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1.
Stroke Vasc Neurol ; 5(4): 331-336, 2020 12.
Article in English | MEDLINE | ID: covidwho-1318206

ABSTRACT

BACKGROUND: COVID-19, caused by SARS-CoV-2, is a global pandemic that has been an immense burden on healthcare systems all over the world. These patients may be at higher risk for acute ischaemic stroke (AIS). We present our experience with AIS in patients with COVID-19. METHODS: We reviewed all patients admitted to our hospital during a 6-week period with a positive nasopharyngeal swab test for SARS-CoV-2. Among these patients, we identified AIS. We reviewed the demographics, clinical, laboratory, imaging characteristics, treatments received and outcomes of AIS in patients with COVID-19. RESULTS: We identified 683 patients admitted with COVID-19 during the study period, of which 20 patients had AIS. Large-vessel occlusion (LVO) was noted in 11 patients (55%). Intravenous alteplase was administered in four patients (20%) and mechanical thrombectomy was performed in five patients (25%). Respiratory symptoms preceded the onset of AIS in most of the patients (70%) by 1 to 21 days. Mortality in patients with AIS was 50% compared with 26% of all COVID-19 admissions. Most of these patients died due to non-neurological causes (70%). Three patients with AIS had clinical and imaging findings consistent with COVID-19, but were negative for multiple nasopharyngeal swab tests. INTERPRETATION: LVO was more common in patients with AIS and COVID-19. They had more severe disease and higher mortality rates. Most of the patients had respiratory symptoms preceding AIS by days to weeks. This could explain certain patients with clinical picture of COVID-19 but negative nasopharyngeal swab tests.


Subject(s)
Brain Ischemia , COVID-19 , Stroke , Humans , Pandemics , SARS-CoV-2 , Stroke/diagnosis , Thrombectomy
2.
Am J Case Rep ; 22: e930291, 2021 Apr 12.
Article in English | MEDLINE | ID: covidwho-1241342

ABSTRACT

BACKGROUND National guidelines and consensus statements suggest a 24-hour window for endovascular recanalization in patients presenting with acute ischemic stroke due to large-vessel occlusion. However, the safety and efficacy of extending the window for intervention remains to be definitively established. CASE REPORT A healthy 26-year-old woman presented with headache, left-sided hemiplegia, and rightward gaze palsy 2 days after a minor trauma. Time last known well was approximately 50 hours prior to presentation. Computed tomography angiography revealed dissection of the distal right internal carotid artery and occlusion of the M1 segment of the right middle cerebral artery. Magnetic resonance imaging showed a small area of acute infarct in the right basal ganglia and right insular cortex, but suggested a large ischemic penumbra; this was confirmed with cerebral perfusion analysis. In light of the patient's young age and potential for penumbral salvage, mechanical thrombectomy of an M1 thrombus and stenting of an internal carotid artery dissection were performed nearly 60 hours after the onset of symptoms. The patient demonstrated marked clinical improvement over the following days and was discharged home in excellent condition one week after presentation. Based on our clinical experience and other emerging data, we propose that extension of the 24-hour window for endovascular intervention may improve functional outcomes among select individuals. CONCLUSIONS A 24-hour window for endovascular thrombectomy is appropriate for many patients presenting with acute ischemic stroke. However, in select individuals, extension of the window to 48 hours or beyond may improve functional outcomes.


Subject(s)
Brain Ischemia , Endovascular Procedures , Ischemic Stroke , Stroke , Adult , Brain Ischemia/etiology , Carotid Artery, Internal , Female , Humans , Stroke/etiology , Thrombectomy , Treatment Outcome
3.
Indian J Ophthalmol ; 69(5): 1325-1327, 2021 May.
Article in English | MEDLINE | ID: covidwho-1207847

ABSTRACT

Covid-19 infection has been declared a pandemic by the World Health Organization. We present a unique case of a middle-aged gentleman, who recovered from asymptomatic Covid-19 infection and presented again with delayed stroke. He had vision loss secondary to internal carotid artery occlusion in the absence of neurological symptoms. To the best of our knowledge, this is the first case that describes cerebrovascular stroke due to delayed large vessel occlusion secondary to Covid-19 infection presenting as monocular vision loss.


Subject(s)
COVID-19 , Carotid Artery Diseases , Carotid Stenosis , Stroke , Carotid Stenosis/complications , Carotid Stenosis/diagnosis , Humans , Male , Middle Aged , SARS-CoV-2 , Stroke/diagnosis , Stroke/etiology , Vision, Monocular
4.
Stroke ; 52(5): e117-e130, 2021 05.
Article in English | MEDLINE | ID: covidwho-1195876
5.
Stroke ; 52(7): 2422-2426, 2021 07.
Article in English | MEDLINE | ID: covidwho-1195875

ABSTRACT

BACKGROUND AND PURPOSE: Stroke may complicate coronavirus disease 2019 (COVID-19) infection based on clinical hypercoagulability. We investigated whether transcranial Doppler ultrasound has utility for identifying microemboli and clinically relevant cerebral blood flow velocities (CBFVs) in COVID-19. METHODS: We performed transcranial Doppler for a consecutive series of patients with confirmed or suspected COVID-19 infection admitted to 2 intensive care units at a large academic center including evaluation for microembolic signals. Variables specific to hypercoagulability and blood flow including transthoracic echocardiography were analyzed as a part of routine care. RESULTS: Twenty-six patients were included in this analysis, 16 with confirmed COVID-19 infection. Of those, 2 had acute ischemic stroke secondary to large vessel occlusion. Ten non-COVID stroke patients were included for comparison. Two COVID-negative patients had severe acute respiratory distress syndrome and stroke due to large vessel occlusion. In patients with COVID-19, relatively low CBFVs were observed diffusely at median hospital day 4 (interquartile range, 3-9) despite low hematocrit (29.5% [25.7%-31.6%]); CBFVs in comparable COVID-negative stroke patients were significantly higher compared with COVID-positive stroke patients. Microembolic signals were not detected in any patient. Median left ventricular ejection fraction was 60% (interquartile range, 60%-65%). CBFVs were correlated with arterial oxygen content, and C-reactive protein (Spearman ρ=0.28 [P=0.04]; 0.58 [P<0.001], respectively) but not with left ventricular ejection fraction (ρ=-0.18; P=0.42). CONCLUSIONS: In this cohort of critically ill patients with COVID-19 infection, we observed lower than expected CBFVs in setting of low arterial oxygen content and low hematocrit but not associated with suppression of cardiac output.


Subject(s)
Blood Flow Velocity , Brain/diagnostic imaging , COVID-19/diagnostic imaging , Cerebrovascular Circulation , Ischemic Stroke/diagnostic imaging , Adult , Aged , Blood Gas Analysis , Brain/blood supply , C-Reactive Protein/metabolism , COVID-19/physiopathology , Case-Control Studies , Critical Illness , Female , Humans , Ischemic Stroke/physiopathology , Male , Middle Aged , Oxygen/blood , Respiratory Distress Syndrome/diagnostic imaging , Respiratory Distress Syndrome/physiopathology , SARS-CoV-2 , Stroke Volume/physiology , Ultrasonography, Doppler, Transcranial
6.
BMJ Neurol Open ; 3(1): e000084, 2021.
Article in English | MEDLINE | ID: covidwho-1119310

ABSTRACT

INTRODUCTION: The COVID-19 pandemic has resulted in a dramatic unexplained decline in hospital admissions due to acute coronary syndromes and stroke. Several theories have emerged aiming to explain this decline, mostly revolving around the fear of contracting the disease and thus avoiding hospital visits. AIMS: In this study, we aim to examine the impact of the COVID-19 pandemic on stroke admissions to a tertiary care centre in Qatar. METHODS: The Hamad General Hospital stroke database was interrogated for stroke admissions between September 2019 and May 2020. The number of stroke admissions, stroke subtypes and short-term outcomes was compared between the 'pre-COVID-19' period (September 2019 to February 2020) and the COVID-19 pandemic period (March to May 2020). RESULTS: We observed a significant decline in monthly admissions in March (157), April (128) and May (135) compared with the pre-COVID-19 6-month average (229) (p=0.024). The reduction in admissions was most evident in functional stroke mimics. The average admissions decreased from 87 to 34 per month (p=0.0001). Although there were no significant differences in admissions due to ischaemic stroke (IS), intracranial haemorrhage or transient ischaemic attacks between the two periods, we noted a relative decrease in IS due to small vessel disease and an increase in those due to large vessel atherosclerosis in March to May 2020. CONCLUSIONS: The decline in overall stroke admissions during the COVID-19 pandemic is most likely related to concerns of contracting the infection, evidenced mainly by a decline in admissions of stroke mimics. However, a relative increase in large vessel occlusions raises suspicion of pathophysiological effects of the virus, and requires further investigation.

7.
Clin Neurol Neurosurg ; 201: 106436, 2021 02.
Article in English | MEDLINE | ID: covidwho-1059739

ABSTRACT

BACKGROUND: To evaluate overall ischemic stroke volumes and rates, specific subtypes, and clinical presentation during the COVID-19 pandemic in a multicenter observational study from eight states across US. METHODS: We compared all ischemic strokes admitted between January 2019 and May 2020, grouped as; March-May 2020 (COVID-19 period) and March-May 2019 (seasonal pre-COVID-19 period). Primary outcome was stroke severity at admission measured by NIHSS stratified as mild (0-7), moderate [8-14], and severe (>14). Secondary outcomes were volume of large vessel occlusions (LVOs), stroke etiology, IV-tPA rates, and discharge disposition. RESULTS: Of the 7969 patients diagnosed with acute ischemic stroke during the study period, 933 (12 %) presented in the COVID-19 period while 1319 (17 %) presented in the seasonal pre-COVID-19 period. Significant decline was observed in the mean weekly volumes of newly diagnosed ischemic strokes (98 ± 3 vs 50 ± 20,p = 0.003), LVOs (16.5 ± 3.8 vs 8.3 ± 5.9,p = 0.008), and IV-tPA (10.9 ± 3.4 vs 5.3 ± 2.9,p = 0.0047), whereas the mean weekly proportion of LVOs (18 % ±5 vs 16 % ±7,p = 0.24) and IV-tPA (10.4 % ±4.5 vs. 9.9 % ±2.4,p = 0.66) remained the same, when compared to the seasonal pre-COVID-19 period. Additionally, an increased proportion of patients presented with a severe disease (NIHSS > 14) during the COVID-19 period (29.7 % vs 24.5 %,p < 0.025). The odds of being discharged to home were 26 % greater in the COVID-19 period when compared to seasonal pre-COVID-19 period (OR:1.26, 95 % CI:1.07-1.49,p = 0.016). CONCLUSIONS: During COVID-19 period there was a decrease in volume of newly diagnosed ischemic stroke cases and IV-tPA administration. Patients admitted to the hospital had severe neurological clinical presentation and were more likely to discharge home.


Subject(s)
COVID-19/epidemiology , Neurology/trends , Societies, Medical/trends , Stroke/drug therapy , Stroke/epidemiology , Thrombolytic Therapy/trends , Administration, Intravenous , Adult , Aged , Aged, 80 and over , COVID-19/diagnosis , Cohort Studies , Female , Humans , Male , Middle Aged , Pandemics , Retrospective Studies , Stroke/diagnosis , Tissue Plasminogen Activator/administration & dosage , United States/epidemiology , Vascular Diseases/drug therapy , Vascular Diseases/epidemiology
8.
J Stroke Cerebrovasc Dis ; 30(3): 105609, 2021 Mar.
Article in English | MEDLINE | ID: covidwho-1012468

ABSTRACT

The case of a 70-year-old male presenting an ischemic stroke related to COVID-19 infection is described. He was initially admitted to the hospital with respiratory insufficiency syndrome secondary to pneumonia caused by SARS Co2. In the next days, he developed rapid neurological deterioration characterized by drowsiness which progressed to deep coma. D-dimer was elevated. Brain CT scan showed bilateral massive ischemic stroke located in the anterior circulation, CT angiogram showed occlusion in the left internal carotid artery and the right middle cerebral artery. The deterioration of the patient continued and he subsequently died. Large vessel occlusion has been reported in COVID-19 patients, but this clinical presentation is usually unilateral. Cases of bilateral occlusion of large vessels have not been previously reported in COVID-19 patients. This report shows that bilateral massive stroke may occur in COVID-19 cases and it should be suspected in patients who show rapid neurological deterioration without focal deficits.


Subject(s)
Arterial Occlusive Diseases/etiology , COVID-19/complications , Ischemic Stroke/etiology , Aged , Brain/diagnostic imaging , COVID-19/diagnostic imaging , Carotid Stenosis/diagnostic imaging , Carotid Stenosis/etiology , Coma/etiology , Computed Tomography Angiography , Fibrin Fibrinogen Degradation Products/analysis , Humans , Infarction, Middle Cerebral Artery/diagnostic imaging , Infarction, Middle Cerebral Artery/etiology , Ischemic Stroke/diagnostic imaging , Male , Nervous System Diseases/etiology , Respiratory Insufficiency/etiology , Respiratory Insufficiency/therapy , Thrombectomy
9.
Cerebrovasc Dis Extra ; 10(3): 159-165, 2020.
Article in English | MEDLINE | ID: covidwho-917828

ABSTRACT

OBJECTIVE: Our study aims to evaluate the impact of a stay-at-home order on stroke metrics during the 2019-novel coronavirus (COVID-19) pandemic. METHODS: Data on baseline characteristics, stroke subtype, initial National Institutes of Health Stroke Scale (NIHSS) score, the time between last known well (LKW) to emergency department (ED) arrival, tissue plasminogen activator (tPA) administration, the involvement of large vessel occlusion (LVO), and whether mechanical thrombectomy (MT) was pursued in patients with acute stroke were extracted from 24 March to 23 April 2020 (the time period of a stay-at-home order was placed due to the COVID-19 pandemic as the study group) at a tertiary care hospital in West Michigan, USA, compared with data from 24 March to 23 April 2019 (control group). RESULTS: Our study demonstrated a reduction in cases of acute ischemic stroke (AIS), although this did not reach statistical significance. However, there was an increase in hemorrhagic stroke (7.5% controls vs. 19.2% study group). The age of stroke patients was significantly younger during the period of the stay-at-home order compared to the control group. We identified a significant overall delay of ED arrivals from LKW in the study group. Additionally, an increased number of AIS patients with LVO in the study group (34.8%) was found compared to the control group (17.5%). A significantly increased number of patients received MT in the study group. Additionally, 11 patients were COVID-19 PCR-positive in the study group, 10 with AIS and only 1 with hemorrhagic stroke. Patients with COVID-19 had a high incidence of atrial fibrillation and hyperlipidemia. One AIS patient with COVID-19 rapidly developed cytotoxic edema with corresponding elevated inflammatory biomarkers. No statistical significance was noted when stroke subtype, LVO, and MT groups were compared. CONCLUSIONS: There was a trend of decreasing AIS admissions during the COVID-19 pandemic. There was also a significantly increased number of AIS patients with LVO who received MT, especially those with COVID-19. We conclude that cytokine storm resulting from SARS-CoV-2 infection might play a role in AIS patients with COVID-19.


Subject(s)
COVID-19 , Cerebrovascular Disorders , Communicable Disease Control , Patient Admission/trends , Stroke , Thrombectomy , Age Factors , Aged , COVID-19/epidemiology , COVID-19/prevention & control , Cerebrovascular Disorders/complications , Cerebrovascular Disorders/epidemiology , Communicable Disease Control/methods , Communicable Disease Control/statistics & numerical data , Female , Humans , Male , SARS-CoV-2 , Social Isolation , Stroke/classification , Stroke/epidemiology , Stroke/etiology , Stroke/therapy , Thrombectomy/methods , Thrombectomy/statistics & numerical data , Thrombolytic Therapy/methods , Thrombolytic Therapy/statistics & numerical data , United States/epidemiology
10.
J Stroke Cerebrovasc Dis ; 29(12): 105325, 2020 Dec.
Article in English | MEDLINE | ID: covidwho-811980

ABSTRACT

INTRODUCTION: Coronavirus disease 2019 has been associated with stroke, particular characteristics of these patients are not fully understood. The adequate management of these patients depends on the comprehension of factors such as temporality, clinical presentation and etiology. We hypothesize there is an important temporal relationship between COVID-19 severity and stroke onset. METHODS: a systematic review of the available literature was conducted using Pubmed and Scopus, studies reporting patients with Coronavirus disease 19 and stroke were included. Clinical, sociodemographic and laboratory characteristics of patients were extracted and analyzed. RESULTS: Forty-seven studies and 176 patients were included, with a mean age of 63.1 years (SD= 16 n=122), most of them were males (63.2% n=171). The most frequent etiology was cryptogenic 40.9% n=66), and a mean National Institute of Health Stroke Scale of 14.4 points was found (SD= 8.6 n=73). Large vessel occlusion was reported in 65.9% patients (n=91) and these patients were younger with greater stroke severity. D-dimer, C-reactive protein, fibrinogen, ferritin and lactate dehydrogenase were elevated in most patients with reported findings. Most patients had severe Coronavirus disease 2019. The mean time from onset of respiratory symptoms to stroke was 9 days (SD=9.9), the shortest time was noted in those with mild and moderate disease. CONCLUSIONS: There is a trend between the severity of Coronavirus disease 2019 and time to stroke onset. Also, age and stroke severity were found to be related to the development of large vessel occlusion. Inflammation and hypercoagulability markers are elevated in this disease, we propose to not discard hypercoagulability secondary to severe acute respiratory syndrome-coronavirus-2 as an underlying cause of stroke in these patients.


Subject(s)
COVID-19/epidemiology , Global Health , Stroke/epidemiology , Adult , Age Factors , Aged , Aged, 80 and over , COVID-19/diagnosis , Female , Humans , Male , Middle Aged , Prognosis , Risk Assessment , Risk Factors , Severity of Illness Index , Stroke/diagnosis , Thrombophilia/epidemiology , Time Factors
11.
BMC Neurol ; 20(1): 358, 2020 Sep 24.
Article in English | MEDLINE | ID: covidwho-792799

ABSTRACT

BACKGROUND: The novel coronavirus (COVID-19) global pandemic is associated with an increased incidence of acute ischemic stroke (AIS) secondary to large vessel occlusion (LVO). The treatment of these patients poses unique and significant challenges to health care providers requiring changes in existing protocols. CASE PRESENTATION: A 54-year-old COVID-19 positive patient developed sudden onset left hemiparesis secondary to an acute right middle cerebral artery occlusion (National Institutes of Health Stroke Scale (NIHSS) score = 11). Mechanical thrombectomy (MT) was performed under a new protocol specifically designed to maximize protective measures for the team involved in the care of the patient. Mechanical Thrombectomy was performed successfully under general anesthesia resulting in TICI 3 recanalization. With regards to time metrics, time from door to reperfusion was 60 mins. The 24-h NIHSS score decreased to 2. Patient was discharged after 19 days after improvement of her pulmonary status with modified Rankin Scale = 1. CONCLUSION: Patients infected by COVID-19 can develop LVO that is multifactorial in etiology. Mechanical thrombectomy in a COVID-19 confirmed patient presenting with AIS due to LVO is feasible with current mechanical thrombectomy devices. A change in stroke workflow and protocols is now necessary in order to deliver the appropriate life-saving therapy for COVID-19 positive patients while protecting medical providers.


Subject(s)
Coronavirus Infections/complications , Endovascular Procedures/methods , Infarction, Middle Cerebral Artery/surgery , Personal Protective Equipment , Pneumonia, Viral/complications , Thrombectomy/methods , Betacoronavirus , Brain Ischemia/complications , Brain Ischemia/diagnostic imaging , Brain Ischemia/surgery , COVID-19 , Cerebral Angiography , Computed Tomography Angiography , Emergency Medical Services , Female , Humans , Infarction, Middle Cerebral Artery/complications , Infarction, Middle Cerebral Artery/diagnostic imaging , Intubation, Intratracheal , Middle Aged , Pandemics , Reperfusion , SARS-CoV-2 , Stroke/complications , Stroke/diagnostic imaging , Stroke/surgery , Time-to-Treatment , Treatment Outcome
12.
Front Immunol ; 11: 1648, 2020.
Article in English | MEDLINE | ID: covidwho-685338

ABSTRACT

Cytokine storm is an acute hyperinflammatory response that may be responsible for critical illness in many conditions including viral infections, cancer, sepsis, and multi-organ failure. The phenomenon has been implicated in critically ill patients infected with SARS-CoV-2, the novel coronavirus implicated in COVID-19. Critically ill COVID-19 patients experiencing cytokine storm are believed to have a worse prognosis and increased fatality rate. In SARS-CoV-2 infected patients, cytokine storm appears important to the pathogenesis of several severe manifestations of COVID-19: acute respiratory distress syndrome, thromboembolic diseases such as acute ischemic strokes caused by large vessel occlusion and myocardial infarction, encephalitis, acute kidney injury, and vasculitis (Kawasaki-like syndrome in children and renal vasculitis in adult). Understanding the pathogenesis of cytokine storm will help unravel not only risk factors for the condition but also therapeutic strategies to modulate the immune response and deliver improved outcomes in COVID-19 patients at high risk for severe disease. In this article, we present an overview of the cytokine storm and its implications in COVID-19 settings and identify potential pathways or biomarkers that could be targeted for therapy. Leveraging expert opinion, emerging evidence, and a case-based approach, this position paper provides critical insights on cytokine storm from both a prognostic and therapeutic standpoint.


Subject(s)
Betacoronavirus/immunology , Coronavirus Infections/drug therapy , Coronavirus Infections/immunology , Critical Care/methods , Cytokines/blood , Pneumonia, Viral/drug therapy , Pneumonia, Viral/immunology , Adrenal Cortex Hormones/therapeutic use , Angiotensin-Converting Enzyme 2 , Anti-Inflammatory Agents, Non-Steroidal/therapeutic use , CD4-CD8 Ratio , CD4-Positive T-Lymphocytes/immunology , CD8-Positive T-Lymphocytes/immunology , COVID-19 , Clinical Decision-Making/methods , Coronavirus Infections/blood , Coronavirus Infections/mortality , Critical Illness , Endothelial Cells/metabolism , Female , Humans , Immunocompromised Host , Interleukin-6/antagonists & inhibitors , Janus Kinase Inhibitors/therapeutic use , Male , Pandemics , Peptidyl-Dipeptidase A/metabolism , Pneumonia, Viral/blood , Pneumonia, Viral/mortality , SARS-CoV-2 , Sex Factors , Thrombosis
13.
Stroke ; 51(8): 2593-2596, 2020 08.
Article in English | MEDLINE | ID: covidwho-680787

ABSTRACT

During the coronavirus disease 2019 (COVID-19) pandemic, the World Health Organization recommended measures to mitigate the outbreak such as social distancing and confinement. Since these measures have been put in place, anecdotal reports describe a decrease in the number of endovascular therapy (EVT) treatments for acute ischemic stroke due to large vessel occlusion. The purpose of our study was to determine the effect on EVT for patients with acute ischemic stroke during the COVID-19 confinement. In this retrospective, observational study, data were collected from November 1, 2019, to April 15, 2020, at 17 stroke centers in countries where confinement measures have been in place since March 2020 for the COVID-19 pandemic (Switzerland, Italy, France, Spain, Portugal, Germany, Canada, and United States). This study included 1600 patients treated by EVT for acute ischemic stroke. Date of EVT and symptom onset-to-groin puncture time were collected. Mean number of EVTs performed per hospital per 2-week interval and mean stroke onset-to-groin puncture time were calculated before confinement measures and after confinement measures. Distributions (non-normal) between the 2 groups (before COVID-19 confinement versus after COVID-19 confinement) were compared using 2-sample Wilcoxon rank-sum test. The results show a significant decrease in mean number of EVTs performed per hospital per 2-week interval between before COVID-19 confinement (9.0 [95% CI, 7.8-10.1]) and after COVID-19 confinement (6.1 [95% CI, 4.5-7.7]), (P<0.001). In addition, there is a significant increase in mean stroke onset-to-groin puncture time (P<0.001), between before COVID-19 confinement (300.3 minutes [95% CI, 285.3-315.4]) and after COVID-19 confinement (354.5 minutes [95% CI, 316.2-392.7]). Our preliminary analysis indicates a 32% reduction in EVT procedures and an estimated 54-minute increase in symptom onset-to-groin puncture time after confinement measures for COVID-19 pandemic were put into place.


Subject(s)
Coronavirus Infections , Disease Management , Endovascular Procedures/statistics & numerical data , Pandemics , Pneumonia, Viral , Quarantine , Stroke/therapy , Brain Ischemia/therapy , COVID-19 , Eligibility Determination , Female , Humans , Male , Middle Aged , Retrospective Studies , Spain , Time-to-Treatment , Treatment Outcome
14.
J Stroke Cerebrovasc Dis ; 29(8): 104953, 2020 Aug.
Article in English | MEDLINE | ID: covidwho-665503

ABSTRACT

INTRODUCTION: Although there is evidence to suggest a high rate of cerebrovascular complications in patients with SARS-CoV-2 infection, anecdotal reports indicate a falling rate of new ischemic stroke diagnoses. We conducted an exploratory single-center analysis to estimate the change in number of new stroke diagnoses in our region, and evaluate the proximate reasons for this change during the COVID-19 pandemic at a tertiary care center in New Jersey. PATIENTS AND METHODS: A Comprehensive Stroke Center prospective cohort was retrospectively analyzed for the number of stroke admissions, demographic features, and short-term outcomes 5 months prior to 3/1/2020 (pre-COVID-19), and in the 6 weeks that followed (COVID-19 period). The primary outcome was the number of new acute stroke diagnoses before and during the COVID-19 period, as well as the potential reasons for a decline in the number of new diagnoses. RESULTS: Of the 328 included patients, 53 (16%) presented in the COVID-19 period. There was a mean fall of 38% in new stroke diagnoses (mean 1.13/day [SD 1.07] from 1.82/day [SD 1.38], p<0.01), which was related to a 59% decline in the number of daily transfers from referral centers (p<0.01), 25% fewer telestroke consultations (p=0.08), and 55% fewer patients presenting directly to our institution by private vehicle (p<0.01) and 29% fewer patients through emergency services (p=0.09). There was no significant change in the monthly number of strokes due to large vessel occlusion (LVO), however the proportion of new LVOs nearly doubled in the COVID-19 period (38% vs. 21%, p=0.01). CONCLUSIONS: The observations at our tertiary care center corroborate anecdotal reports that the number of new stroke diagnoses is falling, which seems related to a smaller proportion of patients seeking healthcare services for milder symptoms. These preliminary data warrant validation in larger, multi-center studies.


Subject(s)
Coronavirus Infections/epidemiology , Pneumonia, Viral/epidemiology , Stroke/epidemiology , Tertiary Care Centers , Aged , Aged, 80 and over , Betacoronavirus/pathogenicity , COVID-19 , Coronavirus Infections/diagnosis , Coronavirus Infections/virology , Emergency Medical Services , Female , Humans , Incidence , Male , Middle Aged , New Jersey/epidemiology , Pandemics , Patient Acceptance of Health Care , Patient Transfer , Pneumonia, Viral/diagnosis , Pneumonia, Viral/virology , Remote Consultation , Retrospective Studies , Risk Factors , SARS-CoV-2 , Stroke/diagnosis , Stroke/therapy , Stroke/virology , Time Factors
15.
Stroke ; 51(8): 2540-2543, 2020 08.
Article in English | MEDLINE | ID: covidwho-418810

ABSTRACT

BACKGROUND AND PURPOSE: Higher rates of strokes have been observed in patients with coronavirus disease 2019 (COVID-19), but data regarding the outcomes of COVID-19 patients suffering from acute ischemic stroke due to large vessel occlusion (LVO) are lacking. We report our initial experience in the treatment of acute ischemic stroke with LVO in patients with COVID-19. METHODS: All consecutive patients with COVID-19 with acute ischemic stroke due to LVO treated in our institution during the 6 first weeks of the COVID-19 outbreak were included. Baseline clinical and radiological findings, treatment, and short-term outcomes are reported. RESULTS: We identified 10 patients with confirmed COVID-19 treated for an acute ischemic stroke due to LVO. Eight were men, with a median age of 59.5 years. Seven had none or mild symptoms of COVID-19 at stroke onset. Median time from COVID-19 symptoms to stroke onset was 6 days. All patients had brain imaging within 3 hours from symptoms onset. Five patients had multi-territory LVO. Five received intravenous alteplase. All patients had mechanical thrombectomy. Nine patients achieved successful recanalization (mTICI2B-3), none experienced early neurological improvement, 4 had early cerebral reocclusion, and a total of 6 patients (60%) died in the hospital. CONCLUSIONS: Best medical care including early intravenous thrombolysis, and successful and prompt recanalization achieved with mechanical thrombectomy, resulted in poor outcomes in patients with COVID-19. Although our results require further confirmation, a different pharmacological approach (antiplatelet or other) should be investigated to take in account inflammatory and coagulation disorders associated with COVID-19.


Subject(s)
Arterial Occlusive Diseases/complications , Brain Ischemia/etiology , Brain Ischemia/therapy , Coronavirus Infections/complications , Pneumonia, Viral/complications , Stroke/etiology , Stroke/therapy , Aged , Arterial Occlusive Diseases/diagnostic imaging , Blood Coagulation Disorders/etiology , Brain/diagnostic imaging , Brain Ischemia/diagnostic imaging , COVID-19 , Cerebral Arteries , Cerebral Veins , Female , Hospital Mortality , Humans , Male , Middle Aged , Pandemics , Plasminogen Activators/therapeutic use , Stroke/diagnostic imaging , Thrombectomy , Thrombolytic Therapy , Time-to-Treatment , Tissue Plasminogen Activator/therapeutic use , Treatment Outcome
16.
Front Neurol ; 11: 468, 2020.
Article in English | MEDLINE | ID: covidwho-381222

ABSTRACT

The current coronavirus disease (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 has led to immense strain on healthcare systems and workers. Patients with severe symptoms of COVID-19 may also present with acute neurological emergencies such as ischemic stroke. Ischemic stroke in these patients may result from COVID-19 related complications or decompensation of previously asymptomatic cerebrovascular disorders, or concurrent ischemic stroke from common stroke risk factors in a patient with COVID-19. Acute ischemic stroke patients with large vessel occlusions require emergent triage, intensive care, and mechanical thrombectomy. Management of patients with large vessel occlusions (LVO) requires special considerations in the current pandemic. Physicians must now account for prognosis of severe COVID-19, resource utilization, and risk of infection to healthcare workers when determining eligibility for mechanical thrombectomy (MT). Here, we describe important prognostic factors including age, laboratory, and imaging findings to consider for MT selection and provide suggestions for taking care of patients with LVO and possible or confirmed COVID-19. It is recommended to perform MT in patients within the established guidelines, and consider a conservative approach in cases where there is clinical equipoise to minimize futile reperfusion. Lastly, we describe an illustrative case of a patient with ischemic stroke and COVID-19.

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