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1.
Turk Neurosurg ; 31(5): 763-770, 2021.
Article in English | MEDLINE | ID: covidwho-1512942

ABSTRACT

AIM: To identify the characteristics of patients admitted to the emergency department with intracranial hemorrhages in the era of the COVID-19 pandemic. MATERIAL AND METHODS: Seventy-eight patients with spontaneous intracranial bleeding who were admitted to emergency departments and treated in neurosurgery clinics between March 11, 2020, and September 11, 2020, were included in the study. RESULTS: The most frequent symptom was the loss of consciousness (32.1%), followed by headache (15.4%), syncope (10.3%), motor loss (9%), and seizures (9%). Antiaggregant and anticoagulant drug use were detected in 37.2% of the patients. Intraparenchymal hematoma was the most common type of intracranial hemorrhage (59%). Viral pneumonia was detected in 52.6% of the patients in thorax CTs. Surgical treatment was applied to 23.1% of the patients. There was no significant difference between patients with pneumonia and patients without pneumonia in the treatment modalities or 30-day mortality. CONCLUSION: In this study, we found that low Glasgow Coma Scores affected mortality and that mechanical ventilation needs are higher in ICH patients with COVID-19. Nevertheless, the treatment differences may not have affected the outcomes.


Subject(s)
COVID-19 , Pandemics , Humans , Intracranial Hemorrhages/epidemiology , Retrospective Studies , SARS-CoV-2
2.
World Neurosurg ; 154: e473-e480, 2021 10.
Article in English | MEDLINE | ID: covidwho-1376112

ABSTRACT

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic is an ongoing public health emergency. While most cases end in asymptomatic or minor illness, there is growing evidence that some COVID-19 infections result in nonconventional dire consequences. We sought to describe the characteristics of patients with intracranial hemorrhage who were infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Also, with the existing literature, we raise the idea of a possible association between SARS-CoV-2 infection and intracranial hemorrhage and propose possible pathophysiological mechanisms connecting the two. METHODS: We retrospectively collected and analyzed intracranial hemorrhage cases who were also positive for SARS-CoV-2 from 4 tertiary-care cerebrovascular centers. RESULTS: We identified a total of 19 patients consisting of 11 males (58%) and 8 females (42%). Mean age was 52.2, with 95% younger than 75 years of age. With respect to COVID-19 illness, 50% had mild-to-moderate disease, 21% had severe disease, and 20% had critical disease requiring intubation. Of the 19 cases, 12 patients had intraparenchymal hemorrhage (63%), 6 had subarachnoid hemorrhage (32%), and 1 patient had a subdural hematoma (5%). A total of 43% had an intracerebral hemorrhage score of 0-2 and 57% a score of 3-6. Modified Rankin Scale cores at discharge were 0-2 in 23% and 3-6 in 77%. The mortality rate was 59%. CONCLUSIONS: Our series sheds light on a distinct pattern of intracerebral hemorrhage in COVID-19-positive cases compared with typical non-COVID-19 cases, namely the severity of hemorrhage, high mortality rate, and the young age of patients. Further research is warranted to delineate a potential association between SARS-CoV-2 infection and intracranial hemorrhage.


Subject(s)
COVID-19/complications , Intracranial Hemorrhages/epidemiology , Intracranial Hemorrhages/etiology , Adult , Age Factors , Aged , Aged, 80 and over , COVID-19/mortality , COVID-19/physiopathology , Female , Hematoma, Subdural/epidemiology , Hematoma, Subdural/etiology , Humans , Intracranial Hemorrhages/mortality , Intubation, Intratracheal , Male , Middle Aged , Retrospective Studies , Subarachnoid Hemorrhage/epidemiology , Subarachnoid Hemorrhage/etiology , Treatment Outcome , Young Adult
3.
Turk Neurosurg ; 31(5): 763-770, 2021.
Article in English | MEDLINE | ID: covidwho-1350488

ABSTRACT

AIM: To identify the characteristics of patients admitted to the emergency department with intracranial hemorrhages in the era of the COVID-19 pandemic. MATERIAL AND METHODS: Seventy-eight patients with spontaneous intracranial bleeding who were admitted to emergency departments and treated in neurosurgery clinics between March 11, 2020, and September 11, 2020, were included in the study. RESULTS: The most frequent symptom was the loss of consciousness (32.1%), followed by headache (15.4%), syncope (10.3%), motor loss (9%), and seizures (9%). Antiaggregant and anticoagulant drug use were detected in 37.2% of the patients. Intraparenchymal hematoma was the most common type of intracranial hemorrhage (59%). Viral pneumonia was detected in 52.6% of the patients in thorax CTs. Surgical treatment was applied to 23.1% of the patients. There was no significant difference between patients with pneumonia and patients without pneumonia in the treatment modalities or 30-day mortality. CONCLUSION: In this study, we found that low Glasgow Coma Scores affected mortality and that mechanical ventilation needs are higher in ICH patients with COVID-19. Nevertheless, the treatment differences may not have affected the outcomes.


Subject(s)
COVID-19 , Pandemics , Humans , Intracranial Hemorrhages/epidemiology , Retrospective Studies , SARS-CoV-2
4.
Stroke ; 52(5): e117-e130, 2021 05.
Article in English | MEDLINE | ID: covidwho-1195876
5.
Int J Stroke ; 16(5): 573-584, 2021 07.
Article in English | MEDLINE | ID: covidwho-1156042

ABSTRACT

BACKGROUND: The COVID-19 pandemic led to profound changes in the organization of health care systems worldwide. AIMS: We sought to measure the global impact of the COVID-19 pandemic on the volumes for mechanical thrombectomy, stroke, and intracranial hemorrhage hospitalizations over a three-month period at the height of the pandemic (1 March-31 May 2020) compared with two control three-month periods (immediately preceding and one year prior). METHODS: Retrospective, observational, international study, across 6 continents, 40 countries, and 187 comprehensive stroke centers. The diagnoses were identified by their ICD-10 codes and/or classifications in stroke databases at participating centers. RESULTS: The hospitalization volumes for any stroke, intracranial hemorrhage, and mechanical thrombectomy were 26,699, 4002, and 5191 in the three months immediately before versus 21,576, 3540, and 4533 during the first three pandemic months, representing declines of 19.2% (95%CI, -19.7 to -18.7), 11.5% (95%CI, -12.6 to -10.6), and 12.7% (95%CI, -13.6 to -11.8), respectively. The decreases were noted across centers with high, mid, and low COVID-19 hospitalization burden, and also across high, mid, and low volume stroke/mechanical thrombectomy centers. High-volume COVID-19 centers (-20.5%) had greater declines in mechanical thrombectomy volumes than mid- (-10.1%) and low-volume (-8.7%) centers (p < 0.0001). There was a 1.5% stroke rate across 54,366 COVID-19 hospitalizations. SARS-CoV-2 infection was noted in 3.9% (784/20,250) of all stroke admissions. CONCLUSION: The COVID-19 pandemic was associated with a global decline in the volume of overall stroke hospitalizations, mechanical thrombectomy procedures, and intracranial hemorrhage admission volumes. Despite geographic variations, these volume reductions were observed regardless of COVID-19 hospitalization burden and pre-pandemic stroke/mechanical thrombectomy volumes.


Subject(s)
COVID-19 , Global Health , Hospitalization/trends , Intracranial Hemorrhages/therapy , Stroke/therapy , Thrombectomy/trends , Cross-Sectional Studies , Hospitals, High-Volume/trends , Hospitals, Low-Volume/trends , Humans , Intracranial Hemorrhages/diagnosis , Intracranial Hemorrhages/epidemiology , Registries , Retrospective Studies , Stroke/diagnosis , Stroke/epidemiology , Time Factors
6.
Neuroradiol J ; 34(5): 435-439, 2021 Oct.
Article in English | MEDLINE | ID: covidwho-1153951

ABSTRACT

BACKGROUND: Diffuse intracranial susceptibility abnormalities have recently been described among patients with coronavirus disease 2019 (COVID-19), although prior studies have consisted of case reports and/or series. This brief literature review seeks to compile and catalogue the available data to elucidate characteristic features of such findings. MATERIALS AND METHODS: Scientific articles and studies on intracranial microhemorrhages in the setting of COVID-19 were searched on PubMed, Google Scholar, and the Cochrane Library. Included studies described intracranial microbleed(s) on magnetic resonance imaging in patients with COVID-19. If multiple patients were described, only patients with intracranial microhemorrhage on magnetic resonance imaging were included for analysis. Patient demographics, severity of illness (e.g. intensive care unit admission and/or intubation), time from diagnosis of COVID-19 to magnetic resonance imaging, and location(s) of any observed microhemorrhages were noted. RESULTS: A total of 39 patients with suspected intracranial microhemorrhages have been described in prior studies. The average age of patients was 64.7 years; 21.9% were women. The average time between COVID-19 diagnosis and magnetic resonance imaging was 31.7 days. All patients in the cohort were admitted to critical care and were either intubated or treated with extracorporeal membrane oxygenation during their clinical course. Microhemorrhages were most commonly located in the subcortical/juxtacortical white matter and corpus callosum. CONCLUSIONS: Intracranial microbleeds are a well-documented finding in patients with severe COVID-19, and are most commonly callosal and subcortical/juxtacortical in location.


Subject(s)
COVID-19/complications , Intracranial Hemorrhages/etiology , COVID-19/epidemiology , COVID-19 Testing , Disease Susceptibility , Humans , Intracranial Hemorrhages/epidemiology , Magnetic Resonance Imaging , Neuroimaging
7.
Shock ; 56(2): 206-214, 2021 08 01.
Article in English | MEDLINE | ID: covidwho-1080750

ABSTRACT

ABSTRACT: COVID-19-related coagulopathy is a known complication of SARS-CoV-2 infection and can lead to intracranial hemorrhage (ICH), one of the most feared complications of extracorporeal membrane oxygenation (ECMO). We sought to evaluate the incidence and etiology of ICH in patients with COVID-19 requiring ECMO. Patients at two academic medical centers with COVID-19 who required venovenous-ECMO support for acute respiratory distress syndrome (ARDS) were evaluated retrospectively. During the study period, 33 patients required ECMO support; 16 (48.5%) were discharged alive, 13 died (39.4%), and 4 (12.1%) had ongoing care. Eleven patients had ICH (33.3%). All ICH events occurred in patients who received intravenous anticoagulation. The ICH group had higher C-reactive protein (P = 0.04), procalcitonin levels (P = 0.02), and IL-6 levels (P = 0.05), lower blood pH before and after ECMO (P < 0.01), and higher activated partial thromboplastin times throughout the hospital stay (P < 0.0001). ICH-free survival was lower in COVID-19 patients than in patients on ECMO for ARDS caused by other viruses (49% vs. 79%, P = 0.02). In conclusion, patients with COVID-19 can be successfully bridged to recovery using ECMO but may suffer higher rates of ICH compared to those with other viral respiratory infections.


Subject(s)
Apoptosis Regulatory Proteins/blood , COVID-19/therapy , Extracorporeal Membrane Oxygenation/methods , Intracranial Hemorrhages/epidemiology , Mitochondrial Proteins/blood , SARS-CoV-2 , Adult , Biomarkers/blood , COVID-19/complications , COVID-19/epidemiology , Female , Follow-Up Studies , Humans , Incidence , Intracranial Hemorrhages/blood , Intracranial Hemorrhages/etiology , Male , Middle Aged , Pandemics , Retrospective Studies , United States/epidemiology
8.
J Stroke Cerebrovasc Dis ; 30(4): 105603, 2021 Apr.
Article in English | MEDLINE | ID: covidwho-1065395

ABSTRACT

OBJECTIVE: To describe the clinical, laboratory, temporal, radiographic, and outcome features of acute Intracranial Hemorrhage (ICH) in COVID-19 patients. METHODS: Retrospective, observational, consecutive case series of patients admitted with ICH to Maimonides Medical Center from March 1 through July 31, 2020, who had confirmed or highly suspected COVID-19. Demographic, clinical, laboratory, imaging, and outcome data were analyzed. ICH rates among all strokes were compared to the same time period in 2019 in two-week time intervals. Correlation of systolic blood pressure variability (SBPV) and neutrophil-to-lymphocyte ratio (NLR) to clinical outcomes were performed. RESULTS: Of 324 patients who presented with stroke, 65 (20%) were diagnosed with non-traumatic ICH: 8 had confirmed and 3 had highly suspected COVID-19. Nine (82%) had at least one associated risk factor for ICH. Three ICHs occurred during inpatient anticoagulation. More than half (6) suffered either deep or cerebellar hemorrhages; only 2 were lobar hemorrhages. Two of 8 patients with severe pneumonia survived. During the NYC COVID-19 peak period in April, ICH comprised the highest percentage of all strokes (40%), and then steadily decreased week-after-week (p = 0.02). SBPV and NLR were moderately and weakly positively correlated to discharge modified Rankin Scale, respectively. CONCLUSIONS: COVID-19 associated ICH is often associated with at least one known ICH risk factor and severe pneumonia. There was a suggestive relative surge in ICH among all stroke types during the first peak of the NYC pandemic. It is important to be vigilant of ICH as a possible and important manifestation of COVID-19.


Subject(s)
COVID-19/epidemiology , Intracranial Hemorrhages/epidemiology , Adult , Aged , Aged, 80 and over , COVID-19/diagnosis , COVID-19/therapy , Female , Humans , Intracranial Hemorrhages/diagnostic imaging , Intracranial Hemorrhages/therapy , Male , New York/epidemiology , Prevalence , Prognosis , Retrospective Studies , Risk Assessment , Risk Factors , Severity of Illness Index , Time Factors
9.
J Stroke Cerebrovasc Dis ; 30(3): 105536, 2021 Mar.
Article in English | MEDLINE | ID: covidwho-988559

ABSTRACT

BACKGROUND AND PURPOSE: The coronavirus disease 2019 (COVID-19) pandemic has had a comprehensive impact on healthcare services worldwide. We sought to determine whether COVID-19 affected the treatment and prognosis of hemorrhagic stroke in a regional medical center in mainland China. METHODS: Patients with hemorrhagic stroke admitted in the Neurosurgery Department of West China Hospital from January 24, 2020, to March 25, 2020 (COVID-19 period), and from January 24, 2019, to March 25, 2019 (pre-COVID-19 period), were identified. Clinical characteristics, hospital arrival to neurosurgery department arrival time (door-to-department time), reporting rate of pneumonia and 3-month mRS (outcome) were compared. RESULTS: A total of 224 patients in the pre-COVID-19 period were compared with 126 patients in the COVID-19 period. Milder stroke severity was observed in the COVID-19 period (NIHSS 6 [2-20] vs. 3 [2-15], p = 0.005). The median door-to-department time in the COVID-19 period was approximately 50 minutes longer than that in the pre-COVID-19 period (96.5 [70.3-193.3] vs. 144.5 [93.8-504.5], p = 0.000). A higher rate of pneumonia complications was reported in the COVID-19 period (40.6% vs. 60.7%, p = 0.000). In patients with moderate hemorrhagic stroke, the percentage of good outcomes (mRS < 3) in the pre-COVID-19 period was much higher than that in the COVID-19 period (53.1% vs. 26.3%, p = 0.047). CONCLUSIONS: COVID-19 may have several impacts on the treatment of hemorrhagic stroke and may influence the clinical outcomes of specific patients. Improvements in the treatment process for patients with moderate stroke may help to improve the overall outcome of hemorrhagic stroke during COVID-19.


Subject(s)
COVID-19 , Intracranial Hemorrhages/therapy , Pandemics , Stroke/therapy , Adult , Aged , Aged, 80 and over , China/epidemiology , Female , Humans , Intracranial Hemorrhages/complications , Intracranial Hemorrhages/epidemiology , Male , Middle Aged , Neurosurgical Procedures , Pneumonia/epidemiology , Pneumonia/etiology , Retrospective Studies , Risk Factors , Stroke/epidemiology , Stroke/etiology , Thrombectomy , Thrombolytic Therapy , Time-to-Treatment , Treatment Outcome
10.
Int J Stroke ; 16(4): 429-436, 2021 06.
Article in English | MEDLINE | ID: covidwho-968101

ABSTRACT

BACKGROUND: COVID-19-related strokes are increasingly being diagnosed across the world. Knowledge about the clinical profile, imaging findings, and outcomes is still evolving. Here we describe the characteristics of a cohort of 62 COVID-19-related stroke patients from 13 hospitals, from Bangalore city, south India. OBJECTIVE: To describe the clinical profile, neuroimaging findings, interventions, and outcomes in COVID-19-related stroke patients. METHODS: This is a multicenter retrospective study of all COVID-19-related stroke patients from 13 hospitals from south India; 1st June 2020-31st August 2020. The demographic, clinical, laboratory, and neuroimaging data were collected along with treatment administered and outcomes. SARS-CoV-2 infection was confirmed in all cases by RT-PCR testing. The data obtained from the case records were entered in SPSS 25 for statistical analysis. RESULTS: During the three-month period, we had 62 COVID-19-related stroke patients, across 13 centers; 60 (97%) had ischemic strokes, while 2 (3%) had hemorrhagic strokes. The mean age of patients was 55.66 ± 13.20 years, with 34 (77.4%) males. Twenty-six percent (16/62) of patients did not have any conventional risk factors for stroke. Diabetes mellitus was seen in 54.8%, hypertension was present in 61.3%, coronary artery disease in 8%, and atrial fibrillation in 4.8%. Baseline National Institutes of Health Stroke Scale score was 12.7 ± 6.44. Stroke severity was moderate (National Institutes of Health Stroke Scale 5-15) in 27 (61.3%) patients, moderate to severe (National Institutes of Health Stroke Scale 16-20) in 13 (20.9%) patients and severe (National Institutes of Health Stroke Scale 21-42) in 11 (17.7%) patients. According to TOAST classification, 48.3% was stroke of undetermined etiology, 36.6% had large artery atherosclerosis, 10% had small vessel occlusion, and 5% had cardioembolic strokes. Three (5%) received intravenous thrombolysis with tenecteplase 0.2 mg/kg and 3 (5%) underwent mechanical thrombectomy, two endovascular and one surgical. Duration of hospital stay was 16.16 ± 6.39 days; 21% (13/62) died in hospital, while 37 (59.7%) had a modified Rankin score of 3-5 at discharge. Hypertension, atrial fibrillation, and higher baseline National Institutes of Health Stroke Scale scores were associated with increased mortality. A comparison to 111 historical controls during the non-COVID period showed a higher proportion of strokes of undetermined etiology, higher mortality, and higher morbidity in COVID-19-related stroke patients. CONCLUSION: COVID-19-related strokes are increasingly being recognized in developing countries, like India. Stroke of undetermined etiology appears to be the most common TOAST subtype of COVID-19-related strokes. COVID-19-related strokes were more severe in nature and resulted in higher mortality and morbidity. Hypertension, atrial fibrillation, and higher baseline National Institutes of Health Stroke Scale scores were associated with increased mortality.


Subject(s)
COVID-19/complications , COVID-19/mortality , Stroke/etiology , Stroke/mortality , Adult , Aged , Aged, 80 and over , COVID-19/diagnostic imaging , COVID-19 Testing , Diabetes Complications/mortality , Female , Humans , Hypertension/complications , India/epidemiology , Intracranial Hemorrhages/diagnostic imaging , Intracranial Hemorrhages/epidemiology , Intracranial Hemorrhages/mortality , Ischemic Stroke/diagnostic imaging , Ischemic Stroke/epidemiology , Ischemic Stroke/mortality , Male , Middle Aged , Neuroimaging , Real-Time Polymerase Chain Reaction , Retrospective Studies , Sex Factors , Stroke/diagnostic imaging , Thrombolytic Therapy , Treatment Outcome , Young Adult
11.
Int J Stroke ; 16(4): 437-447, 2021 06.
Article in English | MEDLINE | ID: covidwho-806135

ABSTRACT

BACKGROUND: Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) has been associated with a significant risk of thrombotic events in critically ill patients. AIM: To summarize the findings of a multinational observational cohort of patients with SARS-CoV-2 and cerebrovascular disease. METHODS: Retrospective observational cohort of consecutive adults evaluated in the emergency department and/or admitted with coronavirus disease 2019 (COVID-19) across 31 hospitals in four countries (1 February 2020-16 June 2020). The primary outcome was the incidence rate of cerebrovascular events, inclusive of acute ischemic stroke, intracranial hemorrhages (ICH), and cortical vein and/or sinus thrombosis (CVST). RESULTS: Of the 14,483 patients with laboratory-confirmed SARS-CoV-2, 172 were diagnosed with an acute cerebrovascular event (1.13% of cohort; 1130/100,000 patients, 95%CI 970-1320/100,000), 68/171 (40.5%) were female and 96/172 (55.8%) were between the ages 60 and 79 years. Of these, 156 had acute ischemic stroke (1.08%; 1080/100,000 95%CI 920-1260/100,000), 28 ICH (0.19%; 190/100,000 95%CI 130-280/100,000), and 3 with CVST (0.02%; 20/100,000, 95%CI 4-60/100,000). The in-hospital mortality rate for SARS-CoV-2-associated stroke was 38.1% and for ICH 58.3%. After adjusting for clustering by site and age, baseline stroke severity, and all predictors of in-hospital mortality found in univariate regression (p < 0.1: male sex, tobacco use, arrival by emergency medical services, lower platelet and lymphocyte counts, and intracranial occlusion), cryptogenic stroke mechanism (aOR 5.01, 95%CI 1.63-15.44, p < 0.01), older age (aOR 1.78, 95%CI 1.07-2.94, p = 0.03), and lower lymphocyte count on admission (aOR 0.58, 95%CI 0.34-0.98, p = 0.04) were the only independent predictors of mortality among patients with stroke and COVID-19. CONCLUSIONS: COVID-19 is associated with a small but significant risk of clinically relevant cerebrovascular events, particularly ischemic stroke. The mortality rate is high for COVID-19-associated cerebrovascular complications; therefore, aggressive monitoring and early intervention should be pursued to mitigate poor outcomes.


Subject(s)
COVID-19/epidemiology , Cerebrovascular Disorders/epidemiology , Adult , Age Factors , Aged , Aged, 80 and over , COVID-19/complications , COVID-19/therapy , Cerebrovascular Disorders/etiology , Cerebrovascular Disorders/therapy , Cohort Studies , Female , Hospital Mortality , Humans , Intracranial Hemorrhages/epidemiology , Ischemic Stroke/epidemiology , Ischemic Stroke/etiology , Ischemic Stroke/therapy , Lymphocyte Count , Male , Middle Aged , Prevalence , Registries , Retrospective Studies , Risk Factors , Sex Factors , Thrombosis/etiology , Tobacco Use , Young Adult
12.
J Stroke Cerebrovasc Dis ; 29(11): 105314, 2020 Nov.
Article in English | MEDLINE | ID: covidwho-753197

ABSTRACT

BACKGROUND AND PURPOSE: Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection is associated with stroke. The role of sex on stroke outcome has not been investigated. To objective of this paper is to describe the characteristics of a diverse cohort of acute stroke patients with COVID-19 disease and determine the role of sex on outcome. METHODS: This is a retrospective study of patients with acute stroke and SARS-CoV-2 infection admitted between March 15 to May 15, 2020 to one of the six participating comprehensive stroke centers. Baseline characteristics, stroke subtype, workup, treatment and outcome are presented as total number and percentage or median and interquartile range. Outcome at discharge was determined by the modified Rankin Scale Score (mRS). Variables and outcomes were compared for males and females using univariate and multivariate analysis. RESULTS: The study included 83 patients, 47% of which were Black, 28% Hispanics/Latinos, and 16% whites. Median age was 64 years. Approximately 89% had at least one preexisting vascular risk factor (VRF). The most common complications were respiratory failure (59%) and septic shock (34%). Compared with females, a higher proportion of males experienced severe SARS-CoV-2 symptoms requiring ICU hospitalization (73% vs. 49%; p = 0.04). When divided by stroke subtype, there were 77% ischemic, 19% intracerebral hemorrhage and 3% subarachnoid hemorrhage. The most common ischemic stroke etiologies were cryptogenic (39%) and cardioembolic (27%). Compared with females, males had higher mortality (38% vs. 13%; p = 0.02) and were less likely to be discharged home (12% vs. 33%; p = 0.04). After adjustment for age, race/ethnicity, and number of VRFs, mRS was higher in males than in females (OR = 1.47, 95% CI = 1.03-2.09). CONCLUSION: In this cohort of SARS-CoV-2 stroke patients, most had clinical evidence of coronavirus infection on admission and preexisting VRFs. Severe in-hospital complications and worse outcomes after ischemic strokes were higher in males, than females.


Subject(s)
Brain Ischemia/epidemiology , Coronavirus Infections/epidemiology , Health Status Disparities , Intracranial Hemorrhages/epidemiology , Pneumonia, Viral/epidemiology , Stroke/epidemiology , Aged , Aged, 80 and over , Brain Ischemia/diagnosis , Brain Ischemia/therapy , COVID-19 , Chicago/epidemiology , Coronavirus Infections/diagnosis , Coronavirus Infections/therapy , Female , Humans , Intracranial Hemorrhages/diagnosis , Intracranial Hemorrhages/therapy , Male , Middle Aged , Pandemics , Pneumonia, Viral/diagnosis , Pneumonia, Viral/therapy , Prognosis , Retrospective Studies , Risk Assessment , Risk Factors , Sex Factors , Stroke/diagnosis , Stroke/therapy , Time Factors
13.
AJNR Am J Neuroradiol ; 41(11): 2009-2011, 2020 11.
Article in English | MEDLINE | ID: covidwho-732928

ABSTRACT

In this clinical case series, we report our experience to date with neurologic complications of extracorporeal membrane oxygenation therapy for COVID-19 Acute Respiratory Distress Syndrome. We have found an unexpectedly increased rate of complications as demonstrated by neuroimaging compared with meta-analysis data in extracorporeal membrane oxygenation therapy for all Acute Respiratory Distress Syndrome etiologies over the past few decades and compared with the most recent baseline data describing the incidence of neurologic complication in all patients with COVID-19. For our 12-patient cohort, there was a rate of intracranial hemorrhage of 41.7%. Representative cases and images of devastating intracranial hemorrhage are presented. We hypothesize that the interplay between hematologic changes inherent to extracorporeal membrane oxygenation and inflammatory and coagulopathic changes that have begun to be elucidated as part of the COVID-19 disease process are responsible. Continued analysis of extracorporeal membrane oxygenation therapy in this disease paradigm is warranted.


Subject(s)
Coronavirus Infections/complications , Extracorporeal Membrane Oxygenation/adverse effects , Pneumonia, Viral/complications , Respiratory Distress Syndrome/therapy , Respiratory Distress Syndrome/virology , Aged , Betacoronavirus , COVID-19 , Cohort Studies , Female , Humans , Intracranial Hemorrhages/epidemiology , Intracranial Hemorrhages/etiology , Male , Middle Aged , Pandemics , Retrospective Studies , SARS-CoV-2 , Tertiary Care Centers
14.
Stroke ; 51(9): 2664-2673, 2020 09.
Article in English | MEDLINE | ID: covidwho-695899

ABSTRACT

BACKGROUND: Anecdotal reports suggest fewer patients with stroke symptoms are presenting to hospitals during the coronavirus disease 2019 (COVID-19) pandemic. We quantify trends in stroke code calls and treatments at 3 Connecticut hospitals during the local emergence of COVID-19 and examine patient characteristics and stroke process measures at a Comprehensive Stroke Center (CSC) before and during the pandemic. METHODS: Stroke code activity was analyzed from January 1 to April 28, 2020, and corresponding dates in 2019. Piecewise linear regression and spline models identified when stroke codes in 2020 began to decline and when they fell below 2019 levels. Patient-level data were analyzed in February versus March and April 2020 at the CSC to identify differences in patient characteristics during the pandemic. RESULTS: A total of 822 stroke codes were activated at 3 hospitals from January 1 to April 28, 2020. The number of stroke codes/wk decreased by 12.8/wk from February 18 to March 16 (P=0.0360) with nadir of 39.6% of expected stroke codes called from March 10 to 16 (30% decrease in total stroke codes during the pandemic weeks in 2020 versus 2019). There was no commensurate increase in within-network telestroke utilization. Compared with before the pandemic (n=167), pandemic-epoch stroke code patients at the CSC (n=211) were more likely to have histories of hypertension, dyslipidemia, coronary artery disease, and substance abuse; no or public health insurance; lower median household income; and to live in the CSC city (P<0.05). There was no difference in age, sex, race/ethnicity, stroke severity, time to presentation, door-to-needle/door-to-reperfusion times, or discharge modified Rankin Scale. CONCLUSIONS: Hospital presentation for stroke-like symptoms decreased during the COVID-19 pandemic, without differences in stroke severity or early outcomes. Individuals living outside of the CSC city were less likely to present for stroke codes at the CSC during the pandemic. Public health initiatives to increase awareness of presenting for non-COVID-19 medical emergencies such as stroke during the pandemic are critical.


Subject(s)
Brain Ischemia/epidemiology , Intracranial Hemorrhages/epidemiology , Stroke/epidemiology , Time-to-Treatment/statistics & numerical data , Aged , Aged, 80 and over , Betacoronavirus , Brain Ischemia/diagnosis , Brain Ischemia/physiopathology , Brain Ischemia/therapy , COVID-19 , Cohort Studies , Comorbidity , Connecticut/epidemiology , Coronary Artery Disease/epidemiology , Coronavirus Infections/epidemiology , Dyslipidemias/epidemiology , Emergency Medical Services , Female , Humans , Hypertension/epidemiology , Income , Insurance, Health , Intracranial Hemorrhages/diagnosis , Intracranial Hemorrhages/physiopathology , Intracranial Hemorrhages/therapy , Male , Medically Uninsured , Middle Aged , Outcome and Process Assessment, Health Care , Pandemics , Pneumonia, Viral/epidemiology , Retrospective Studies , SARS-CoV-2 , Severity of Illness Index , Stroke/diagnosis , Stroke/physiopathology , Stroke/therapy , Substance-Related Disorders/epidemiology , Telemedicine , Thrombectomy , Thrombolytic Therapy
15.
Clin Neurol Neurosurg ; 198: 106112, 2020 11.
Article in English | MEDLINE | ID: covidwho-669659

ABSTRACT

OBJECTIVE: We aim to characterize the incidence, risk for mortality, and identify risk factors for mortality in patients presenting with hemorrhage and COVID-19. METHODS: This retrospective cohort study included a cohort of patients admitted to one of three major hospitals of our healthcare network including, an academic medical center and comprehensive stroke center, which accepts transfers for complex cases from eight community hospitals, during March 1 to May 1, 2020. All patients that received imaging of the neuroaxis and had positive PCR testing for COVID-19 were identified and reviewed by an attending neuroradiologist. Demographics and comorbidities were recorded. Biomarkers were recorded from the day of the hemorrhagic event. Vital signs from the day of the hemorrhagic event mechanical ventilation orders at admission were recorded. Imaging findings were divided into 5 subtypes; acute subdural hematoma (SDH), subarachnoid hemorrhage (SAH), multi-compartmental hemorrhage (MCH), multi-focal intracerebral hemorrhage (MFH), and focal intracerebral hemorrhage (fICH). Outcomes were recorded as non-routine discharge and mortality. RESULTS: We found a total of 35 out of 5227 patients with COVID-19 that had hemorrhage of some kind. Mortality for the entire cohort was 45.7 % (n = 16). SDH patients had a mortality rate of 35.3 % (n = 6), SAH had a mortality of 50 % (n = 1), MCH patients had a mortality of 71.4 % (n = 5), MFH patients had a mortality of 50 % (n = 2), fICH patients had a mortality of 40 % (n = 2). Patients with severe pulmonary COVID requiring mechanical ventilation (OR 10.24 [.43-243.12] p = 0.015), with INR > 1.2 on the day of the hemorrhagic event (OR 14.36 [1.69-122.14] p = 0.015], and patients presenting with spontaneous vs. traumatic hemorrhage (OR 6.11 [.31-118.89] p = 0.023) had significantly higher risk for mortality. CONCLUSIONS: Hemorrhagic presentations with COVID-19 are a rare but serious way in which the illness can manifest. It is important for neurosurgeons to realize that patients can present with these findings without primary pulmonary symptoms, and that severe pulmonary symptoms, elevated INR, and spontaneous hemorrhagic presentations is associated with increased risk for mortality.


Subject(s)
Betacoronavirus , Coronavirus Infections/complications , Coronavirus Infections/mortality , Intracranial Hemorrhages/epidemiology , Intracranial Hemorrhages/virology , Pneumonia, Viral/complications , Pneumonia, Viral/mortality , Adult , Aged , Aged, 80 and over , COVID-19 , Coronavirus Infections/diagnosis , Female , Humans , Incidence , Intracranial Hemorrhages/diagnosis , Male , Middle Aged , Pandemics , Pneumonia, Viral/diagnosis , Retrospective Studies , Risk Factors , SARS-CoV-2 , Survival Rate
16.
Stroke ; 51(9): e219-e222, 2020 09.
Article in English | MEDLINE | ID: covidwho-655151

ABSTRACT

BACKGROUND AND PURPOSE: Initial reports suggest a significant risk of thrombotic events, including stroke, in patients hospitalized with coronavirus disease 2019 (COVID-19). However, there is little systematic data on stroke incidence and mechanisms, particularly in racially diverse populations in the United States. METHODS: We performed a retrospective, observational study of stroke incidence and mechanisms in all patients with COVID-19 hospitalized from March 15 to May 3, 2020, at 3 Philadelphia hospitals. RESULTS: We identified 844 hospitalized patients with COVID-19 (mean age 59 years, 52% female, 68% Black); 20 (2.4%) had confirmed ischemic stroke; and 8 (0.9%) had intracranial hemorrhage. Of the ischemic stroke patients, mean age was 64 years, with only one patient (5%) under age 50, and 80% were Black. Conventional vascular risk factors were common, with 95% of patients having a history of hypertension and 60% a history of diabetes mellitus. Median time from onset of COVID symptoms to stroke diagnosis was 21 days. Stroke mechanism was cardioembolism in 40%, small vessel disease in 5%, other determined mechanism in 20%, and cryptogenic in 35%. Of the 11 patients with complete vascular imaging, 3 (27%) had large vessel occlusion. Newly positive antiphospholipid antibodies were present in >75% of tested patients. Of the patients with intracranial hemorrhage, 5/8 (63%) were lobar intraparenchymal hemorrhages, and 3/8 (38%) were subarachnoid hemorrhage; 4/8 (50%) were on extracorporeal membrane oxygenation. CONCLUSIONS: We found a low risk of acute cerebrovascular events in patients hospitalized with COVID-19. Most patients with ischemic stroke had conventional vascular risk factors, and traditional stroke mechanisms were common.


Subject(s)
Cerebrovascular Disorders/complications , Cerebrovascular Disorders/epidemiology , Coronavirus Infections/complications , Coronavirus Infections/epidemiology , Pneumonia, Viral/complications , Pneumonia, Viral/epidemiology , Aged , Brain Ischemia/complications , Brain Ischemia/epidemiology , COVID-19 , Diabetes Complications/epidemiology , Female , Humans , Hypertension/complications , Incidence , Inpatients , Intracranial Hemorrhages/complications , Intracranial Hemorrhages/epidemiology , Male , Middle Aged , Pandemics , Philadelphia/epidemiology , Retrospective Studies , Risk Factors , Stroke/complications , Stroke/epidemiology , Thrombosis/complications , Thrombosis/epidemiology
17.
J Stroke Cerebrovasc Dis ; 29(10): 105114, 2020 Oct.
Article in English | MEDLINE | ID: covidwho-640910

ABSTRACT

BACKGROUND: Little is known about the effect of the Coronavirus disease 2019 pandemic on stroke care and the impact of the epidemic on acute stroke hospitalizations has not been described. METHODS: We analyze the stroke admission rate in three hospitals in New York City from January 1, 2020 through April 17, 2020, identifying all cases of acute ischemic stroke, intraparenchymal hemorrhage and subarachnoid hemorrhage. RESULTS: We confirmed 518 cases of out-of-hospital stroke. During the baseline period up to February 25, 2020, the daily stroke admission rate was stable, with the slope of the regression describing the number of admissions over time equal to -0.33 (se = 1.21), not significantly different from 0 (p = 0.79), with daily admissions averaging 41. During the pandemic period, the slope was -4.4 (se = 1.00); i.e., the number of stroke admissions decreased an average of 4.4 per week, (p = 0.005), with weekly admissions averaging 23, a reduction of 44% versus baseline. This general result was not different by patient age, sex, or race/ethnicity. CONCLUSIONS: The weekly stroke admission rate started declining two weeks prior to the local surge of coronavirus admissions. The consequences of lack of diagnosis and treatment of a large proportion of acute stroke patients are likely severe and lasting.


Subject(s)
Coronavirus Infections/therapy , Delivery of Health Care/trends , Intracranial Hemorrhages/therapy , Patient Admission/trends , Pneumonia, Viral/therapy , Stroke/therapy , Aged , Betacoronavirus/pathogenicity , COVID-19 , Coronavirus Infections/diagnosis , Coronavirus Infections/epidemiology , Coronavirus Infections/virology , Female , Host Microbial Interactions , Humans , Intracranial Hemorrhages/diagnosis , Intracranial Hemorrhages/epidemiology , Intracranial Hemorrhages/virology , Male , Middle Aged , New York City/epidemiology , Pandemics , Pneumonia, Viral/diagnosis , Pneumonia, Viral/epidemiology , Pneumonia, Viral/virology , Prognosis , SARS-CoV-2 , Stroke/diagnosis , Stroke/epidemiology , Stroke/virology , Subarachnoid Hemorrhage/epidemiology , Subarachnoid Hemorrhage/therapy , Time Factors
18.
Int J Stroke ; 15(7): 733-742, 2020 10.
Article in English | MEDLINE | ID: covidwho-636180

ABSTRACT

BACKGROUND: The coronavirus disease 2019 is associated with neurological manifestations including stroke. OBJECTIVES: We present a case series of coronavirus disease 2019 patients from two institutions with acute cerebrovascular pathologies. In addition, we present a pooled analysis of published data on large vessel occlusion in the setting of coronavirus disease 2019 and a concise summary of the pathophysiology of acute cerebrovascular disease in the setting of coronavirus disease 2019. METHODS: A retrospective study across two institutions was conducted between 20 March 2020 and 20 May 2020, for patients developing acute cerebrovascular disease and diagnosed with coronavirus disease 2019. We performed a literature review using the PubMed search engine. RESULTS: The total sample size was 22 patients. The mean age was 59.5 years, and 12 patients were female. The cerebrovascular pathologies were 17 cases of acute ischemic stroke, 3 cases of aneurysm rupture, and 2 cases of sinus thrombosis. Of the stroke and sinus thrombosis patients, the mean National Institute of Health Stroke Scale was 13.8 ± 8.0, and 16 (84.2%) patients underwent a mechanical thrombectomy procedure. A favorable thrombolysis in cerebral infarction score was achieved in all patients. Of the 16 patients that underwent a mechanical thrombectomy, the mortality incidence was five (31.3%). Of all patients (22), three (13.6%) patients developed hemorrhagic conversion requiring decompressive surgery. Eleven (50%) patients had a poor functional status (modified Rankin Score 3-6) at discharge, and the total mortality incidence was eight (36.4%). CONCLUSIONS: Despite timely intervention and favorable reperfusion, the mortality rate in coronavirus disease 2019 patients with large vessel occlusion was high in our series and in the pooled analysis. Notable features were younger age group, involvement of both the arterial and venous vasculature, multivessel involvement, and complicated procedures due to the clot consistency and burden.


Subject(s)
Betacoronavirus , Brain Ischemia/epidemiology , Brain Ischemia/virology , Coronavirus Infections/complications , Intracranial Hemorrhages/epidemiology , Intracranial Hemorrhages/virology , Pneumonia, Viral/complications , Acute Disease , Adult , Aged , Brain Ischemia/diagnosis , COVID-19 , Coronavirus Infections/diagnosis , Coronavirus Infections/epidemiology , Female , Humans , Intracranial Hemorrhages/diagnosis , Male , Middle Aged , Pandemics , Pneumonia, Viral/diagnosis , Pneumonia, Viral/epidemiology , Retrospective Studies , SARS-CoV-2 , Survival Rate
20.
Stroke ; 51(8): 2315-2321, 2020 08.
Article in English | MEDLINE | ID: covidwho-596641

ABSTRACT

BACKGROUND AND PURPOSE: Since the onset of the coronavirus disease 2019 (COVID-19) pandemic, doctors and public authorities have demonstrated concern about the reduction in quality of care for other health conditions due to social restrictions and lack of resources. Using a population-based stroke registry, we investigated the impact of the onset of the COVID-19 pandemic in stroke admissions in Joinville, Brazil. METHODS: Patients admitted after the onset of COVID-19 restrictions in the city (defined as March 17, 2020) were compared with those admitted in 2019. We analyzed differences between stroke incidence, types, severity, reperfusion therapies, and time from stroke onset to admission. Statistical tests were also performed to compare the 30 days before and after COVID-19 to the same period in 2019. RESULTS: We observed a decrease in total stroke admissions from an average of 12.9/100 000 per month in 2019 to 8.3 after COVID-19 (P=0.0029). When compared with the same period in 2019, there was a 36.4% reduction in stroke admissions. There was no difference in admissions for severe stroke (National Institutes of Health Stroke Scale score >8), intraparenchymal hemorrhage, and subarachnoid hemorrhage. CONCLUSIONS: The onset of COVID-19 was correlated with a reduction in admissions for transient, mild, and moderate strokes. Given the need to prevent the worsening of symptoms and the occurrence of medical complications in these groups, a reorganization of the stroke-care networks is necessary to reduce collateral damage caused by COVID-19.


Subject(s)
Coronavirus Infections/epidemiology , Ischemic Attack, Transient/epidemiology , Pandemics , Patient Admission/statistics & numerical data , Pneumonia, Viral/epidemiology , Stroke/epidemiology , Adult , Aged , Aged, 80 and over , Brazil/epidemiology , COVID-19 , Female , Humans , Incidence , Intracranial Hemorrhages/epidemiology , Intracranial Hemorrhages/therapy , Ischemic Attack, Transient/therapy , Male , Middle Aged , Quality of Health Care , Reperfusion , Stroke/therapy , Subarachnoid Hemorrhage/epidemiology , Subarachnoid Hemorrhage/therapy
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