis enrolled in the CREST2 trial. CREST2 is comparing intensive medical management alone versus intensive medical management plus revascularization with endarterectomy or stenting. We performed a study to evaluate the feasibility of a home-based program for testing blood pressure (BP) and low-density lipoprotein (LDL) in CREST2. METHODS: This study involved 45 patients at 10 sites in the CREST2 trial. The initial patients were identified by the Medical Management Core (MMC) as high-risk patients defined by stage 2 hypertension, LDL > 90 mg/dl, or both. If a patient at the site declined participation, another was substituted. All patients who agreed to participate were sent a BP monitoring device and a commercially available at-home lipid test kit that uses a self-performed finger-stick blood sample that was resulted to the patient. Training on the use of the equipment and obtaining the risk factor results was done by the study coordinator by telephone. RESULTS: Ten of the 130 currently active CREST2 sites participated, 8 in the LDL portion and 5 in the BP portion (3 sites did both). Twenty-six BP devices and 23 lipid tests were sent to patients. Of the 26 patients who obtained BP readings with the devices, 9 were out of the study target and adjustments in BP medications were made in 3. Of the 23 patients sent LDL tests, 13 were able to perform the test showing 7 were out of target, leading to adjustments in lipid medications in 4. CONCLUSION: This study established the feasibility of at-home monitoring of BP and LDL in a clinical trial and identified implementation challenges prior to widespread use in the trial. (ClinicalTrials.gov number NCT02089217).


Subject(s)
Blood Pressure Monitoring, Ambulatory , Blood Pressure , COVID-19 , Carotid Stenosis/therapy , Lipoproteins, LDL/blood , Reagent Kits, Diagnostic , Biomarkers/blood , Carotid Stenosis/blood , Carotid Stenosis/diagnosis , Carotid Stenosis/physiopathology , Feasibility Studies , Humans , Predictive Value of Tests , Reproducibility of Results , Treatment Outcome , United States
4.
J Stroke Cerebrovasc Dis ; 29(12): 105353, 2020 Dec.
Article in English | MEDLINE | ID: covidwho-796759

ABSTRACT

Coronavirus disease-19 (COVID-19) pandemic continues to grow all over the world. Neurological manifestations related to COVID-19, including acute ischemic Stroke (AIS), have been reported in recent studies. In most of these, the patients are older, have multiple co-morbidities as risk factors for AIS and have developed a severe respiratory illness. Herein, we report a 36-year-old man with no significant past medical history who recently recovered from a mild COVID-19 infection and presented with unusual pattern of arterial macrothrombosis causing AIS. When the AIS happened, he had no COVID-19 related symptoms, had two negative screening tests for the infection and his chest CT was unremarkable.


Subject(s)
Brain Ischemia/etiology , COVID-19/complications , Carotid Stenosis/etiology , Intracranial Thrombosis/etiology , Stroke/etiology , Adult , Age Factors , Anticoagulants/administration & dosage , Brain Ischemia/diagnostic imaging , Brain Ischemia/therapy , COVID-19/diagnosis , Carotid Stenosis/diagnostic imaging , Carotid Stenosis/therapy , Heparin/administration & dosage , Humans , Intracranial Thrombosis/diagnostic imaging , Intracranial Thrombosis/therapy , Male , Stroke/diagnostic imaging , Stroke/therapy , Thrombectomy , Time Factors , Treatment Outcome
5.
J Stroke Cerebrovasc Dis ; 29(12): 105307, 2020 Dec.
Article in English | MEDLINE | ID: covidwho-753198

ABSTRACT

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) initially most appreciated for its pulmonary symptoms, is now increasingly recognized for causing multi-organ disease and stroke in the setting of a hypercoagulable state. We report a case of 33-year-old African American woman with COVID-19 who developed acute malignant middle cerebral artery infarction due to thromboembolic occlusion of the left terminal internal carotid artery and middle cerebral artery stem. Mechanical thrombectomy was challenging and ultimately unsuccessful resulting in limited reperfusion of <67% of the affected vascular territory, and thrombectomized clot was over 50 mm in length, at least three times the average clot length. The final stroke size was estimated at 224 cubic centimeters. On admission her D-dimer level was 94,589 ng/mL (normal 0-500 ng/ml). Throughout the hospitalization D-dimer decreased but never reached normal values while fibrinogen trended upward. Hypercoagulability panel was remarkable for mildly elevated anticardiolipin IgM of 16.3 MPL/mL (normal: 0-11.0 MPL/mL). With respect to remaining stroke workup, there was no evidence of clinically significant stenosis or dissection in the proximal internal carotid artery or significant cardioembolic source including cardiomyopathy, atrial fibrillation, cardiac thrombus, cardiac tumor, valvular abnormality, aortic arch atheroma, or patent foramen ovale. She developed malignant cytotoxic cerebral edema and succumbed to complications. This case underscores the importance of recognizing hypercoagulability as a cause of severe stroke and poor outcome in young patients with COVID-19 and highlights the need for further studies to define correlation between markers of coagulopathy in patients with COVID-19 infection and outcome post stroke.


Subject(s)
Blood Coagulation , COVID-19/complications , Carotid Stenosis/etiology , Infarction, Middle Cerebral Artery/etiology , Thrombophilia/etiology , Adult , Biomarkers/blood , Brain Edema/etiology , COVID-19/blood , COVID-19/diagnosis , COVID-19/therapy , Carotid Stenosis/blood , Carotid Stenosis/diagnostic imaging , Carotid Stenosis/therapy , Disease Progression , Fatal Outcome , Female , Fibrin Fibrinogen Degradation Products/metabolism , Humans , Infarction, Middle Cerebral Artery/blood , Infarction, Middle Cerebral Artery/diagnostic imaging , Infarction, Middle Cerebral Artery/therapy , Thrombectomy , Thrombophilia/complications , Thrombophilia/diagnosis , Treatment Outcome
6.
Neurology ; 95(1): 29-36, 2020 07 07.
Article in English | MEDLINE | ID: covidwho-155213

ABSTRACT

The coronavirus disease 2019 pandemic has disrupted the lives of whole communities and nations. The multinational multicenter National Institute of Neurological Disorders and Stroke Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial stroke prevention trial rapidly experienced the effects of the pandemic and had to temporarily suspend new enrollments and shift patient follow-up activities from in-person clinic visits to telephone contacts. There is an ethical obligation to the patients to protect their health while taking every feasible step to ensure that the goals of the trial are successfully met. Here, we describe the effects of the pandemic on the trial and steps that are being taken to mitigate the effects of the pandemic so that trial objectives can be met.


Subject(s)
Carotid Stenosis/therapy , Coronavirus Infections/epidemiology , Pandemics , Pneumonia, Viral/epidemiology , Randomized Controlled Trials as Topic/methods , Stroke/prevention & control , Aged , Aged, 80 and over , Angiotensin II Type 1 Receptor Blockers/therapeutic use , Angiotensin-Converting Enzyme Inhibitors/therapeutic use , Asymptomatic Diseases , Betacoronavirus , COVID-19 , Canada/epidemiology , Carotid Stenosis/epidemiology , Communicable Disease Control/methods , Comorbidity , Diabetes Mellitus/epidemiology , Dyslipidemias/epidemiology , Elective Surgical Procedures , Female , Humans , Hypertension/epidemiology , Infection Control/methods , Male , Middle Aged , Patient Selection , Risk Factors , SARS-CoV-2 , Spain/epidemiology , Telemedicine , United States/epidemiology
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