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Liu JL, Shah K, Marji A, Sareini R, Bhasin A, Rao S, Mohamed W, Rajamani K, Chamiraju P, Khawaja A. Descriptive analysis of Acute Ischemic stroke in COVID-19 patients through the course of the COVID-19 pandemic. J Clin Neurosci 2021; 96:221-226. [PMID: 34801399 PMCID: PMC8554005 DOI: 10.1016/j.jocn.2021.10.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 10/04/2021] [Accepted: 10/22/2021] [Indexed: 02/06/2023]
Abstract
Coronavirus disease 2019 (COVID-19) has been associated with Acute Ischemic Stroke (AIS). Here, we characterize our institutional experience with management of COVID-19 and AIS. Baseline demographics, clinical, imaging, and outcomes data were determined in patients with COVID-19 and AIS presenting within March 2020 to October 2020, and November 2020 to August 2021, based on institutional COVID-19 hospitalization volume. Of 2512 COVID-19 patients, 35 (1.39%, mean age 63.3 years, 54% women) had AIS. AIS recognition was frequently delayed after COVID-19 symptoms (median 19.5 days). Four patients (11%) were on therapeutic anticoagulation at AIS recognition. AIS mechanism was undetermined or due to multiple etiologies in most cases (n = 20, 57%). Three patients underwent IV TPA, and three underwent mechanical thrombectomy, of which two suffered re-occlusion. Three patients had incomplete mRNA vaccination course. Fourteen (40%) died, with 26 (74%) having poor outcomes. Critical COVID-19 severity was associated with worsened mortality (p = 0.02). More patients (12/16; 75%) had either worsened or similar 3-month functional outcomes, than those with improvement, indicating the devastating impact of co-existing AIS and COVID-19. Comparative analysis showed that patients in the later cohort had earlier AIS presentation, fewer stroke risk factors, more comprehensive workup, more defined stroke mechanisms, less instance of critical COVID-19 severity, more utilization of IV TPA, and a trend towards worse outcomes for the sub-group of mild-to-moderate COVID-19 severity. AIS incidence, NIHSS, and overall outcomes were similar. Further studies should investigate outcomes beyond 3 months and their predictive factors, impact of completed vaccination course, and access to neurologic care.
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Affiliation(s)
- Jay Liuhong Liu
- Department of Neurology, Wayne State University-Detroit Medical Center, Detroit, MI, USA
| | - Keval Shah
- Department of Neurology, Wayne State University-Detroit Medical Center, Detroit, MI, USA
| | - Amin Marji
- Department of Neurology, Wayne State University-Detroit Medical Center, Detroit, MI, USA
| | - Ricky Sareini
- Wayne State University School of Medicine, Detroit, MI, USA
| | - Amman Bhasin
- Wayne State University School of Medicine, Detroit, MI, USA
| | - Shishir Rao
- Department of Neurology, Wayne State University-Detroit Medical Center, Detroit, MI, USA
| | - Wazim Mohamed
- Department of Neurology, Wayne State University-Detroit Medical Center, Detroit, MI, USA
| | - Kumar Rajamani
- Department of Neurology, Wayne State University-Detroit Medical Center, Detroit, MI, USA
| | | | - Ayaz Khawaja
- Department of Neurology, Wayne State University-Detroit Medical Center, Detroit, MI, USA.
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Desai PV, Krepostman N, Collins M, De Sirkar S, Hinkleman A, Walsh K, Fareed J, Darki A. Neurological Complications of Pulmonary Embolism: a Literature Review. Curr Neurol Neurosci Rep 2021; 21:59. [PMID: 34669060 PMCID: PMC8526526 DOI: 10.1007/s11910-021-01145-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2021] [Indexed: 01/21/2023]
Abstract
PURPOSE OF REVIEW The present review discusses in-depth about neurological complications following acute venous thromboembolism (VTE). RECENT FINDINGS Intracranial hemorrhage, acute ischemic cerebrovascular events, and VTE in brain tumors are described as central nervous system (CNS) complications of PE, while peripheral neuropathy and neuropathic pain are reported as peripheral nervous system (PNS) sequelae of PE. Syncope and seizure are illustrated as atypical neurological presentations of PE. Mounting evidence suggests higher risk of venous thromboembolism (VTE) in patients with neurological diseases, but data on reverse, i.e., neurological sequelae following VTE, is underexplored. The present review is an attempt to explore some of the latter issues categorized into CNS, PNS, and atypical complications following VTE.
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Affiliation(s)
- Parth V Desai
- Department of Cardiovascular Medicine, Loyola University Medical Center, Maywood, IL, 60153, USA
| | - Nicolas Krepostman
- Departmet of Internal Medicine, Loyola University Medical Center, Maywood, IL, 60153, USA
| | - Matthew Collins
- Departmet of Internal Medicine, Loyola University Medical Center, Maywood, IL, 60153, USA
| | - Sovik De Sirkar
- Departmet of Internal Medicine, Loyola University Medical Center, Maywood, IL, 60153, USA
| | - Alexa Hinkleman
- Departmet of Internal Medicine, Loyola University Medical Center, Maywood, IL, 60153, USA
| | - Kevin Walsh
- Departmet of Internal Medicine, Loyola University Medical Center, Maywood, IL, 60153, USA
| | - Jawed Fareed
- Department of Pathology and Laboratory Medicine and Department of Pharmacology and Neuroscience, Health Science Division, Cardiovascular Research Institute, Hemostasis and Thrombosis Research Division, Loyola University, Maywood, IL, 60153, USA
| | - Amir Darki
- Department of Cardiovascular Medicine, Loyola University Medical Center, Maywood, IL, 60153, USA.
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Gavriilaki E, Eftychidis I, Papassotiriou I. Update on endothelial dysfunction in COVID-19: severe disease, long COVID-19 and pediatric characteristics. J LAB MED 2021. [DOI: 10.1515/labmed-2021-0134] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Abstract
Objectives
To review current literature on the role of endothelial dysfunction in coronavirus disease-2019 (COVID-19) infection in terms of pathophysiology, laboratory features and markers, clinical phenotype in adults and children, as well as long COVID-19.
Content
We conducted a thorough assessment of the literature and critically analyzed current data, mostly utilizing the PubMed and Medline search engines to find original studies published in the previous decade.
Summary and Outlook
Accumulating evidence suggests that endothelial dysfunction may be a common denominator of severe COVID-19 in adults and children, as well as long COVID-19, implicating mutual pathophysiological pathways. This narrative review summarizes the up-to-date knowledge of endothelial dysfunction caused by COVID-19, including novel aspects of long COVID-19 and pediatric disease. This knowledge is important in order not only to understand the multisystemic attack of COVID-19, but also to improve patient management and prognosis.
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Affiliation(s)
- Eleni Gavriilaki
- Hematology Department – BMT Unit , G. Papanikolaou Hospital , Thessaloniki , Greece
| | - Ioannis Eftychidis
- Hematology Department – BMT Unit , G. Papanikolaou Hospital , Thessaloniki , Greece
| | - Ioannis Papassotiriou
- Department of Clinical Biochemistry , “Aghia Sophia” Children’s Hospital , Athens , Greece
- IFCC Emerging Technologies Division , Emerging Technologies in Pediatric Laboratory Medicine (C-ETPLM) , Milan , Italy
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54
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Jillella DV, Philbrook B, Ortolani E, Grossberg JA, Stani T, Samuels O, Pimentel C, Harrison A, Polu AR, Siegel BI, McCullough I, Cawley M, Nahab F. Successful Endovascular Therapy in COVID-19 Associated Pediatric Ischemic Stroke. J Stroke Cerebrovasc Dis 2021; 30:106152. [PMID: 34649038 PMCID: PMC8491968 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 09/25/2021] [Accepted: 09/29/2021] [Indexed: 12/12/2022] Open
Abstract
Cerebrovascular diseases attributed to coronavirus disease 2019 (COVID-19) are uncommon but can result in devastating outcomes. Pediatric acute ischemic strokes are themselves rare and with very few large vessel occlusion related acute ischemic strokes attributed to COVID-19 described in the literature as of date. COVID-19 pandemic has contributed to acute stroke care delays across the world and with pediatric endovascular therapy still in its infancy, it poses a great challenge in facilitating good outcomes in children presenting with acute ischemic strokes in the setting of COVID-19. We present a pediatric patient who underwent endovascular therapy for an internal carotid artery occlusion related acute ischemic stroke in the setting of active COVID-19 and had an excellent outcome thanks to a streamlined stroke pathway involving the vascular neurology, neuro-interventional, neurocritical care, and anesthesiology teams.
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Affiliation(s)
- Dinesh V Jillella
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, United States.
| | - Bryan Philbrook
- Department of Pediatrics, Pediatric Neurology, Emory University School of Medicine, Atlanta, GA, United States.
| | - Elissa Ortolani
- Department of Pediatrics, Pediatric Neurology, Emory University School of Medicine, Atlanta, GA, United States.
| | - Jonathan A Grossberg
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, United States.
| | - Tristan Stani
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, United States.
| | - Owen Samuels
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, United States; Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, United States.
| | - Cederic Pimentel
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, United States; Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, United States.
| | - Amy Harrison
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, United States
| | - Ashok R Polu
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, United States.
| | - Benjamin I Siegel
- Department of Pediatrics, Pediatric Neurology, Emory University School of Medicine, Atlanta, GA, United States.
| | - Ian McCullough
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, United States.
| | - Michael Cawley
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, United States.
| | - Fadi Nahab
- Department of Neurology & Pediatrics, Emory University School of Medicine, Atlanta, GA, United States.
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Lin W, Ko CA, Sung YF, Chen YC, Lee JT, Lin YQ, Lin YK. Cerebral Venous Sinus Thrombosis, Pulmonary Embolism, and Thrombocytopenia After COVID-19 Vaccination in a Taiwanese Man: A Case Report and Literature Review. Front Neurol 2021; 12:738329. [PMID: 34630307 PMCID: PMC8498326 DOI: 10.3389/fneur.2021.738329] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 08/26/2021] [Indexed: 11/29/2022] Open
Abstract
Objective: Coronavirus disease (COVID-19) vaccine-induced immune thrombotic thrombocytopenia (VITT) is a rare but fatal complication observed within 2 weeks of adenovirus-vectored vaccination. Case Report: A 52-year-old male patient, with a family history of autoimmune diseases, presented with a new onset of worsening headache with nausea and vomiting post-vaccination. The patient was diagnosed with VITT based on laboratory findings demonstrating thrombocytopenia, elevated D-dimer, and dural sinus thrombosis identified on neuroimaging. The patient was successfully treated with high-dose immunoglobulin, steroids, and non-heparin anticoagulants, without any neurologic sequelae. Finally, a confirmatory test with anti-platelet factor 4 antibody was strongly positive. Conclusion: Physicians should be vigilant when treating patients presenting with new-onset thunderclap headache, progressive worsening headache, and awakening headache accompanied by nausea or vomiting after vaccination, even if no definite clinical neurological deficits are identified. Emergency laboratory test results for demonstrating elevated D-dimer levels, decreased platelet count, and neuroimaging correlation are integral for diagnosis and must be the standard protocol. Treatment with non-heparin anticoagulants, high-dose intravenous immunoglobulin, and steroids that halt or slow the immune-mediated prothrombotic process should be initiated immediately. Considering the high mortality rate of VITT, treatment should be initiated prior to confirmatory test results.
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Affiliation(s)
- Wei Lin
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chien-An Ko
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yueh-Feng Sung
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yeu-Chin Chen
- Department of Hematology and Oncology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Jiunn-Tay Lee
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yun-Qian Lin
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yu-Kai Lin
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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Siow I, Lee KS, Zhang JJY, Saffari SE, Ng A. Encephalitis as a neurological complication of COVID-19: A systematic review and meta-analysis of incidence, outcomes, and predictors. Eur J Neurol 2021; 28:3491-3502. [PMID: 33982853 PMCID: PMC8239820 DOI: 10.1111/ene.14913] [Citation(s) in RCA: 91] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 04/28/2021] [Accepted: 05/06/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND PURPOSE Although COVID-19 predominantly affects the respiratory system, recent studies have reported the occurrence of neurological disorders such as stroke in relation to COVID-19 infection. Encephalitis is an inflammatory condition of the brain that has been described as a severe neurological complication of COVID-19. Despite a growing number of reported cases, encephalitis related to COVID-19 infection has not been adequately characterised. To address this gap, this systematic review and meta-analysis aims to describe the incidence, clinical course, and outcomes of patients who suffer from encephalitis as a complication of COVID-19. METHODS All studies published between 1 November 2019 and 24 October 2020 that reported on patients who developed encephalitis as a complication of COVID-19 were included. Only cases with radiological and/or biochemical evidence of encephalitis were included. RESULTS In this study, 610 studies were screened and 23 studies reporting findings from 129,008 patients, including 138 with encephalitis, were included. The average time from diagnosis of COVID-19 to onset of encephalitis was 14.5 days (range = 10.8-18.2 days). The average incidence of encephalitis as a complication of COVID-19 was 0.215% (95% confidence interval [CI] = 0.056%-0.441%). The average mortality rate of encephalitis in COVID-19 patients was 13.4% (95% CI = 3.8%-25.9%). These patients also had deranged clinical parameters, including raised serum inflammatory markers and cerebrospinal fluid pleocytosis. CONCLUSIONS Although encephalitis is an uncommon complication of COVID-19, when present, it results in significant morbidity and mortality. Severely ill COVID-19 patients are at higher risk of suffering from encephalitis as a complication of the infection.
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Affiliation(s)
- Isabel Siow
- Yong Loo Lin School of MedicineNational University of SingaporeSingaporeSingapore
| | - Keng Siang Lee
- Bristol Medical SchoolFaculty of Health SciencesUniversity of BristolBristolUK
| | - John J. Y. Zhang
- Yong Loo Lin School of MedicineNational University of SingaporeSingaporeSingapore
| | | | - Adeline Ng
- Department of NeurologyNational Neuroscience InstituteSingaporeSingapore
- Neuroscience and Behavioural DisordersDuke‐NUSSingaporeSingapore
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Arandela K, Samudrala S, Abdalkader M, Anand P, Daneshmand A, Dasenbrock H, Nguyen T, Ong C, Takahashi C, Shulman J, Babi MA, Sivakumar S, Shah N, Jain S, Anand S, Nobleza COS, Shekhar S, Venkatasubramanian C, Salahuddin H, Taqi MA, Nour HA, Nofar JB, Cervantes-Arslanian AM. Reversible Cerebral Vasoconstriction Syndrome in Patients with Coronavirus Disease: A Multicenter Case Series. J Stroke Cerebrovasc Dis 2021; 30:106118. [PMID: 34560378 PMCID: PMC8445803 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106118] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 09/07/2021] [Accepted: 09/10/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND AND OBJECTIVES RCVS (Reversible Cerebral Vasoconstrictive Syndrome) is a condition associated with vasoactive agents that alter endothelial function. There is growing evidence that endothelial inflammation contributes to cerebrovascular disease in patients with coronavirus disease 2019 (COVID-19). In our study, we describe the clinical features, risk factors, and outcomes of RCVS in a multicenter case series of patients with COVID-19. MATERIALS AND METHODS Multicenter retrospective case series. We collected clinical characteristics, imaging, and outcomes of patients with RCVS and COVID-19 identified at each participating site. RESULTS Ten patients were identified, 7 women, ages 21 - 62 years. Risk factors included use of vasoconstrictive agents in 7 and history of migraine in 2. Presenting symptoms included thunderclap headache in 5 patients with recurrent headaches in 4. Eight were hypertensive on arrival to the hospital. Symptoms of COVID-19 included fever in 2, respiratory symptoms in 8, and gastrointestinal symptoms in 1. One patient did not have systemic COVID-19 symptoms. MRI showed subarachnoid hemorrhage in 3 cases, intraparenchymal hemorrhage in 2, acute ischemic stroke in 4, FLAIR hyperintensities in 2, and no abnormalities in 1 case. Neurovascular imaging showed focal segment irregularity and narrowing concerning for vasospasm of the left MCA in 4 cases and diffuse, multifocal narrowing of the intracranial vasculature in 6 cases. Outcomes varied, with 2 deaths, 2 remaining in the ICU, and 6 surviving to discharge with modified Rankin scale (mRS) scores of 0 (n=3), 2 (n=2), and 3 (n=1). CONCLUSIONS Our series suggests that patients with COVID-19 may be at risk for RCVS, particularly in the setting of additional risk factors such as exposure to vasoactive agents. There was variability in the symptoms and severity of COVID-19, clinical characteristics, abnormalities on imaging, and mRS scores. However, a larger study is needed to validate a causal relationship between RCVS and COVID-19.
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Affiliation(s)
- Kristine Arandela
- Departments of Neurology, Boston University School of Medicine and Boston Medical Center, United States
| | - Shilpa Samudrala
- Departments of Neurology, Boston University School of Medicine and Boston Medical Center, United States
| | - Mohamad Abdalkader
- Departments of Radiology, Boston University School of Medicine and Boston Medical Center, United States
| | - Pria Anand
- Departments of Neurology, Boston University School of Medicine and Boston Medical Center, United States
| | - Ali Daneshmand
- Departments of Neurology, Boston University School of Medicine and Boston Medical Center, United States; Departments of Neurosurgery, Boston University School of Medicine and Boston Medical Center, United States
| | - Hormuzdiyar Dasenbrock
- Departments of Neurology, Boston University School of Medicine and Boston Medical Center, United States; Departments of Neurosurgery, Boston University School of Medicine and Boston Medical Center, United States
| | - Thanh Nguyen
- Departments of Neurology, Boston University School of Medicine and Boston Medical Center, United States; Departments of Radiology, Boston University School of Medicine and Boston Medical Center, United States
| | - Charlene Ong
- Departments of Neurology, Boston University School of Medicine and Boston Medical Center, United States; Departments of Neurosurgery, Boston University School of Medicine and Boston Medical Center, United States
| | - Courtney Takahashi
- Departments of Neurology, Boston University School of Medicine and Boston Medical Center, United States; Departments of Neurosurgery, Boston University School of Medicine and Boston Medical Center, United States
| | - Julie Shulman
- Departments of Neurology, Boston University School of Medicine and Boston Medical Center, United States
| | - Marc Alain Babi
- Departments of Neurology and Neurosurgery, University of Florida, United States
| | - Sanjeev Sivakumar
- Department of Neurology, University of South Carolina Greenville School of Medicine, United States
| | - Neel Shah
- Department of Neurology, University of South Carolina Greenville School of Medicine, United States
| | - Sandip Jain
- Department of Neurology, University of South Carolina Greenville School of Medicine, United States
| | - Samyuktha Anand
- Department of Neurology, Prisma Health-Upstate, United States
| | | | - Shashank Shekhar
- Departments Neurology and Neurosurgery, University of Mississippi Medical Center, United States
| | | | | | - Muhammad A Taqi
- Department of Neurology, Los Robles Medical Center, United States
| | | | - Justin B Nofar
- Department of Neurology, Henry Ford Health System, United States
| | - Anna M Cervantes-Arslanian
- Departments of Neurology, Boston University School of Medicine and Boston Medical Center, United States; Departments of Neurosurgery, Boston University School of Medicine and Boston Medical Center, United States; Departments of Medicine Infectious Diseases, Boston University School of Medicine and Boston Medical Center, United States.
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Zabolotnaya SV, Bogolepova AN, Tairova RT. [COVID-19-associated stroke]. Zh Nevrol Psikhiatr Im S S Korsakova 2021; 121:5-10. [PMID: 34553575 DOI: 10.17116/jnevro20211210825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Neurological complications of COVID-19 occur in almost a third of patients. According to various studies, the frequency of cerebrovascular manifestations in patients with a positive test result for SARS-CoV-2 ranges from 1% to 3%. The most common manifestation was acute ischemic stroke. Cerebrovascular complications in COVID-19 patients are likely multifactorial. They can be associated with coagulopathy, systemic inflammatory response, endothelial dysfunction and microthrombosis, as well as organ failure, impaired cardiac functions. The peculiarities of stroke in patients with COVID-19 include occlusion of large vessels, involvement of several vascular pools, a high incidence of damage to the vertebrobasilar system, a cryptogenic nature and a high severity of the course with high mortality and disability. Particular attention should be paid to impaired cognitive functions as a clinical manifestation of the consequences of stroke associated with a new coronavirus infection.
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Affiliation(s)
- S V Zabolotnaya
- Federal Center of Brain Research and Neurotechnologies, Moscow, Russia
| | - A N Bogolepova
- Federal Center of Brain Research and Neurotechnologies, Moscow, Russia.,Pirogov Russian National Research Medical University, Moscow, Russia
| | - R T Tairova
- Federal Center of Brain Research and Neurotechnologies, Moscow, Russia
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Piras IS, Huentelman MJ, Walker JE, Arce R, Glass MJ, Vargas D, Sue LI, Intorcia AJ, Nelson CM, Suszczewicz KE, Borja CL, Desforges M, Deture M, Dickson DW, Beach TG, Serrano GE. Olfactory Bulb and Amygdala Gene Expression Changes in Subjects Dying with COVID-19. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2021:2021.09.12.21263291. [PMID: 34545375 PMCID: PMC8452114 DOI: 10.1101/2021.09.12.21263291] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In this study we conducted RNA sequencing on two brain regions (olfactory bulb and amygdala) from subjects who died from COVID-19 or who died of other causes. We found several-fold more transcriptional changes in the olfactory bulb than in the amygdala, consistent with our own work and that of others indicating that the olfactory bulb may be the initial and most common brain region infected. To some extent our results converge with pseudotime analysis towards common processes shared between the brain regions, possibly induced by the systemic immune reaction following SARS-CoV-2 infection. Changes in amygdala emphasized upregulation of interferon-related neuroinflammation genes, as well as downregulation of synaptic and other neuronal genes, and may represent the substrate of reported acute and subacute COVID-19 neurological effects. Additionally, and only in olfactory bulb, we observed an increase in angiogenesis and platelet activation genes, possibly associated with microvascular damages induced by neuroinflammation. Through coexpression analysis we identified two key genes (CAMK2B for the synaptic neuronal network and COL1A2 for the angiogenesis/platelet network) that might be interesting potential targets to reverse the effects induced by SARS-CoV-2 infection. Finally, in olfactory bulb we detected an upregulation of olfactory and taste genes, possibly as a compensatory response to functional deafferentation caused by viral entry into primary olfactory sensory neurons. In conclusion, we were able to identify transcriptional profiles and key genes involved in neuroinflammation, neuronal reaction and olfaction induced by direct CNS infection and/or the systemic immune response to SARS-CoV-2 infection.
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Affiliation(s)
- Ignazio S. Piras
- Translational Genomics Research Institute, Neurogenomics Division
| | | | | | - Richard Arce
- Banner Sun Health Research Institute, Sun City, AZ
| | | | - Daisy Vargas
- Banner Sun Health Research Institute, Sun City, AZ
| | - Lucia I. Sue
- Banner Sun Health Research Institute, Sun City, AZ
| | | | | | | | | | - Marc Desforges
- Centre Hospitalier Universitaire Sainte-Justine, Laboratory of Virology, Montreal, Canada
| | - Michael Deture
- Mayo Clinic College of Medicine, Mayo Clinic Florida, Jacksonville, FL
| | - Dennis W. Dickson
- Mayo Clinic College of Medicine, Mayo Clinic Florida, Jacksonville, FL
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Goyal N, Sodani AK, Jain R, Ram H. Do Elevated Levels of Inflammatory Biomarkers Predict the Risk of Occurrence of Ischemic Stroke in SARS-CoV2 ?: An Observational Study. J Stroke Cerebrovasc Dis 2021; 30:106063. [PMID: 34464929 PMCID: PMC8376664 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106063] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 07/20/2021] [Accepted: 08/15/2021] [Indexed: 12/21/2022] Open
Abstract
Introduction Stroke, a dreaded complication of SARS-CoV2, has been reported in 0.9 to 5% of SARS-CoV2 patients. There are concerns that SARS-CoV2 infection has a significant independent association with acute ischemic stroke, even in the absence of conventional cerebrovascular risk factors. Whether elevated levels of inflammatory biomarkers have predictive value in the occurrence of stroke in SARS-CoV2 is poorly understood. Aim To profile the characteristics of SARS-CoV2 positive patients with ischemic stroke (COVID-Stroke) and to identify the significance of elevated IBMs in the prediction of ischemic COVID-stroke. Materials and methods Clinical characteristics, stroke risk factors, laboratory parameters- including levels of inflammatory biomarkers, and outcome of SARS-CoV2 patients with stroke (n=60) were collected. SARS-CoV2 RT- PCR positive age, gender, and pulmonary severity matched non-stroke patients were taken as controls (n = 60). Binary multivariate logistic regression analysis was used to find the predictors of ischemic COVID-stroke. Results D-dimer > 441.8 ng/mL, LDH> 395U/L, ESR >19 mm/h and CRP> 0.2 mg/dL were independently found to be very strong predictors of occurrence of ischemic COVID-stroke (p < 0.001 for each). On multivariate analysis, D-dimer > 441.8 ng/mL, ESR > 19 mm/h, and RDW > 16.1% were found to be the most strong predictors of the occurrence of ischemic COVID-stroke. Conventional CVD risk factors- higher age (> 60years), presence of diabetes mellitus, and hypertension were not found to be significant predictors in multivariate analysis. Conclusion In SARS-CoV2 patients, D-dimer elevated beyond 441.8 ng/mL, ESR greater than 19 mm/h, and RDW widened more than 16.1% were the strongest predictors of the occurrence of ischemic stroke. This is the first study that attempts to find cut-off levels of IBMs in the prediction of ischemic COVID-stroke.
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Affiliation(s)
- Nitisha Goyal
- Department of Neurology, Sri Aurobindo Institute of Medical Sciences, Indore, Madhya Pradesh, India.
| | - Ajoy K Sodani
- Department of Neurology, Sri Aurobindo Institute of Medical Sciences, Indore, Madhya Pradesh, India.
| | - Rahul Jain
- Department of Neurology, Sri Aurobindo Institute of Medical Sciences, Indore, Madhya Pradesh, India.
| | - Heera Ram
- Department of Radiology, Sri Aurobindo Institute of Medical Sciences, Indore, Madhya Pradesh, India.
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Nia AM, Srinivasan VM, Hayworth MK, Lall RR, Kan P. A History of Cerebrovascular Disease Is Independently Associated with Increased Morbidity and Mortality in Patients with COVID-19: A Cohort Study of 369,563 COVID-19 Cases in the USA. Cerebrovasc Dis 2021; 51:20-28. [PMID: 34515073 PMCID: PMC8450865 DOI: 10.1159/000517499] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 05/27/2021] [Indexed: 01/06/2023] Open
Abstract
Objectives We set out to evaluate the risk for severe coronavirus disease 2019 (COVID-19) infection and subsequent cerebrovascular disease (CVD) in the population with a prior diagnosis of CVD within the past 10 years. Methods We utilized the TriNetX Analytics Network to query 369,563 COVID-19 cases up to December 30, 2020. We created 8 cohorts of patients with COVID-19 diagnosis based on a previous diagnosis of CVD. We measured the odds ratios, relative risks, risk differences for hospitalizations, ICU/critical care services, intubation, mortality, and CVD recurrence within 90 days of COVID-19 diagnosis, compared to a propensity-matched cohort with no prior history of CVD within 90 days of COVID-19 diagnosis. Results 369,563 patients had a confirmed diagnosis of COVID-19 with a subset of 22,497 (6.09%) patients with a prior diagnosis of CVD within 10 years. All cohorts with a CVD diagnosis had an increased risk of hospitalization, critical care services, and mortality within 90 days of COVID-19 diagnosis. Additionally, the data demonstrate that any history of CVD is associated with significantly increased odds of subsequent CVD post-COVID-19 compared to a matched control. Conclusions CVD, a known complication of COVID-19, is more frequent in patients with a prior history of CVD. Patients with any previous diagnosis of CVD are at higher risks of morbidity and mortality from COVID-19 infection. In patients admitted to the ED due to COVID-19 symptoms, these risk factors should be promptly identified as delayed or missed risk stratification and could lead to an ineffective and untimely diagnosis of subsequent CVD, which would lead to protracted hospitalization and poor prognosis.
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Affiliation(s)
- Anna M Nia
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA,
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Miranda K Hayworth
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
| | - Rishi R Lall
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
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Sierra-Hidalgo F, Aragón Revilla E, Arranz García P, Martínez-Acebes E, Gómez-Moreno SM, Muñoz-Rivas N, Esquivel López A. Increased Incidence of In-Hospital Ischemic Stroke During SARS-CoV-2 Outbreak: A Single-Center Study. Neurocrit Care 2021; 36:208-215. [PMID: 34268645 PMCID: PMC8281805 DOI: 10.1007/s12028-021-01286-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 05/21/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Meta-analyses of observational studies report a 1.1-1.7% pooled risk of stroke among patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection requiring hospitalization, but consultations for stroke and reperfusion procedures have decreased during the outbreak that occurred during the first half of the year 2020. It is still unclear whether a true increase in the risk of stroke exists among patients with coronavirus disease 2019 (COVID-19). In-hospital ischemic stroke (IHIS) complicated the 0.04-0.06% of all admissions in the pre-COVID-19 era, but its incidence has not been assessed among inpatients with COVID-19. We aimed to compare IHIS incidence among patients with SARS-CoV-2 infection with that of inpatients with non-COVID-19 illnesses from the same outbreak period and from previous periods. METHODS This historical cohort study belongs to the COVID-19@Vallecas cohort. The incidence of IHIS was estimated for patients with SARS-CoV-2 hospitalized during March-April 2020 [COVID-19 cohort (CC)], for patients with non-COVID-19 medical illness hospitalized during the same outbreak period [2020 non-COVID-19 cohort (20NCC)], and for inpatients with non-COVID-19 illness admitted during March-April of the years 2016-2019 [historical non-COVID-19 cohort (HNCC)]. Unadjusted risk of IHIS was compared between the three cohorts, and adjusted incidence rate ratio (IRR) of IHIS between cohorts was obtained by means of Poisson regression. RESULTS Overall, 8126 inpatients were included in this study. Patients in the CC were younger and more commonly men than those from the HNCC and 20NCC. Absolute risk of IHIS was 0.05% for HNCC, 0.23% for 20NCC, and 0.36% for CC, (p = 0.004 for HNCC vs. CC). Cumulative incidence for IHIS by day nine after admission, with death as a competing risk, was 0.09% for HNCC, 0.23% for 20NCC, and 0.50% for CC. In an adjusted Poisson regression model with sex, age, needing of intensive care unit admission, and cohort (HNCC as reference) as covariates, COVID-19 was an independent predictor for IHIS (IRR 6.76, 95% confidence interval 1.66-27.54, p = 0.01). A nonsignificant increase in the risk of IHIS was observed for the 20NCC (IRR 5.62, 95% confidence interval 0.93-33.9, p = 0.06). CONCLUSIONS SARS-CoV-2 outbreak was associated with an increase in the incidence of IHIS when compared with inpatients from a historical cohort. Viral infection itself may be related to the increased risk of IHIS among patients with COVID-19, but in view of our results from the 20NCC, it is likely that other factors, such as hospital saturation and overwhelming of health systems, may have played a role in the increased frequency of IHIS.
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Affiliation(s)
- Fernando Sierra-Hidalgo
- Department of Neurology, Hospital Universitario Infanta Leonor, Avenida Gran Vía del Este 80, 28031, Madrid, Spain.
| | - Esther Aragón Revilla
- Department of Neurology, Hospital Universitario Infanta Leonor, Avenida Gran Vía del Este 80, 28031, Madrid, Spain
| | - Paz Arranz García
- Department of Medical Administration, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Eva Martínez-Acebes
- Department of Neurology, Hospital Universitario Infanta Leonor, Avenida Gran Vía del Este 80, 28031, Madrid, Spain
| | - Sonia Mayra Gómez-Moreno
- Department of Neurology, Hospital Universitario Infanta Leonor, Avenida Gran Vía del Este 80, 28031, Madrid, Spain
| | - Nuria Muñoz-Rivas
- Department of Internal Medicine, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Alberto Esquivel López
- Department of Neurology, Hospital Universitario Infanta Leonor, Avenida Gran Vía del Este 80, 28031, Madrid, Spain
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Gabet A, Grave C, Chatignoux E, Tuppin P, Béjot Y, Olié V. Characteristics, Management, and Case-Fatality of Patients Hospitalized for Stroke with a Diagnosis of COVID-19 in France. Neuroepidemiology 2021; 55:323-330. [PMID: 34167111 PMCID: PMC8339027 DOI: 10.1159/000516670] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 04/18/2021] [Indexed: 12/15/2022] Open
Abstract
Introduction COVID-19 was found to be associated with an increased risk of stroke. This study aimed to compare characteristics, management, and outcomes of hospitalized stroke patients with or without a hospital diagnosis of COVID-19 at a nationwide scale. Methods This is a cross-sectional study on all French hospitals covering the entire French population using the French national hospital discharge databases (Programme de Médicalisation des Systèmes d'Information, included in the Système National des Données de Santé). All patients hospitalized for stroke between 1 January and 14 June 2020 in France were selected. A diagnosis of COVID-19 was searched for during the index hospitalization for stroke or in a prior hospitalization that had occurred after 1 January 2020. Results Among the 56,195 patients hospitalized for stroke, 800 (1.4%) had a concomitant COVID-19 diagnosis. Inhospital case-fatality rates were higher in stroke patients with COVID-19, particularly for patients with a primary diagnosis of COVID-19 (33.2%), as compared to patients hospitalized for stroke without COVID-19 diagnosis (14.1%). Similar findings were observed for 3-month case-fatality rates adjusted for age and sex that reached 41.7% in patients hospitalized for stroke with a concomitant primary diagnosis of COVID-19 versus 20.0% in strokes without COVID-19. Conclusion Patients hospitalized for stroke with a concomitant COVID-19 diagnosis had a higher inhospital and 3 months case-fatality rates compared to patients hospitalized for stroke without a COVID-19 diagnosis. Further research is needed to better understand the excess of mortality related to these cases.
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Affiliation(s)
- Amélie Gabet
- Department of Non-Communicable Diseases, Cardiovascular Diseases and Stroke Program, Santé Publique France, Saint-Maurice, France
| | - Clémence Grave
- Department of Non-Communicable Diseases, Cardiovascular Diseases and Stroke Program, Santé Publique France, Saint-Maurice, France
| | - Edouard Chatignoux
- Department of Non-Communicable Diseases, Cardiovascular Diseases and Stroke Program, Santé Publique France, Saint-Maurice, France
| | - Philippe Tuppin
- Department of strategy and statistical studies, Caisse Nationale d'Assurance Maladie, Paris, France
| | - Yannick Béjot
- Neurology Department, Dijon University Hospital, Dijon, France
| | - Valérie Olié
- Department of Non-Communicable Diseases, Cardiovascular Diseases and Stroke Program, Santé Publique France, Saint-Maurice, France
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Au SCL. Comments on Stroke as a Neurological Complication of COVID-19: A Systematic Review and Meta-Analysis of Incidence, Outcomes and Predictors. J Stroke Cerebrovasc Dis 2021; 30:105863. [PMID: 34059440 PMCID: PMC8130513 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 04/25/2021] [Indexed: 12/04/2022] Open
Affiliation(s)
- Sunny Chi Lik Au
- Department of Ophthalmology, L2W SOPD, Pamela Youde Nethersole Eastern Hospital, 3 Lok Man Road, Chai Wan, Hong Kong, Hong Kong Special Administrative Region.
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Siepmann T, Barlinn K. [Association of COVID-19 and Stroke: Pathophysiology and Clinical Relevance]. FORTSCHRITTE DER NEUROLOGIE-PSYCHIATRIE 2021; 89:289-295. [PMID: 34020462 DOI: 10.1055/a-1484-0224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
ZusammenfassungDass COVID-19 mit einem erhöhten Risiko für das Auftreten ischämischer Schlaganfälle einhergeht, wurde bereits in den ersten Monaten nach dem weltweiten Bekanntwerden des Ausbruchs der Pandemie im Ground Zero Wuhan deutlich. Spätere Kohortenanalysen, Fallserien und Meta-Analysen bestätigten diesen Zusammenhang. Eine nicht unerhebliche geographische Variabilität der Prävalenz COVID-19-bezogener Schlaganfälle verdeutlicht allerdings den fortbestehenden Bedarf an umfassenden epidemiologischen Analysen. Im Übrigen fanden sich zunehmend Hinweise dafür, dass dem mit COVID-19 assoziierten Schlaganfall ein multifaktorieller pathophysiologischer Mechanismus zugrundeliegenden könnte. Neben einer durch die SARS-CoV-2-Infektion verursachten Hyperkoagubilität, die sowohl im mikrovaskulären System als auch in Großgefäßen thrombogen wirkt, scheinen vaskulitische arterielle Veränderungen und kardiogene Embolien infolge virusassoziierter myokardialer Schädigung bei der Ätiologie des COVID-19-assoziierten Schlaganfalls eine Rolle zu spielen. Die Versorgung von Schlaganfallpatienten/innen in Zeiten der Pandemie durch multidisziplinäre Teams scheint in insgesamt kompensierten Kliniken im Wesentlichen nicht kompromittiert zu sein. Hinweise, dass Patienten/innen mit COVID-19-assoziiertem Schlaganfall von einem intensivierten Monitoring und einer aggressiveren Sekundärprävention profitieren, bedarf klinischer Prüfung.
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Affiliation(s)
- Timo Siepmann
- Klinik und Poliklinik für Neurologie, Universitätsklinik Carl Gustav Carus, Technische Universität Dresden
| | - Kristian Barlinn
- Klinik und Poliklinik für Neurologie, Universitätsklinik Carl Gustav Carus, Technische Universität Dresden
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Aljamaan FS. Unusual Presentation of a Severe COVID-19 Case With Axillary Artery Thrombosis. Cureus 2021; 13:e15036. [PMID: 34150387 PMCID: PMC8200903 DOI: 10.7759/cureus.15036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2021] [Indexed: 11/30/2022] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has been evolving since early 2020 with high critical care mortality and morbidity. High mortality rates have been linked largely to respiratory failure. Hypercoagulability status induced by the massive inflammatory storm has led to a high rate of thrombotic events, whether arterial or venous, contributing to COVID-19 mortality especially in critically ill patients. Thrombotic events might be the presenting feature of the disease or might happen during hospitalization. In this case report, we describe a case of a 67-year-old male with severe COVID-19 pneumonia who was found on presentation to have left axillary artery thrombosis requiring embolectomy; the case was managed successfully. We reviewed the pathophysiology of hypercoagulability associated with COVID-19, clinical implications, and most recent treatment recommendations.
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67
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Taquet M, Geddes JR, Husain M, Luciano S, Harrison PJ. 6-month neurological and psychiatric outcomes in 236 379 survivors of COVID-19: a retrospective cohort study using electronic health records. Lancet Psychiatry 2021; 8:416-427. [PMID: 33836148 PMCID: PMC8023694 DOI: 10.1016/s2215-0366(21)00084-5] [Citation(s) in RCA: 1144] [Impact Index Per Article: 381.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 02/16/2021] [Accepted: 02/23/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Neurological and psychiatric sequelae of COVID-19 have been reported, but more data are needed to adequately assess the effects of COVID-19 on brain health. We aimed to provide robust estimates of incidence rates and relative risks of neurological and psychiatric diagnoses in patients in the 6 months following a COVID-19 diagnosis. METHODS For this retrospective cohort study and time-to-event analysis, we used data obtained from the TriNetX electronic health records network (with over 81 million patients). Our primary cohort comprised patients who had a COVID-19 diagnosis; one matched control cohort included patients diagnosed with influenza, and the other matched control cohort included patients diagnosed with any respiratory tract infection including influenza in the same period. Patients with a diagnosis of COVID-19 or a positive test for SARS-CoV-2 were excluded from the control cohorts. All cohorts included patients older than 10 years who had an index event on or after Jan 20, 2020, and who were still alive on Dec 13, 2020. We estimated the incidence of 14 neurological and psychiatric outcomes in the 6 months after a confirmed diagnosis of COVID-19: intracranial haemorrhage; ischaemic stroke; parkinsonism; Guillain-Barré syndrome; nerve, nerve root, and plexus disorders; myoneural junction and muscle disease; encephalitis; dementia; psychotic, mood, and anxiety disorders (grouped and separately); substance use disorder; and insomnia. Using a Cox model, we compared incidences with those in propensity score-matched cohorts of patients with influenza or other respiratory tract infections. We investigated how these estimates were affected by COVID-19 severity, as proxied by hospitalisation, intensive therapy unit (ITU) admission, and encephalopathy (delirium and related disorders). We assessed the robustness of the differences in outcomes between cohorts by repeating the analysis in different scenarios. To provide benchmarking for the incidence and risk of neurological and psychiatric sequelae, we compared our primary cohort with four cohorts of patients diagnosed in the same period with additional index events: skin infection, urolithiasis, fracture of a large bone, and pulmonary embolism. FINDINGS Among 236 379 patients diagnosed with COVID-19, the estimated incidence of a neurological or psychiatric diagnosis in the following 6 months was 33·62% (95% CI 33·17-34·07), with 12·84% (12·36-13·33) receiving their first such diagnosis. For patients who had been admitted to an ITU, the estimated incidence of a diagnosis was 46·42% (44·78-48·09) and for a first diagnosis was 25·79% (23·50-28·25). Regarding individual diagnoses of the study outcomes, the whole COVID-19 cohort had estimated incidences of 0·56% (0·50-0·63) for intracranial haemorrhage, 2·10% (1·97-2·23) for ischaemic stroke, 0·11% (0·08-0·14) for parkinsonism, 0·67% (0·59-0·75) for dementia, 17·39% (17·04-17·74) for anxiety disorder, and 1·40% (1·30-1·51) for psychotic disorder, among others. In the group with ITU admission, estimated incidences were 2·66% (2·24-3·16) for intracranial haemorrhage, 6·92% (6·17-7·76) for ischaemic stroke, 0·26% (0·15-0·45) for parkinsonism, 1·74% (1·31-2·30) for dementia, 19·15% (17·90-20·48) for anxiety disorder, and 2·77% (2·31-3·33) for psychotic disorder. Most diagnostic categories were more common in patients who had COVID-19 than in those who had influenza (hazard ratio [HR] 1·44, 95% CI 1·40-1·47, for any diagnosis; 1·78, 1·68-1·89, for any first diagnosis) and those who had other respiratory tract infections (1·16, 1·14-1·17, for any diagnosis; 1·32, 1·27-1·36, for any first diagnosis). As with incidences, HRs were higher in patients who had more severe COVID-19 (eg, those admitted to ITU compared with those who were not: 1·58, 1·50-1·67, for any diagnosis; 2·87, 2·45-3·35, for any first diagnosis). Results were robust to various sensitivity analyses and benchmarking against the four additional index health events. INTERPRETATION Our study provides evidence for substantial neurological and psychiatric morbidity in the 6 months after COVID-19 infection. Risks were greatest in, but not limited to, patients who had severe COVID-19. This information could help in service planning and identification of research priorities. Complementary study designs, including prospective cohorts, are needed to corroborate and explain these findings. FUNDING National Institute for Health Research (NIHR) Oxford Health Biomedical Research Centre.
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Affiliation(s)
- Maxime Taquet
- Department of Psychiatry, University of Oxford, Oxford, UK; Oxford Health NHS Foundation Trust, Oxford, UK
| | - John R Geddes
- Department of Psychiatry, University of Oxford, Oxford, UK; Oxford Health NHS Foundation Trust, Oxford, UK
| | - Masud Husain
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Paul J Harrison
- Department of Psychiatry, University of Oxford, Oxford, UK; Oxford Health NHS Foundation Trust, Oxford, UK.
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Beach TG, Sue LI, Intorcia AJ, Glass MJ, Walker JE, Arce R, Nelson CM, Serrano GE. Acute Brain Ischemia, Infarction and Hemorrhage in Subjects Dying with or Without Autopsy-Proven Acute Pneumonia. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2021:2021.03.22.21254139. [PMID: 33791728 PMCID: PMC8010760 DOI: 10.1101/2021.03.22.21254139] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Stroke is one of the most serious complications of Covid-19 disease but it is still unclear whether stroke is more common with Covid-19 pneumonia as compared to non-Covid-19 pneumonia. We investigated the concurrence rate of autopsy-confirmed acute brain ischemia, acute brain infarction and acute brain hemorrhage with autopsy-proven acute non-Covid pneumonia in consecutive autopsies in the Arizona Study of Aging and Neurodegenerative Disorders (AZSAND), a longitudinal clinicopathological study of normal aging and neurodegenerative diseases. Of 691 subjects with a mean age of 83.4 years, acute pneumonia was histopathologically diagnosed in 343 (49.6%); the concurrence rates for histopathologically-confirmed acute ischemia, acute infarction or subacute infarction was 14% and did not differ between pneumonia and non-pneumonia groups while the rates of acute brain hemorrhage were 1.4% and 2.0% of those with or without acute pneumonia, respectively. In comparison, in reviews of Covid-19 publications, reported clinically-determined rates of acute brain infarction range from 0.5% to 20% while rates of acute brain hemorrhage range from 0.13% to 2%. In reviews of Covid-19 autopsy studies, concurrence rates for both acute brain infarction and acute brain hemorrhage average about 10%. Covid-19 pneumonia and non-Covid-19 pneumonia may have similar risks tor concurrent acute brain infarction and acute brain hemorrhage when pneumonia is severe enough to cause death. Additionally, acute brain ischemia, infarction or hemorrhage may not be more common in subjects dying of acute pneumonia than in subjects dying without acute pneumonia.
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Affiliation(s)
| | - Lucia I Sue
- Banner Sun Health Research Institute, Sun City, AZ
| | | | | | | | - Richard Arce
- Banner Sun Health Research Institute, Sun City, AZ
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Robba C, Ball L, Battaglini D, Cardim D, Moncalvo E, Brunetti I, Bassetti M, Giacobbe DR, Vena A, Patroniti N, Rocco PRM, Matta BF, Pelosi P. Early effects of ventilatory rescue therapies on systemic and cerebral oxygenation in mechanically ventilated COVID-19 patients with acute respiratory distress syndrome: a prospective observational study. Crit Care 2021; 25:111. [PMID: 33741052 PMCID: PMC7978164 DOI: 10.1186/s13054-021-03537-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 03/05/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In COVID-19 patients with acute respiratory distress syndrome (ARDS), the effectiveness of ventilatory rescue strategies remains uncertain, with controversial efficacy on systemic oxygenation and no data available regarding cerebral oxygenation and hemodynamics. METHODS This is a prospective observational study conducted at San Martino Policlinico Hospital, Genoa, Italy. We included adult COVID-19 patients who underwent at least one of the following rescue therapies: recruitment maneuvers (RMs), prone positioning (PP), inhaled nitric oxide (iNO), and extracorporeal carbon dioxide (CO2) removal (ECCO2R). Arterial blood gas values (oxygen saturation [SpO2], partial pressure of oxygen [PaO2] and of carbon dioxide [PaCO2]) and cerebral oxygenation (rSO2) were analyzed before (T0) and after (T1) the use of any of the aforementioned rescue therapies. The primary aim was to assess the early effects of different ventilatory rescue therapies on systemic and cerebral oxygenation. The secondary aim was to evaluate the correlation between systemic and cerebral oxygenation in COVID-19 patients. RESULTS Forty-five rescue therapies were performed in 22 patients. The median [interquartile range] age of the population was 62 [57-69] years, and 18/22 [82%] were male. After RMs, no significant changes were observed in systemic PaO2 and PaCO2 values, but cerebral oxygenation decreased significantly (52 [51-54]% vs. 49 [47-50]%, p < 0.001). After PP, a significant increase was observed in PaO2 (from 62 [56-71] to 82 [76-87] mmHg, p = 0.005) and rSO2 (from 53 [52-54]% to 60 [59-64]%, p = 0.005). The use of iNO increased PaO2 (from 65 [67-73] to 72 [67-73] mmHg, p = 0.015) and rSO2 (from 53 [51-56]% to 57 [55-59]%, p = 0.007). The use of ECCO2R decreased PaO2 (from 75 [75-79] to 64 [60-70] mmHg, p = 0.009), with reduction of rSO2 values (59 [56-65]% vs. 56 [53-62]%, p = 0.002). In the whole population, a significant relationship was found between SpO2 and rSO2 (R = 0.62, p < 0.001) and between PaO2 and rSO2 (R0 0.54, p < 0.001). CONCLUSIONS Rescue therapies exert specific pathophysiological mechanisms, resulting in different effects on systemic and cerebral oxygenation in critically ill COVID-19 patients with ARDS. Cerebral and systemic oxygenation are correlated. The choice of rescue strategy to be adopted should take into account both lung and brain needs. Registration The study protocol was approved by the ethics review board (Comitato Etico Regione Liguria, protocol n. CER Liguria: 23/2020).
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Affiliation(s)
- Chiara Robba
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
- IRCCS for Oncology and Neuroscience, Ospedale Policlinico San Martino, Genoa, Italy
| | - Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
- IRCCS for Oncology and Neuroscience, Ospedale Policlinico San Martino, Genoa, Italy
| | - Denise Battaglini
- IRCCS for Oncology and Neuroscience, Ospedale Policlinico San Martino, Genoa, Italy
| | - Danilo Cardim
- Department of Neurology, University of Texas, Austin, USA
| | - Emanuela Moncalvo
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Iole Brunetti
- IRCCS for Oncology and Neuroscience, Ospedale Policlinico San Martino, Genoa, Italy
| | - Matteo Bassetti
- Department of Health Sciences (DISSAL), University of Genoa, Genoa , Italy
- Infectious Diseases Unit, IRCCS for Oncology and Neuroscience, Ospedale Policlinico San Martino, Genoa, Italy
| | - Daniele R. Giacobbe
- Department of Health Sciences (DISSAL), University of Genoa, Genoa , Italy
- Infectious Diseases Unit, IRCCS for Oncology and Neuroscience, Ospedale Policlinico San Martino, Genoa, Italy
| | - Antonio Vena
- Infectious Diseases Unit, IRCCS for Oncology and Neuroscience, Ospedale Policlinico San Martino, Genoa, Italy
| | - Nicolò Patroniti
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
- IRCCS for Oncology and Neuroscience, Ospedale Policlinico San Martino, Genoa, Italy
| | - Patricia R. M. Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio De Janeiro, Brazil
| | - Basil F. Matta
- Neurocritical Care Unit, Addenbrooke’s Hospital, Cambridge, UK
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
- IRCCS for Oncology and Neuroscience, Ospedale Policlinico San Martino, Genoa, Italy
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Characteristics and outcomes of 100 consecutive patients with acute stroke and COVID-19. J Neurol Sci 2021; 423:117348. [PMID: 33636660 PMCID: PMC7887446 DOI: 10.1016/j.jns.2021.117348] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 01/06/2021] [Accepted: 02/12/2021] [Indexed: 01/06/2023]
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Syahrul S, Maliga HA, Ilmawan M, Fahriani M, Mamada SS, Fajar JK, Frediansyah A, Syahrul FN, Imran I, Haris S, Rambe AS, Emran TB, Rabaan AA, Tiwari R, Dhama K, Nainu F, Mutiawati E, Harapan H. Hemorrhagic and ischemic stroke in patients with coronavirus disease 2019: incidence, risk factors, and pathogenesis - a systematic review and meta-analysis. F1000Res 2021; 10:34. [PMID: 33708378 PMCID: PMC7934095 DOI: 10.12688/f1000research.42308.1] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2021] [Indexed: 12/17/2022] Open
Abstract
Background: In this study, we aimed to determine the global prevalence, chronological order of symptom appearance, and mortality rates with regard to hemorrhagic and ischemic stroke in patients with coronavirus disease 2019 (COVID-19) and to discuss possible pathogeneses of hemorrhagic and ischemic stroke in individuals with the disease. Methods: We searched the PubMed, Scopus, and Web of Science databases for relevant articles published up to November 8, 2020. Data regarding study characteristics, hemorrhagic stroke, ischemic stroke, and COVID-19 were retrieved in accordance with the PRISMA guidelines. The Newcastle-Ottawa scale was used to assess the quality of the eligible studies. The pooled prevalence and mortality rate of hemorrhagic and ischemic stroke were calculated. Results: The pooled estimate of prevalence of hemorrhagic stroke was 0.46% (95% CI 0.40%–0.53%;
I
2=89.81%) among 67,155 COVID-19 patients and that of ischemic stroke was 1.11% (95% CI 1.03%–1.22%;
I
2=94.07%) among 58,104 COVID-19 patients. Ischemic stroke was more predominant (incidence: 71.58%) than hemorrhagic stroke (incidence: 28.42%) in COVID-19 patients who experienced a stroke. In COVID-19 patients who experienced a stroke, hospital admission with respiratory symptoms was more commonly reported than that with neurological symptoms (20.83% for hemorrhagic stroke and 5.51% for ischemic stroke versus
6.94% for hemorrhagic stroke and 5.33% for ischemic stroke, respectively). The pooled mortality rate of COVID-19 patients who experienced a hemorrhagic and ischemic stroke was 44.72% (95% CI 36.73%–52.98%) and 36.23% (95% CI 30.63%–42.24%), respectively. Conclusions: Although the occurrence of hemorrhagic and ischemic stroke is low, the mortality rates of both stroke types in patients with COVID-19 are concerning, and therefore, despite several potential pathogeneses that have been proposed, studies aimed at definitively elucidating the mechanisms of hemorrhagic and ischemic stroke in individuals with COVID-19 are warranted. PROSPERO registration: CRD42020224470 (04/12/20)
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Affiliation(s)
- Syahrul Syahrul
- Department of Neurology, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Aceh, 23111, Indonesia.,Department of Neurology, Dr. Zainoel Abidin Hospital, Banda Aceh, Aceh, 23111, Indonesia
| | | | - Muhammad Ilmawan
- Faculty of Medicine, Universitas Brawijaya, Malang, East Java, 65117, Indonesia
| | - Marhami Fahriani
- Medical Research Unit, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Aceh, 23111, Indonesia
| | - Sukamto S Mamada
- Faculty of Pharmacy, Hasanuddin University, Makassar, South Sulawesi, 90245, Indonesia
| | - Jonny Karunia Fajar
- Faculty of Medicine, Universitas Brawijaya, Malang, East Java, 65117, Indonesia.,Brawijaya Internal Medicine Research Center, Department of Internal Medicine, Faculty of Medicine, Universitas Brawijaya, Malang, East Java, 65145, Indonesia
| | - Andri Frediansyah
- Research Division for Natural Product Technology (BPTBA), Indonesian Institute of Sciences (LIPI), Wonosari, 55861, Indonesia
| | - Faza Nabila Syahrul
- Department of Neurology, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Aceh, 23111, Indonesia
| | - Imran Imran
- Department of Neurology, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Aceh, 23111, Indonesia.,Department of Neurology, Dr. Zainoel Abidin Hospital, Banda Aceh, Aceh, 23111, Indonesia
| | - Salim Haris
- Department of Neurology, Faculty of Medicine, Universitas Indonesia, Jakarta, 10430, Indonesia
| | - Aldy Safruddin Rambe
- Department of Neurology, Faculty of Medicine, Universitas Sumatera Utara, Medan, North Sumatra, 20155, Indonesia
| | - Talha Bin Emran
- Department of Pharmacy, BGC Trust University Bangladesh, Chittagong-4381, Bangladesh
| | - Ali A Rabaan
- Molecular Diagnostic Laboratory, Johns Hopkins Aramco Healthcare, Dhahran, 31311, Saudi Arabia
| | - Ruchi Tiwari
- Department of Veterinary Microbiology and Immunology, College of Veterinary Sciences, UP Pandit Deen Dayal Upadhayay Pashu Chikitsa Vigyan Vishwavidyalay Evum Go-Anusandhan Sansthan (DUVASU), Mathura, Uttar Pradesh, 281 001, India
| | - Kuldeep Dhama
- Division of Pathology, ICAR-Indian Veterinary Research Institute, Izatnagar, Uttar Pradesh, 243122, India
| | - Firzan Nainu
- Faculty of Pharmacy, Hasanuddin University, Makassar, South Sulawesi, 90245, Indonesia
| | - Endang Mutiawati
- Department of Neurology, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Aceh, 23111, Indonesia.,Department of Neurology, Dr. Zainoel Abidin Hospital, Banda Aceh, Aceh, 23111, Indonesia
| | - Harapan Harapan
- Medical Research Unit, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Aceh, 23111, Indonesia.,Department of Microbiology, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Aceh, 23111, Indonesia.,Tropical Disease Centre, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Aceh, 23111, Indonesia
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Abstract
PURPOSE OF REVIEW Cryptogenic stroke represents a heterogenous but clinically important collection of stroke etiologies for which our understanding continues to grow. Here, we review our current knowledge and most recent recommendations on secondary prevention for common causes of cryptogenic stroke including paroxysmal atrial fibrillation, atrial cardiopathy, patent foramen ovale, and substenotic atherosclerotic disease as well as the under-recognized mechanisms of occult malignancy, heart failure, and, most recently, infection with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). RECENT FINDINGS The results from recent observational studies and randomized clinical trials have provided greater insight into the causal relationship and attributable risk of these suspected etiologies and have identified potential strategies to reduce the rates of recurrence. However, further clinical trials are needed to confirm the benefits of specific stroke prevention strategies, including the patient populations most likely to benefit from anticoagulation. There is ongoing research aimed at both reducing the proportion of ischemic strokes classified as cryptogenic and resolving much of the clinical equipoise that still exists. The results of these studies have the potential to provide us with a better understanding of these occult mechanisms and allow for more targeted interventions.
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Affiliation(s)
- Chinwe Ibeh
- grid.413734.60000 0000 8499 1112Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University and New York-Presbyterian Hospital, 710 W 168th St, New York, NY USA
| | - Mitchell S. V. Elkind
- grid.413734.60000 0000 8499 1112Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University and New York-Presbyterian Hospital, 710 W 168th St, New York, NY USA ,grid.21729.3f0000000419368729Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY USA
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