Incidence and Long-term Functional Outcome of Neurologic Disorders in Hospitalized Patients With COVID-19 Infected With Pre-Omicron Variants.

BACKGROUND AND OBJECTIVES: A variety of neurologic disorders have been reported as presentations or complications of coronavirus disease 2019 (COVID-19) infection. The objective of this study was to determine their incidence dynamics and long-term functional outcome. METHODS: The Neuro-COVID Italy study was a multicenter, observational, cohort study with ambispective recruitment and prospective follow-up. Consecutive hospitalized patients presenting new neurologic disorders associated with COVID-19 infection (neuro-COVID), independently from respiratory severity, were systematically screened and actively recruited by neurology specialists in 38 centers in Italy and the Republic of San Marino. The primary outcomes were incidence of neuro-COVID cases during the first 70 weeks of the pandemic (March 2020-June 2021) and long-term functional outcome at 6 months, categorized as full recovery, mild symptoms, disabling symptoms, or death. RESULTS: Among 52,759 hospitalized patients with COVID-19, 1,865 patients presenting 2,881 new neurologic disorders associated with COVID-19 infection (neuro-COVID) were recruited. The incidence of neuro-COVID cases significantly declined over time, comparing the first 3 pandemic waves (8.4%, 95% CI 7.9-8.9; 5.0%, 95% CI 4.7-5.3; 3.3%, 95% CI 3.0-3.6, respectively; p = 0.027). The most frequent neurologic disorders were acute encephalopathy (25.2%), hyposmia-hypogeusia (20.2%), acute ischemic stroke (18.4%), and cognitive impairment (13.7%). The onset of neurologic disorders was more common in the prodromic phase (44.3%) or during the acute respiratory illness (40.9%), except for cognitive impairment whose onset prevailed during recovery (48.4%). A good functional outcome was achieved by most patients with neuro-COVID (64.6%) during follow-up (median 6.7 months), and the proportion of good outcome increased throughout the study period (r = 0.29, 95% CI 0.05-0.50; p = 0.019). Mild residual symptoms were frequently reported (28.1%) while disabling symptoms were common only in stroke survivors (47.6%). DISCUSSION: Incidence of COVID-associated neurologic disorders decreased during the prevaccination phase of the pandemic. Long-term functional outcome was favorable in most neuro-COVID disorders, although mild symptoms commonly lasted more than 6 months after infection.

SARS-CoV-2 infection and acute ischemic stroke in Lombardy, Italy.

OBJECTIVE: To characterize patients with acute ischemic stroke related to SARS-CoV-2 infection and assess the classification performance of clinical and laboratory parameters in predicting in-hospital outcome of these patients. METHODS: In the setting of the STROKOVID study including patients with acute ischemic stroke consecutively admitted to the ten hub hospitals in Lombardy, Italy, between March 8 and April 30, 2020, we compared clinical features of patients with confirmed infection and non-infected patients by logistic regression models and survival analysis. Then, we trained and tested a random forest (RF) binary classifier for the prediction of in-hospital death among patients with COVID-19. RESULTS: Among 1013 patients, 160 (15.8%) had SARS-CoV-2 infection. Male sex (OR 1.53; 95% CI 1.06-2.27) and atrial fibrillation (OR 1.60; 95% CI 1.05-2.43) were independently associated with COVID-19 status. Patients with COVID-19 had increased stroke severity at admission [median NIHSS score, 9 (25th to75th percentile, 13) vs 6 (25th to75th percentile, 9)] and increased risk of in-hospital death (38.1% deaths vs 7.2%; HR 3.30; 95% CI 2.17-5.02). The RF model based on six clinical and laboratory parameters exhibited high cross-validated classification accuracy (0.86) and precision (0.87), good recall (0.72) and F1-score (0.79) in predicting in-hospital death. CONCLUSIONS: Ischemic strokes in COVID-19 patients have distinctive risk factor profile and etiology, increased clinical severity and higher in-hospital mortality rate compared to non-COVID-19 patients. A simple model based on clinical and routine laboratory parameters may be useful in identifying ischemic stroke patients with SARS-CoV-2 infection who are unlikely to survive the acute phase.

Impact of SARS-CoV-2 on reperfusion therapies for acute ischemic stroke in Lombardy, Italy: the STROKOVID network.

Whether and how SARS-CoV-2 outbreak affected in-hospital acute stroke care system is still matter of debate. In the setting of the STROKOVID network, a collaborative project between the ten centers designed as hubs for the treatment of acute stroke during SARS-CoV-2 outbreak in Lombardy, Italy, we retrospectively compared clinical features and process measures of patients with confirmed infection (COVID-19) and non-infected patients (non-COVID-19) who underwent reperfusion therapies for acute ischemic stroke. Between March 8 and April 30, 2020, 296 consecutive patients [median age, 74 years (interquartile range (IQR), 62-80.75); males, 154 (52.0%); 34 (11.5%) COVID-19] qualified for the analysis. Time from symptoms onset to treatment was longer in the COVID-19 group [230 (IQR 200.5-270) minutes vs. 190 (IQR 150-245) minutes; p = 0.007], especially in the first half of the study period. Patients with COVID-19 who underwent endovascular thrombectomy had more frequently absent collaterals or collaterals filling ≤ 50% of the occluded territory (50.0% vs. 16.6%; OR 5.05; 95% CI 1.82-13.80) and a lower rate of good/complete recanalization of the primary arterial occlusive lesion (55.6% vs. 81.0%; OR 0.29; 95% CI 0.10-0.80). Post-procedural intracranial hemorrhages were more frequent (35.3% vs. 19.5%; OR 2.24; 95% CI 1.04-4.83) and outcome was worse among COVID-19 patients (in-hospital death, 38.2% vs. 8.8%; OR 6.43; 95% CI 2.85-14.50). Our findings showed longer delays in the intra-hospital management of acute ischemic stroke in COVID-19 patients, especially in the early phase of the outbreak, that likely impacted patients outcome and should be the target of future interventions.

Wake-up stroke and TIA due to paradoxical embolism during long obstructive sleep apnoeas: a cross-sectional study.

BACKGROUND AND PURPOSE: Long obstructive sleep apnoeas (LOSAs) can cause brain ischaemia through paradoxical embolism since they can lead to right to left shunting (RLSh) but this has never been assessed as a risk factor for stroke. We investigated whether the combination of LOSA and RLSh is associated with ischaemic stroke or transient ischaemic attack (TIA) on waking (wake-up stroke). METHODS: We prospectively considered patients aged over 18 years, admitted to 13 stroke units for acute ischaemic stroke or TIA. Patients had to be able to give consent, to specify whether the event occurred on waking, and to cooperate sufficiently to undergo contrast transcranial Doppler examination and cardiorespiratory sleep study within 10 days of the onset of symptoms. Single LOSA events, lasting 20 s or more, were considered a possible harbinger of RLSh. RESULTS: Between April 2008 and March 2010, 335 patients (109 women; 61 TIA, mean age 64 years) were enrolled; 202 (60%) had at least one LOSA and 116 (35%) a RLSh; 69 (21%) had both. There were significantly more wake-up strokes/TIAs in subjects with RLSh plus LOSA than those without this association (27/69 vs 70/266; OR 1.91, controlled for age, sex, hypertension, diabetes, atrial fibrillation, antithrombotic therapy; 95% CI 1.08 to 3.38; p=0.03). No other risk factor was associated with an increase in the incidence of events on waking. CONCLUSIONS: The study suggests that the combination of LOSA and RLSh could be a new major, potentially treatable risk factor for cerebrovascular ischaemic events.

Drug abuse and intracranial hemorrhage.

The rate of strokes among amphetamine and cocaine abusers is increasing. The exact mechanism remains unclear. Many factors could be involved including vasospasm, cerebral vasculitis, enhanced platelet aggregation, cardioembolism, and hypertensive surges. Around 40% of patients have pre-existing lesions (aneurysms, artero-venous malformations). Cerebral angiographic examination is recommended in cases of cocaine-related intracerebral hemorrhage, especially if the hemorrhage is lobar or intraventricular.

Is global cardiovascular risk considered in current practice? Treatment and control of hypertension, hyperlipidemia, and diabetes according to patients' risk level.

OBJECTIVES: To assess the pharmacological treatment and the control of major modifiable cardiovascular risk factors in everyday practice according to the patients' cardiovascular risk level. METHODS: In a cross-sectional study general practitioners (GPs) had to identify a random sample of their patients with cardiovascular risk factors or diseases and collect essential data on the pharmacological treatment and control of hypertension, hyperlipidemia, and diabetes according to the patients' cardiovascular risk level and history of cardiovascular disease. Participants were subjects of both sexes, aged 40-80 years, with at least one known cardiovascular risk factor or a history of cardiovascular diseases. RESULTS: From June to December 2000, 162 Italian GPs enrolled 3120 of their patients (2470 hypertensives, 1373 hyperlipidemics, and 604 diabetics). Despite the positive association between the perceived level of global cardiovascular risk and lipid-lowering drug prescriptions in hyperlipidemic subjects (from 26% for lowest risk to 56% for highest risk p < 0.0001) or the prescription of combination therapy in hypertensives (from 41% to 70%, p < 0.0001) and diabetics (from 24% to 43%, p = 0.057), control was still inadequate in 48% of diabetics, 77% of hypertensives, and 85% of hyperlipidemics, with no increase in patients at highest risk. Trends for treatment and control were similar in patients with cardiovascular diseases. CONCLUSIONS: Even in high-risk patients, despite a tendency towards more intensive treatment, pharmacological therapy is still under used and the degree of control of blood pressure, cholesterol level and diabetes is largely unsatisfactory.

Appropriate use of antiplatelets: is prescription in daily practice influenced by the global cardiovascular risk?

OBJECTIVE: To evaluate the appropriate prescription of antiplatelets according to patients' global cardiovascular risk level in everyday practice. METHODS: In a cross-sectional study, general practitioners (GPs) identified a random sample of 10% of patients at cardiovascular risk among all subjects coming to the surgery and collected data on cardiovascular risk factors and history of atherosclerotic cardiovascular diseases (CVD). GPs were asked to do a physical examination and record the results of laboratory tests to define the global cardiovascular risk. The use of antiplatelet drugs in patients with established CVD and in healthy subjects at high risk of developing symptomatic atherosclerotic disease was evaluated. RESULTS: A total of 162 GPs from all over Italy recruited 3,120 subjects (51% female, mean age 64 years). Of the 949 with an indication for antiplatelet treatment for secondary prevention of CVD, 442 (47%) were receiving it. Among the 2,071 without CVD, 11% were taking an antiplatelet drug. In this group, antiplatelets were prescribed in 6, 10, 16 and 23%, respectively, of patients perceived by GPs to be at mild, moderate, high and very high cardiovascular risk. CONCLUSIONS: Prescription of antiplatelets still seems to be far from what is recommended in virtually all patients with a history of CVD. In subjects with cardiovascular risk factors but without CVD antiplatelet prescription increases in relation to global cardiovascular risk but is still low in patients at high or very high risk of cardiovascular events.

How general practitioners perceive and grade the cardiovascular risk of their patients.

BACKGROUND: Although risk assessment charts have been proposed to identify patients at high cardiovascular risk, in everyday practice general practitioners (GPs) often use their knowledge of the patients to estimate the risk subjectively. DESIGN: A cross-sectional study aimed to describe how GPs perceive, qualify and grade cardiovascular risk in everyday practice. METHODS: General practitioners had to identify in a random sample of 10% of their contacts the first 20 consecutive patients perceived as being at cardiovascular risk. For each patient essential data were collected on clinical history, physical examination and laboratory tests, for the qualification of risk. At the end of the process GPs subjectively estimated the overall patient's level of risk. General practitioners grading was compared with the risk estimate from a reference chart. RESULTS: Over a mean time of 25 days 3120 patients perceived as being at cardiovascular risk were enrolled. According to the inclusion scheme each GP had contact with more than 200 patients at cardiovascular risk every month. Thirty percent of these patients had atherosclerotic diseases. Up to 72% of patients without any history of atherosclerotic diseases but perceived to be at risk could be classified according to a reference chart as being at moderate to very high risk. Comparing GPs' grading of risk with a chart estimate there was agreement in 42% of the cases. Major determinants of GPs' underestimation of risk were age, sex and smoking habits, while obesity and family history were independently associated with overestimation. CONCLUSIONS: On the basis of their perception GPs properly identify patients at cardiovascular risk in the majority of cases. General practitioners subjective grading of risk level only partially agreed with that given by a chart.

People's perception of their overall coronary risk: an Italian experience.

BACKGROUND: Strategies to prevent cardiovascular diseases are still not widely applied. It is vital to involve people for effective prevention, and knowledge of their own coronary risk is a first step. Little is known about how people perceive their coronary risk. For this reason, we examined this perception in a sample of the general population and compared it with a reference risk chart. METHODS: We invited the population of two small towns to come for a free check of their blood pressure and blood cholesterol levels. People were first asked to complete a self-administered questionnaire grading their perceived risk of developing a coronary event. Then, basic data were collected for calculating their risk according to a reference chart. RESULTS: A total of 877 individuals (382 males, 495 females, age 30-80 years) without ischemic heart disease completed the questionnaire and had their blood pressure and cholesterol checked. Many important risk factors are still not taken into account by patients, particularly male sex, older age and diabetes. One out of 4 subjects underestimates his level of coronary risk and 9 out of 10 high-risk subjects are not even aware of it. CONCLUSIONS: Our study shows that large numbers of persons are still unaware of their level of coronary risk and of its major determinants. Better counseling by general practitioners is needed since a realistic perception of risk is essential for reducing it.