Abstract
INTRODUCTION:In March 2020, COVID-19 was declared a pandemic by the World Health Organization and cases of stroke related to the virus soon were reported.
OBJECTIVES:To become aware of the experiences different parts of the world have encountered with stroke and COVID 19 in order to enhance our knowledge, improve recognition and response to patients in our clinical setting.
METHODS:A review of the available observational studies was done using PubMed, Scopus and other sources of gray literature for the publications on stroke and COVID-19. Demographic data, time of stroke onset since the diagnosis of COVID-19, main radiological findings, lab tests and prognosis were identified.
RESULTS:Eight studies were selected with 43 subjects who had ischemic stroke and SARS-CoV-2 infection. The average age was 67.4 years, being mostly men (58%). An important finding was the number of stroke cases with large vessel occlusion, with 22 of 31 cases reported (71%). The NIHSS median was 14.5 points, and 27.5% of subjects with stroke and COVID-19 died. The most frequent disease severity for COVID-19 was "severe", accounting for 58% of the cases. The onset of stroke after SARS-CoV-2 infection was 10.6 days on average. In the laboratories an elevation of fibrinogen (92%), D-Dimer (76%) and LDH (82%) were respectively identified. The most frequent treatment received for stroke were antiplatelet medications (51%), while reperfusion therapy was done in 30% of cases. Most patients presented to the hospital with typical symptoms of COVID-19 (93%), (7%) 3 patients did not have respiratory symptoms, however they presented with a decreased level of consciousness associated with stroke findings.
CONCLUSION:Inflammation and hypercoagulability, both present during the infection by SARS-CoV-2, are probably related to the development of a stroke, which in this case could explain the large number of large vessel occlusions. Protected stroke code is a protocol that should be implemented in our region.
References
Cucinotta D, Vanelli M. WHO declares COVID-19 a pandemic. Acta Biomed. 2020;91(1):157-60. DOI: 10.23750/abm.v91i1.9397
Coronavirus (covid-19) en Colombia [Internet]. 2020. Tomado de: https://www.ins.gov.co/Noticias/Paginas/Coronavirus.aspx
Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020;382(18):1708-20. DOI: 10.1056/NEJMoa2002032
Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020;395(10223):507-13. DOI: 10.1016/S0140-6736(20)30211-7
Ruan Q, Yang K, Wang W, Jiang L, Song J. Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan, China. Intensive Care Med. 2020;46(5):846-8. DOI: 10.1007/s00134-020-05991-x
Mao L, Jin H, Wang M, Hu Y, Chen S, He Q, et al. Neurologic manifestations of hospitalized patients with coronavirus disease 2019 in Wuhan, China. JAMA Neurol. 2020. DOI: 10.1001/jamaneurol.2020.1127
Ou X, Liu Y, Lei X, Li P, Mi D, Ren L, et al. Characterization of spike glycoprotein of SARS-CoV-2 on virus entry and its immune cross-reactivity with SARS-CoV. Nat Commun. 2020;11(1):1620. DOI: 10.1038/s41467-020-15562-9
De Felice FG, Tovar-Moll F, Moll J, Munoz DP, Ferreira ST. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the central nervous system. Trends Neurosci. 2020 Apr 21. DOI: 10.1016/j.tins.2020.04.004
Li YC, Bai WZ, Hashikawa T. The neuroinvasive potential of SARS-CoV2 may play a role in the respiratory failure of COVID-19 patients. J Med Virol. 2020;92(6):552-5. DOI: 10.1002/jmv.25728
Connors JM, Levy JH. Thromboinfl animation and the hypercoagulability of COVID-19. J Thromb Haemost. 2020 Apr 17. DOI: 10.1111/jth.14849
Tang N, Li D, Wang X, Sun Z. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. J Thromb Haemost. 2020;18(4):844-7. DOI: 10.1111/jth.14768
Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020;395(10229):1054-62. DOI: 10.1016/S0140-6736(20)30566-3
Spiezia L, Boscolo A, Poletto F, Cerruti L, Tiberio I, Campello E, et al. COVID-19-related severe hypercoagulability in patients admitted to intensive care unit for acute respiratory failure. Thromb Haemost. 2020; Apr 21. doi: 10.1055/s-0040-1710018.
Klok FA, Kruip MJHA, van der Meer NJM, Arbous MS, Gommers DAMPJ, Kant KM, et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res. 2020. DOI: 10.1055/s-0040-1710018
Li Y, Wang M, Zhou Y, Chang J, Xian Y, Mao L, et al. Acute cerebrovascular disease following COVID-19: A single center, retrospective, observational study. SSRN Electron J. 2020;19. DOI: 10.2139/ssrn.3550025
McNamara D. COVID-19: Are acute stroke patients avoiding emergency care? Frontline Medical Communications [Internet]. 2020 Abr; Tomado de: https://www.mdedge.com/neurology/article/220491/stroke/covid-19-are-acute-stroke-patients-avoiding-emergency-care
Beyrouti R, Adams ME, Benjamin L, Cohen H, Farmer SF, Goh YY, et al. Characteristics of ischaemic stroke associated with COVID-19. J Neurol Neurosurg Psychiatry. 2020 Apr 30. DOI: 10.1136/jnnp-2020-323586
Zhang Y, Xiao M, Zhang S, Xia P, Cao W, Jiang W, et al. Coagulopathy and antiphospholipid antibodies in patients with Covid-19. N Engl J Med. 2020;382(17). DOI: 10.1056/NEJMc2007575
Oxley TJ, Mocco J, Majidi S, Kellner CP, Shoirah H, Singh IP, et al. Large-vessel stroke as a presenting feature of covid-19 in the young. N Engl J Med. 2020 Apr 28:e60. DOI: 10.1056/NEJMc2009787
Avula A, Nalleballe K, Narula N, Sapozhnikov S, Dandu V, Toom S, et al. COVID-19 presenting as stroke. Brain Behav Immun. 2020 Apr 28. DOI: 10.1016/j.bbi.2020.04.077
Benjamin EJ, Muntner P, Alonso A, Bittencourt MS, Cal-laway CW, Carson AP, et al. Heart disease and stroke statistics-2019 update: a report from the American Heart Association. Circulation. 2019;139(10):e56-e528. DOI: 10.1161/CIR.0000000000000659
Kamel H, Iadecola C. Brain-immune interactions and ischemic stroke: clinical implications. Arch Neurol. 2012;69(5):576-81. DOI: 10.1001/archneurol.2011.3590
Tunç A, Unlùbas Y, Alemdar M, Akyùz E. Coexistence of COVID-19 and acute ischemic stroke report of four cases. J Clin Neurosci. 2020 May. DOI: 10.1016/j.jocn.2020.05.018
Terpos E, Ntanasis-Stathopoulos I, Elalamy I, Kastritis E, Sergentanis TN, Politou M, et al. Hematological findings and complications of COVID-19. Am J Hematol. 2020. DOI: 10.1002/ajh.25829
Siniscalchi A, Iannacchero R, Anticoli S, Romana Pezzella F, De Sarro G, Gallelli L. Anti-inflammatory strategies in stroke: a potential therapeutic target. Curr Vasc Pharmacol. 2015;14(1):98-105. DOI: 10.2174/1570161113666150923111329
Siniscalchi A, Gallelli L, Malferrari G, Pirritano D, Serra R, Santangelo E, et al. Cerebral stroke injury: The role of cytokines and brain inflammation. J Basic Clin Physiol Pharmacol. 2014;25(2):131-7. DOI: 10.1515/jbcpp-2013-0121
Luo X, Zhou W, Yan X, Guo T, Wang B, Xia H, et al. Prognostic value of C-reactive protein in patients with COVID-19. medRxiv. 2020;1-21. DOI: 10.1101/2020.03.21.20040360
Marulanda-Londono E, Chaturvedi S. Stroke due to large vessel atherosclerosis Five new things. Neurol Clin Pract. 2016;252-8. DOI: 10.1212/CPJ.0000000000000247
Stoll G, Bendszus M. Inflammation and atherosclerosis: Novel insights into plaque formation and destabilization. Stroke. 2006;37(7):1923-32. DOI: 10.1161/01.STR.0000226901.34927.10
Khosravani H, Rajendram P, Notario L, Chapman MG, Menon BK. Protected code stroke: hyperacute stroke management during the coronavirus disease 2019 (COVID-19) pandemic. Stroke. 2020 Apr 1. DOI: 10.1161/STROKEAHA.120.029838
González-Pinto T, Luna-Rodríguez A, Moreno-Estébanez A, Agirre-Beitia G, Rodríguez-Antigüedad A, Ruiz-Lopez M. Emergency room neurology in times of COVID-19: malignant ischemic stroke and SARS-COV2 infection. Eur J Neurol. 2020 Apr 30. DOI: 10.1111/ene.14286
Chen R, Ovbiagele B, Feng W Diabetes and stroke: epidemiology, pathophysiology, pharmaceuticals and outcomes. Am J Med Sci. 2016;351(4):380-6. DOI: 10.1016/j.amjms.2016.01.011
Nam KW, Kwon HM, Jeong HY, Park JH, Kwon H, Jeong SM. Cerebral small vessel disease and stage 1 hypertension defined by the 2017 American College of Cardiology/American Heart Association Guidelines. Hypertension. 2019;73(6):1210-6. DOI: 10.1161/HYPERTENSIONAHA.119.1283
Aronson JK, Ferner RE. Drugs and the renin-angiotensin system in covid-19. BMJ. 2020;369:m1313. DOI: 10.1136/bmj.m1313
Jarcho JA, Ingelfinger JR, Hamel MB, D'Agostino Sr RB, Harrington DP. Inhibitors of the renin-angiotensin-aldosterone system and Covid-19. N Engl J Med. 2020 May 1. DOI: 10.1056/NEJMe2012924
Reynolds HR, Adhikari S, Pulgarin C, Troxel AB, Iturrate E, Johnson SB, et al. Renin-angiotensin-aldosterone system inhibitors and risk of Covid-19. N Engl J Med. 2020 May 1. DOI: 10.1056/NEJMoa2008975
Yang G, Tan Z, Zhou L, Yang M, Peng L, Liu J, et al. Effects of ARBs and ACEIs on virus infection, inflammatory status and clinical outcomes In COVID-19 patients with hypertension: a single center retrospective study. Hypertension. 2020 Apr 29. DOI: 10.1161/HYPERTENSIONAHA.120.15143
Yao Q, Wang P, Wang X, Qie G, Meng M, Tong X, et al. Retrospective study of risk factors for severe SARS-Cov-2 infections in hospitalized adult patients. Pol Arch Intern Med. 2020 Apr 24. DOI: 10.20452/pamw.15312
Ulrich JN, Hesse B, Schuele S, Vlassak I, Sila CA, Jaber WA. Single-vessel versus multivessel territory acute ischemic stroke: value of transesophageal echocardiography in the differentiation of embolic stroke. J Am Soc Echocardiogr. 2006;19(9):1165-9. DOI:10.1016/j.echo.2006.04.004
Jin H, Hong C, Chen S, Zhou Y, Wang Y, Mao L, et al. Consensus for prevention and management of coronavirus disease 2019 (COVID-19) for neurologists. Stroke and Vascular Neurology. 2020 Apr 1:svn-2020. DOI: 10.1136/svn-2020-000382
Ahluwalia J, Sreedharanunni S. The laboratory diagnosis of the antiphospholipid syndrome. Indian J Hematol Blood Transfus. 2017;33(1):8-14. DOI: 10.1007/s12288-016-0739-y
Uthman IW, Gharavi AE. Viral infections and antiphospholipid antibodies. Semin Arthritis Rheum. 2002;31(4):256-63. DOI: 10.1053/sarh.2002.28303
Zhao J, Rudd A, Liu R. Challenges and potential solutions of stroke care during the coronavirus disease 2019 (COVID-19) outbreak. Stroke. 2020;51(5):1356-7 DOI: 10.1161/STROKEAHA.120.029701
Thornton J. Stroke: "striking reductions" are seen in a number of people with symptoms seeking help. BMJ. 2020. DOI: 10.1136/bmj.m1406.
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.