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Jensen-Kondering U, Maurer CJ, Brudermann HCB, Ernst M, Sedaghat S, Margraf NG, Bahmer T, Jansen O, Nawabi J, Vogt E, Büttner L, Siebert E, Bartl M, Maus V, Werding G, Schlamann M, Abdullayev N, Bender B, Richter V, Mengel A, Göpel S, Berlis A, Grams A, Ladenhauf V, Gizewski ER, Kindl P, Schulze-Zachau V, Psychogios M, König IR, Sondermann S, Wallis S, Brüggemann N, Schramm P, Neumann A. Patterns of acute ischemic stroke and intracranial hemorrhage in patients with COVID-19 : Results of a retrospective multicenter neuroimaging-based study from three central European countries. J Neurol 2023; 270:2349-2359. [PMID: 36820915 PMCID: PMC9947908 DOI: 10.1007/s00415-023-11608-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 02/02/2023] [Accepted: 02/03/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) is an infection which can affect the central nervous system. In this study, we sought to investigate associations between neuroimaging findings with clinical, demographic, blood and cerebrospinal fluid (CSF) parameters, pre-existing conditions and the severity of acute COVID-19. MATERIALS AND METHODS Retrospective multicenter data retrieval from 10 university medical centers in Germany, Switzerland and Austria between February 2020 and September 2021. We included patients with COVID-19, acute neurological symptoms and cranial imaging. We collected demographics, neurological symptoms, COVID-19 severity, results of cranial imaging, blood and CSF parameters during the hospital stay. RESULTS 442 patients could be included. COVID-19 severity was mild in 124 (28.1%) patients (moderate n = 134/30.3%, severe n = 43/9.7%, critical n = 141/31.9%). 220 patients (49.8%) presented with respiratory symptoms, 167 (37.8%) presented with neurological symptoms first. Acute ischemic stroke (AIS) was detected in 70 (15.8%), intracranial hemorrhage (IH) in 48 (10.9%) patients. Typical risk factors were associated with AIS; extracorporeal membrane oxygenation therapy and invasive ventilation with IH. No association was found between the severity of COVID-19 or blood/CSF parameters and the occurrence of AIS or IH. DISCUSSION AIS was the most common finding on cranial imaging. IH was more prevalent than expected but a less common finding than AIS. Patients with IH had a distinct clinical profile compared to patients with AIS. There was no association between AIS or IH and the severity of COVID-19. A considerable proportion of patients presented with neurological symptoms first. Laboratory parameters have limited value as a screening tool.
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Affiliation(s)
- Ulf Jensen-Kondering
- Department of Radiology and Neuroradiology, UKSH, Campus Kiel, Kiel, Germany.
- Department of Neuroradiology, UKSH, Campus Lübeck, Lübeck, Germany.
| | - Christoph J Maurer
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Augsburg, Augsburg, Germany
| | - Hanna C B Brudermann
- Institute of Medical Biometry and Statistics (IMBS), UKSH, Campus Lübeck, Lübeck, Germany
| | - Marielle Ernst
- Institute of Diagnostic and Interventional Neuroradiology, University Medical Center, Göttingen, Germany
| | - Sam Sedaghat
- Department of Radiology and Neuroradiology, UKSH, Campus Kiel, Kiel, Germany
- Department of Radiology, University of California San Diego, San Diego, USA
| | - Nils G Margraf
- Department of Neurology, UKSH, Campus Kiel, Kiel, Germany
| | - Thomas Bahmer
- Department of Internal Medicine, UKSH, Campus Kiel, Kiel, Germany
| | - Olav Jansen
- Department of Radiology and Neuroradiology, UKSH, Campus Kiel, Kiel, Germany
| | - Jawed Nawabi
- Department of Radiology, Charité - Universitätsmedizin Berlin, Campus Mitte (CCM), Humboldt-Universität zu Berlin, Freie Universität Berlin, Berlin Institute of Health, Berlin, Germany
- Berlin Institute of Health (BIH), BIH Biomedical Innovation Academy, Berlin, Germany
| | - Estelle Vogt
- Department of Radiology, Charité - Universitätsmedizin Berlin, Campus Mitte (CCM), Humboldt-Universität zu Berlin, Freie Universität Berlin, Berlin Institute of Health, Berlin, Germany
| | - Laura Büttner
- Department of Radiology, Charité - Universitätsmedizin Berlin, Campus Mitte (CCM), Humboldt-Universität zu Berlin, Freie Universität Berlin, Berlin Institute of Health, Berlin, Germany
| | - Eberhard Siebert
- Institute of Neuroradiology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Michael Bartl
- Department of Neurology, University Medical Center, Göttingen, Germany
| | - Volker Maus
- Department of Diagnostic and Interventional Neuroradiology and Nuclear Medicine, University Medical Center Knappschaftskrankenhaus, Bochum, Germany
| | - Gregor Werding
- Department of Diagnostic and Interventional Neuroradiology and Nuclear Medicine, University Medical Center Knappschaftskrankenhaus, Bochum, Germany
| | - Marc Schlamann
- Department of Radiology, Neuroradiology Division, University of Cologne, Cologne, Germany
| | - Nuran Abdullayev
- Department of Radiology, Neuroradiology Division, University of Cologne, Cologne, Germany
- GFO Clinics Troisdorf, Radiology and Neuroradiologie, Troisdorf, Germany
| | - Benjamin Bender
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Tübingen, Tübingen, Germany
| | - Vivien Richter
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Tübingen, Tübingen, Germany
| | - Annerose Mengel
- Department of Neurology and Stroke, University Hospital Tübingen, Tübingen, Germany
| | - Siri Göpel
- Department of Internal Medicine I, University Hospital Tübingen, Tübingen, Germany
| | - Ansgar Berlis
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Augsburg, Augsburg, Germany
| | - Astrid Grams
- Department of Neuroradiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Valentin Ladenhauf
- Department of Neuroradiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Elke R Gizewski
- Department of Neuroradiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Philipp Kindl
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Marios Psychogios
- Department of Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Inke R König
- Institute of Medical Biometry and Statistics (IMBS), UKSH, Campus Lübeck, Lübeck, Germany
| | | | - Sönke Wallis
- Department of Internal Medicine, UKSH, Campus Lübeck, Lübeck, Germany
| | | | - Peter Schramm
- Department of Neuroradiology, UKSH, Campus Lübeck, Lübeck, Germany
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Wada H, Shiraki K, Shimpo H, Shimaoka M, Iba T, Suzuki-Inoue K. Thrombotic Mechanism Involving Platelet Activation, Hypercoagulability and Hypofibrinolysis in Coronavirus Disease 2019. Int J Mol Sci 2023; 24:ijms24097975. [PMID: 37175680 PMCID: PMC10178520 DOI: 10.3390/ijms24097975] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 04/26/2023] [Accepted: 04/26/2023] [Indexed: 05/15/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) has spread, with thrombotic complications being increasingly frequently reported. Although thrombosis is frequently complicated in septic patients, there are some differences in the thrombosis noted with COVID-19 and that noted with bacterial infections. The incidence (6-26%) of thrombosis varied among reports in patients with COVID-19; the incidences of venous thromboembolism and acute arterial thrombosis were 4.8-21.0% and 0.7-3.7%, respectively. Although disseminated intravascular coagulation (DIC) is frequently associated with bacterial infections, a few cases of DIC have been reported in association with COVID-19. Fibrin-related markers, such as D-dimer levels, are extremely high in bacterial infections, whereas soluble C-type lectin-like receptor 2 (sCLEC-2) levels are high in COVID-19, suggesting that hypercoagulable and hyperfibrinolytic states are predominant in bacterial infections, whereas hypercoagulable and hypofibrinolytic states with platelet activation are predominant in COVID-19. Marked platelet activation, hypercoagulability and hypofibrinolytic states may cause thrombosis in patients with COVID-19.
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Affiliation(s)
- Hideo Wada
- Department of General and Laboratory Medicine, Mie Prefectural General Medical Center, Yokkaichi 5450-132, Japan
| | - Katsuya Shiraki
- Department of General and Laboratory Medicine, Mie Prefectural General Medical Center, Yokkaichi 5450-132, Japan
| | - Hideto Shimpo
- Mie Prefectural General Medical Center, Yokkaichi 5450-132, Japan
| | - Motomu Shimaoka
- Department of Molecular Pathobiology and Cell Adhesion Biology, Mie University Graduate School of Medicine, Tsu 514-0001, Japan
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo 113-8431, Japan
| | - Katsue Suzuki-Inoue
- Department of Clinical and Laboratory Medicine, Yamanashi Medical University, Yamanashi 409-3821, Japan
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Mayer-Suess L, Ter Telgte A, Praxmarer S, Willeit J, Wöll E, Geley T, Rinner H, Knoflach M, Kiechl S. Stroke Care Pathway ensures high-quality stroke management in the COVID-19 pandemic. Sci Rep 2023; 13:5587. [PMID: 37019970 PMCID: PMC10075157 DOI: 10.1038/s41598-023-32586-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 03/29/2023] [Indexed: 04/07/2023] Open
Abstract
The aim of our study was to assess whether a well-established federal state-wide Stroke Care Pathway delivering high quality stroke care can cope with the COVID-19 pandemic and associated measures to contain the virus spread. The retrospective analysis is based on a prospective, quality-controlled, population-based registry of all stroke patients in the Tyrol, a federal state of Austria and one of the early hot-spots of COVID-19 in Europe. Patient characteristics, pre-hospital management, intra-hospital management and post-hospital were analysed. All residents of the Tyrol suffering ischemic stroke in 2020 (n = 1160) and four pre-COVID-19 years (n = 4321) were evaluated. In 2020, the annual number of stroke patients was the highest in this population-based registry. When local hospitals were overwhelmed with SARS-CoV-2-patients, stroke subjects were temporarily allocated to the comprehensive stroke centre. Stroke severity, quality metrics of stroke management, serious complications, and post-stroke mortality did not differ between 2020 and the four comparator years. Notably, iv. thrombolysis-rate was similar (19.9% versus 17.4%, P = 0.25) and endovascular stroke treatment even better (5.9% versus 3.9%, P = 0.003) but resources for in-patient rehabilitation were limited (25.8% versus 29.8%, P = 0.009). Concluding, a well-established Stroke Care Pathway was able to maintain high-quality acute stroke care even when challenged by a global pandemic.
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Affiliation(s)
- Lukas Mayer-Suess
- Department of Neurology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Annemieke Ter Telgte
- VASCage, Research Center on Vascular Ageing and Stroke, Anichstraße 5a, 6020, Innsbruck, Austria
| | - Silvia Praxmarer
- Tyrolean Health Care Fund, Eduard-Wallnöfer-Platz 3, 6020, Innsbruck, Austria
| | - Johann Willeit
- Department of Neurology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Ewald Wöll
- Internal Medicine, Hospital St. Vinzenz, Sanatoriumstraße 43, 6511, Zams, Austria
| | - Theresa Geley
- Tyrolean Health Care Fund, Eduard-Wallnöfer-Platz 3, 6020, Innsbruck, Austria
| | - Heinrich Rinner
- Tyrolean Health Care Fund, Eduard-Wallnöfer-Platz 3, 6020, Innsbruck, Austria
| | - Michael Knoflach
- Department of Neurology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria.
- VASCage, Research Center on Vascular Ageing and Stroke, Anichstraße 5a, 6020, Innsbruck, Austria.
| | - Stefan Kiechl
- Department of Neurology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
- VASCage, Research Center on Vascular Ageing and Stroke, Anichstraße 5a, 6020, Innsbruck, Austria
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Louis DW, Saad M, Vijayakumar S, Ilyas S, Kokkirala A, Aronow HD. The Cardiovascular Manifestations of COVID-19. Heart Fail Clin 2023; 19:153-161. [PMID: 36863807 PMCID: PMC9973545 DOI: 10.1016/j.hfc.2022.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
The Coronavirus 2019 (COVID-19) pandemic, caused by the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) virus, has resulted in unprecedented morbidity and mortality worldwide. While COVID-19 typically presents as viral pneumonia, cardiovascular manifestations such as acute coronary syndromes, arterial and venous thrombosis, acutely decompensated heart failure (HF), and arrhythmia are frequently observed. Many of these complications are associated with poorer outcomes, including death. Herein we review the relationship between cardiovascular risk factors and outcomes among patients with COVID-19, cardiovascular manifestations of COVID-19, and cardiovascular complications associated with COVID-19 vaccination.
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Affiliation(s)
- David W. Louis
- Lifespan Cardiovascular Institute, 593 Eddy Street, RIH APC 730, Providence, RI 02903, USA,Department of Medicine, Division of Cardiology, Alpert Medical School of Brown University, 222 Richmond Street, Providence, RI 02903, USA
| | - Marwan Saad
- Lifespan Cardiovascular Institute, 593 Eddy Street, RIH APC 730, Providence, RI 02903, USA,Department of Medicine, Division of Cardiology, Alpert Medical School of Brown University, 222 Richmond Street, Providence, RI 02903, USA
| | - Shilpa Vijayakumar
- Lifespan Cardiovascular Institute, 593 Eddy Street, RIH APC 730, Providence, RI 02903, USA,Department of Medicine, Division of Cardiology, Alpert Medical School of Brown University, 222 Richmond Street, Providence, RI 02903, USA
| | - Suleman Ilyas
- Department of Medicine, Division of Cardiology, Alpert Medical School of Brown University, 222 Richmond Street, Providence, RI 02903, USA
| | - Aravind Kokkirala
- United States Department of Veterans Affairs Providence VA Medical Center, 830 Chalkstone Avenue, Providence, RI 02908, USA
| | - Herbert D. Aronow
- Lifespan Cardiovascular Institute, 593 Eddy Street, RIH APC 730, Providence, RI 02903, USA,Department of Medicine, Division of Cardiology, Alpert Medical School of Brown University, 222 Richmond Street, Providence, RI 02903, USA,Corresponding author. 593 Eddy Street, RIH APC 730, Providence, RI 02903
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Kankaria R, Sanina C, Gabr M, Wiley J, Bortnick AE. Extracardiac Prothrombotic Effects of COVID-19. Heart Fail Clin 2023; 19:213-220. [PMID: 36863813 PMCID: PMC9973540 DOI: 10.1016/j.hfc.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
COVID-19 infection triggers a heightened inflammatory response which in turn, increases thrombosis and thromboembolism. Microvascular thrombosis has been detected in various tissue beds which may account for some of the multi-system organ dysfunction associated with COVID-19. Additional research is needed to understand which prophylactic and therapeutic drug regimens are best for the prevention and treatment of thrombotic complications of COVID-19.
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Affiliation(s)
- Rohan Kankaria
- Albert Einstein College of Medicine, Montefiore Medical Center, 1300 Morris Park Avenue, Bronx, NY 10461, USA
| | - Cristina Sanina
- Albert Einstein College of Medicine, Montefiore Medical Center, 1300 Morris Park Avenue, Bronx, NY 10461, USA; Department of Medicine, Division of Cardiology, Montefiore Medical Center, 111 E 210th Street, Bronx, NY 10467 USA
| | - Mohamed Gabr
- Albert Einstein College of Medicine, Montefiore Medical Center, 1300 Morris Park Avenue, Bronx, NY 10461, USA; Department of Medicine, Division of Cardiology, Montefiore Medical Center, 111 E 210th Street, Bronx, NY 10467 USA
| | - Jose Wiley
- Albert Einstein College of Medicine, Montefiore Medical Center, 1300 Morris Park Avenue, Bronx, NY 10461, USA; Department of Medicine, Division of Cardiology, Montefiore Medical Center, 111 E 210th Street, Bronx, NY 10467 USA
| | - Anna E Bortnick
- Albert Einstein College of Medicine, Montefiore Medical Center, 1300 Morris Park Avenue, Bronx, NY 10461, USA; Department of Medicine, Division of Cardiology, Montefiore Medical Center, 111 E 210th Street, Bronx, NY 10467 USA; Division of Geriatrics, Montefiore Medical Center, 111 E 210th Street, Bronx, NY 10467 USA.
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Khedr EM, Abdelwarith A, Moussa GM, Saber M. Recombinant tissue plasminogen activator (rTPA) management for first onset acute ischemic stroke with covid -19 and non-covid -19 patients. J Stroke Cerebrovasc Dis 2023; 32:107031. [PMID: 36701854 PMCID: PMC9868389 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 01/19/2023] [Accepted: 01/20/2023] [Indexed: 01/24/2023] Open
Abstract
OBJECTIVES Cerebrovascular stroke (CVS) is one of the well-known complications of coronavirus-2019 (Covid-19), but less is known about the outcome and safety of thrombolytic therapy in these patients. In this study we compare the efficacy and safety of Tissue plasminogen activator (rTPA) in acute ischemic stroke (AIS) patients with or without Covid-19 infection. MATERIALS AND METHODS A comparative prospective study in which all patients who presented with AIS and eligible for rTPA were recruited from the emergency department and classified into 2 groups (AIS with Covid-19 infection and AIS without Covid-19 as controls). Demographic data, symptoms of Covid-19, clinical examination, neuroimaging, and laboratory investigations were obtained in each patient. National Institute of Health Stroke Scale (NIHSS) and the Modified Rankin Scale (mRS) were assessed before, immediately after rTPA, and 3 months later. RESULTS There were 22 patients in the COVID-19 group and 25 control patients. Those with COVID-19 were more likely to have a history of smoking and Diabetes Mellitus than controls. On admission, motor symptoms were more severe in patients with COVID-19. COVID-19 patients were more likely to have symptomatic intra-cerebral hemorrhage and radiological hemorrhagic transformation than controls. Onset to door time (ODT) and onset to successful reperfusion time were significantly longer in Covid-19 patients than controls. Clinical improvement and frequency of re-occlusion and recurrent ischemic stroke at 3 months follow-up did not differ between groups, although there was higher number of deaths (27.3%) in the Covid-19 group than controls (16%). CONCLUSIONS Using rTPA is safe and effective in patients with AIS with or without COVID-19 infection despite the high frequency of hemorrhagic transformation and high number of deaths.
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Affiliation(s)
- Eman M Khedr
- Department of Neurology and Psychiatry, Faculty of Medicine, Assiut University, Assiut, Egypt,Corresponding author
| | | | - Gehad M Moussa
- Department of Neuropsychiatry, Aswan University, Aswan, Egypt
| | - Mostafa Saber
- Department of Neuropsychiatry, Aswan University, Aswan, Egypt
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Ramírez-Carreto RJ, Rodríguez-Cortés YM, Torres-Guerrero H, Chavarría A. Possible Implications of Obesity-Primed Microglia that Could Contribute to Stroke-Associated Damage. Cell Mol Neurobiol 2023:10.1007/s10571-023-01329-5. [PMID: 36935429 PMCID: PMC10025068 DOI: 10.1007/s10571-023-01329-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 02/14/2023] [Indexed: 03/21/2023]
Abstract
Microglia, the resident macrophages of the central nervous system, are essential players during physiological and pathological processes. Although they participate in synaptic pruning and maintenance of neuronal circuits, microglia are mainly studied by their activity modulating inflammatory environment and adapting their phenotype and mechanisms to insults detected in the brain parenchyma. Changes in microglial phenotypes are reflected in their morphology, membrane markers, and secreted substances, stimulating neighbor glia and leading their responses to control stimuli. Understanding how microglia react in various microenvironments, such as chronic inflammation, made it possible to establish therapeutic windows and identify synergic interactions with acute damage events like stroke. Obesity is a low-grade chronic inflammatory state that gradually affects the central nervous system, promoting neuroinflammation development. Obese patients have the worst prognosis when they suffer a cerebral infarction due to basal neuroinflammation, then obesity-induced neuroinflammation could promote the priming of microglial cells and favor its neurotoxic response, potentially worsening patients' prognosis. This review discusses the main microglia findings in the obesity context during the course and resolution of cerebral infarction, involving the temporality of the phenotype changes and balance of pro- and anti-inflammatory responses, which is lost in the swollen brain of an obese subject. Obesity enhances proinflammatory responses during a stroke. Obesity-induced systemic inflammation promotes microglial M1 polarization and priming, which enhances stroke-associated damage, increasing M1 and decreasing M2 responses.
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Affiliation(s)
- Ricardo Jair Ramírez-Carreto
- Unidad de Investigación en Medicina Experimental, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Yesica María Rodríguez-Cortés
- Unidad de Investigación en Medicina Experimental, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Haydee Torres-Guerrero
- Unidad de Investigación en Medicina Experimental, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City, Mexico.
| | - Anahí Chavarría
- Unidad de Investigación en Medicina Experimental, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City, Mexico.
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Liu W, Han F, Wan M, Yang XZ. Integrated bioinformatics analysis identifies shared immune changes between ischemic stroke and COVID 19. Front Immunol 2023; 14:1102281. [PMID: 36969251 PMCID: PMC10030956 DOI: 10.3389/fimmu.2023.1102281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 02/23/2023] [Indexed: 03/10/2023] Open
Abstract
Although COVID-19 is primarily a respiratory disease, its neurological complications, such as ischemic stroke (IS), have aroused growing concerns and reports. However, the molecular mechanisms that underlie IS and COVID-19 are not well understood. Therefore, we implemented transcriptomic analysis from eight GEO datasets consist of 1191 samples to detect common pathways and molecular biomarkers in IS and COVID-19 that help understand the linkage between them. Differentially expressed genes (DEGs) were detected for IS and COVID-19 separately for finding shared mechanisms and we found that immune-related pathways were outlined with statistical significance. JAK2, which was identified as a hub gene, was supposed to be a potential therapeutic gene targets during the immunological process of COVID-19 and IS. Besides, we found a decrease in the proportion of CD8+ T and T helper 2 cells in the peripheral circulation of both COVID and IS patients, and NCR3 expression was significantly correlated with this change. In conclusion, we demonstrated that transcriptomic analyses reported in this study could make a deeper understanding of the common mechanism and might be promising for effective therapeutic for IS and COVID-19.
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Affiliation(s)
- Wenhao Liu
- Eight-year program of Clinical Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fei Han
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Mengyao Wan
- Eight-year program of Clinical Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin-Zhuang Yang
- Medical Research Center, State Key laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- *Correspondence: Xin-Zhuang Yang,
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DeVries A, Shambhu S, Sloop S, Overhage JM. One-Year Adverse Outcomes Among US Adults With Post-COVID-19 Condition vs Those Without COVID-19 in a Large Commercial Insurance Database. JAMA HEALTH FORUM 2023; 4:e230010. [PMID: 36867420 PMCID: PMC9984976 DOI: 10.1001/jamahealthforum.2023.0010] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023] Open
Abstract
Importance Many individuals experience ongoing symptoms following the onset of COVID-19, characterized as postacute sequelae of SARS-CoV-2 or post-COVID-19 condition (PCC). Less is known about the long-term outcomes for these individuals. Objective To quantify 1-year outcomes among individuals meeting a PCC definition compared with a control group of individuals without COVID-19. Design, Setting, and Participants This case-control study with a propensity score-matched control group included members of commercial health plans and used national insurance claims data enhanced with laboratory results and mortality data from the Social Security Administration's Death Master File and Datavant Flatiron data. The study sample consisted of adults meeting a claims-based definition for PCC with a 2:1 matched control cohort of individuals with no evidence of COVID-19 during the time period of April 1, 2020, to July 31, 2021. Exposures Individuals experiencing postacute sequelae of SARS-CoV-2 using a Centers for Disease Control and Prevention-based definition. Main Outcomes and Measures Adverse outcomes, including cardiovascular and respiratory outcomes and mortality, for individuals with PCC and controls assessed over a 12-month period. Results The study population included 13 435 individuals with PCC and 26 870 individuals with no evidence of COVID-19 (mean [SD] age, 51 [15.1] years; 58.4% female). During follow-up, the PCC cohort experienced increased health care utilization for a wide range of adverse outcomes: cardiac arrhythmias (relative risk [RR], 2.35; 95% CI, 2.26-2.45), pulmonary embolism (RR, 3.64; 95% CI, 3.23-3.92), ischemic stroke (RR, 2.17; 95% CI, 1.98-2.52), coronary artery disease (RR, 1.78; 95% CI, 1.70-1.88), heart failure (RR, 1.97; 95% CI, 1.84-2.10), chronic obstructive pulmonary disease (RR, 1.94; 95% CI, 1.88-2.00), and asthma (RR, 1.95; 95% CI, 1.86-2.03). The PCC cohort also experienced increased mortality, as 2.8% of individuals with PCC vs 1.2% of controls died, implying an excess death rate of 16.4 per 1000 individuals. Conclusions and Relevance This case-control study leveraged a large commercial insurance database and found increased rates of adverse outcomes over a 1-year period for a PCC cohort surviving the acute phase of illness. The results indicate a need for continued monitoring for at-risk individuals, particularly in the area of cardiovascular and pulmonary management.
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Affiliation(s)
| | | | - Sue Sloop
- Elevance Health, Inc, Indianapolis, Indiana
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Takács TT, Berki ÁJ, Böjti PP, Stang R, Fritz-Reunes PA, Schnekenberg L, Siepmann T, Pintér A, Szatmári S, Bereczki D, Gunda B. The impact of SARS-CoV-2 infection on the outcome of acute ischemic stroke-A retrospective cohort study. PLoS One 2023; 18:e0282045. [PMID: 36862706 PMCID: PMC9980769 DOI: 10.1371/journal.pone.0282045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 02/06/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Acute ischemic stroke (AIS) is a common complication of severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2) infection (COVID-19), but the prognosis of these patients is poorly understood. PURPOSE To explore the impact of COVID-19 on neurological outcomes in AIS patients. METHODS A comparative retrospective cohort study was conducted in 32 consecutive AIS patients with and 51 without COVID-19 between the 1st of March 2020 and 1st of May 2021. The evaluation was based on a detailed chart review for demographic data, medical history, stroke severity, cranial and vessel imaging results, laboratory parameters, COVID-19 severity, hospitalization time, in-hospital mortality, and functional deficits at discharge (modified Rankin Scale, mRS). RESULTS COVID-19 AIS patients showed tendency to worse initial neurological deficit (NIHSS 9 (3-13) vs. 4 (2-10); p = 0.06), higher rate of large vessel occlusion (LVO; 13/32 vs. 14/51; p = 0.21), had prolonged hospitalization (19.4 ± 17.7 vs. 9.7 ± 7 days; p = 0.003), had lower chance of functional independence (mRS≤2) (12/32 vs. 32/51; p = 0.02) and showed higher in-hospital mortality (10/32 vs. 6/51; p = 0.02). In COVID-19 AIS patients, LVO was more common with COVID-19 pneumonia than without (55.6% vs. 23.1%; p = 0.139). CONCLUSION COVID-19-related AIS carries a worse prognosis. COVID-19 with pneumonia seems to be associated with a higher rate of LVO.
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Affiliation(s)
- Tímea Tünde Takács
- Semmelweis University, Department of Neurology, Budapest, Hungary
- Semmelweis University, “János Szentágothai” Doctoral School of Neurosciences, Budapest, Hungary
- * E-mail:
| | - Ádám József Berki
- Semmelweis University, Department of Neurology, Budapest, Hungary
- Semmelweis University, “János Szentágothai” Doctoral School of Neurosciences, Budapest, Hungary
| | - Péter Pál Böjti
- Semmelweis University, Department of Neurology, Budapest, Hungary
- Semmelweis University, “János Szentágothai” Doctoral School of Neurosciences, Budapest, Hungary
- National Institute of Mental Health, Neurology and Neurosurgery, Budapest, Hungary
| | - Rita Stang
- Semmelweis University, Department of Neurology, Budapest, Hungary
- Semmelweis University, “János Szentágothai” Doctoral School of Neurosciences, Budapest, Hungary
| | | | - Luiz Schnekenberg
- University Hospital Carl Gustav Carus, Department of Neurology, Dresden, Germany
| | - Timo Siepmann
- University Hospital Carl Gustav Carus, Department of Neurology, Dresden, Germany
- Division of Health Care Sciences, Center for Clinical Research and Management Education, Dresden International University, Dresden, Germany
| | - Alexandra Pintér
- Division of Health Care Sciences, Center for Clinical Research and Management Education, Dresden International University, Dresden, Germany
- Semmelweis University, Department of Family Medicine, Budapest, Hungary
| | - Szabolcs Szatmári
- Semmelweis University, Department of Neurology, Budapest, Hungary
- MTA-SE Neuroepidemiological Research Group ELKH, Budapest, Hungary
| | - Dániel Bereczki
- Semmelweis University, Department of Neurology, Budapest, Hungary
- MTA-SE Neuroepidemiological Research Group ELKH, Budapest, Hungary
- European Academy of Neurology, EANcore COVID-19 Task Force, Vienna, Austria
| | - Bence Gunda
- Semmelweis University, Department of Neurology, Budapest, Hungary
- Semmelweis University, “János Szentágothai” Doctoral School of Neurosciences, Budapest, Hungary
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61
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Yurtsever G, Karaali R, Bora ES. Evaluation of ABCD2 score during the development of stroke in COVID-19 patients diagnosed with transient ischemic attack in the emergency department. J Stroke Cerebrovasc Dis 2023; 32:106918. [PMID: 36621122 PMCID: PMC9715486 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 11/22/2022] [Accepted: 11/27/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The aim of the present study is to reveal the association between the risk of stroke using ABCD2 score and COVID-19 in patients who presented to our emergency department during the pandemic and were diagnosed with TIA. METHODS According to the recommendations of the European Stroke Association, patients with an ABCD2 score of <4 were classified as low-risk, and patients with an ABCD2 score of ≥4 were classified as high-risk. Within 90 days of the patient's admission to the emergency room, the development of stroke was tracked and recorded on the system. RESULTS Stroke occurred in 35.78% of the patients. Regarding COVID-19, 75.34% of stroke patients were positive for COVID-19 and 65.75% had COVID-19 compatible pneumonia on 'thoracic CT'. Regarding mortality, 16.4% of the patients who were positive for COVID-19 and developed a stroke died. The presence of COVID-19 compatible pneumonia on thorax CT, PCR test result and ABCD2 score were determined as independent risk factors for the development of stroke. According to the PCR test results, the probability of having a stroke decreases 0.283 times in patients who are negative for COVID-19. According to the PCR test results, the probability of having a stroke increased 2.7 times in COVID-19 positive patients. CONCLUSIONS Adding the presence of COVID-19 and the presence of COVID-19 pneumonia to the ABCD2 score, based on the information about the increased risk of stroke in TIA patients, improves the predictive power of the score. More studies are needed in this regard.
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Affiliation(s)
- Güner Yurtsever
- Department of Emergency Medicine, Izmir Ataturk Training and Research Hospital, Izmir, Turkey.
| | - Rezan Karaali
- Department of Emergency Medicine, Izmir Ataturk Training and Research Hospital, Izmir, Turkey
| | - Ejder Saylav Bora
- Department of Emergency Medicine, Izmir Ataturk Training and Research Hospital, Izmir, Turkey
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Pourciau P, Smith BC. Stroke Risk Related to Coronavirus Disease-2019: What Have We Learned? Crit Care Nurs Clin North Am 2023; 35:53-65. [PMID: 36774007 PMCID: PMC9584860 DOI: 10.1016/j.cnc.2022.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Since the intial outbreak of the coronavirus-2019 (COVID-19) in December 2019, a variety of neurologic manifestations have been linked to this virus, including stroke. Comprehensive review of worldwide studies using various methodologies indicated a correlation of increased stroke risk in patients with COVID-19. The literature reivew also revealed increased morbidity and mortality among patients with COVID-19 and stroke as compared to those with only stroke. This pandemic, with its related healthcare staffing shortages, revealed the requisite to utilize innovative technologies such as Tele-Neurology, as well as public health campaigns focusing on stroke recognition and early treatment.
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Affiliation(s)
- Pamela Pourciau
- East Jefferson Neurological Associates, 3800 Houma Boulevard, Suite 325, Metairie, LA 70006, USA.
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63
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Impacts of medication non-adherence to major modifiable stroke-related diseases on stroke prevention and mortality: a meta-analysis. J Neurol 2023; 270:2504-2516. [PMID: 36843040 PMCID: PMC9968645 DOI: 10.1007/s00415-023-11601-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/31/2023] [Accepted: 02/01/2023] [Indexed: 02/28/2023]
Abstract
BACKGROUND Medication adherence is one of the crucial attempts in primary stroke prevention. The available evidence lacks comprehensive reviews exploring the association of medication adherence with stroke prevention. OBJECTIVES To investigate the effects of non-adherence to medications used to treat the modifiable risk of diseases on stroke-associated outcomes in primary stroke prevention. METHODS Study records were searched from PubMed, Embase, and CINAHL. Those studies reported risks relevant to stroke-associated outcomes and medication non-adherence for patients diagnosed with four modifiable stroke-related diseases (atrial fibrillation [AF], hyperlipidemia, hypertension, and type 2 diabetes mellitus) but without stroke history were included for meta-analysis and further subgroup, sensitivity, and publication bias analyses. A random effect model was performed to analyse the pooled risk estimates of relative risk (RR) and 95% confidence intervals (CIs). RESULTS Thirty-nine studies (with 2,117,789 participants in total) designed as cohort or case-control studies were included. Those patients presenting with four stroke-related diseases and categorised as medication non-adherent tended to result in stroke and/or associated death (all pooled RR ≥ 1 and 95% CI did not include 1). The findings of stratification and sensitivity analysis for each stroke-related disease showed a similar trend. Non-adherent patients with AF were prone to stroke occurrence (RR 1.852; 95% CI 1.583-2.166) but inclined to reduced bleeding (RR 0.894; 95% CI 0.803-0.996). The existence of publication bias warrants further interpretation. CONCLUSIONS Non-adherence to medications for the four stroke-related diseases contributes to the development of stroke and/or mortality in primary stroke prevention. More efforts are needed to improve patients' medication adherence.
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64
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Root-Bernstein R. From Co-Infections to Autoimmune Disease via Hyperactivated Innate Immunity: COVID-19 Autoimmune Coagulopathies, Autoimmune Myocarditis and Multisystem Inflammatory Syndrome in Children. Int J Mol Sci 2023; 24:ijms24033001. [PMID: 36769320 PMCID: PMC9917907 DOI: 10.3390/ijms24033001] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/21/2023] [Accepted: 01/23/2023] [Indexed: 02/05/2023] Open
Abstract
Neutrophilia and the production of neutrophil extracellular traps (NETs) are two of many measures of increased inflammation in severe COVID-19 that also accompany its autoimmune complications, including coagulopathies, myocarditis and multisystem inflammatory syndrome in children (MIS-C). This paper integrates currently disparate measures of innate hyperactivation in severe COVID-19 and its autoimmune complications, and relates these to SARS-CoV-2 activation of innate immunity. Aggregated data include activation of Toll-like receptors (TLRs), nucleotide-binding oligomerization domain (NOD) receptors, NOD leucine-rich repeat and pyrin-domain-containing receptors (NLRPs), retinoic acid-inducible gene I (RIG-I) and melanoma-differentiation-associated gene 5 (MDA-5). SARS-CoV-2 mainly activates the virus-associated innate receptors TLR3, TLR7, TLR8, NLRP3, RIG-1 and MDA-5. Severe COVID-19, however, is characterized by additional activation of TLR1, TLR2, TLR4, TLR5, TLR6, NOD1 and NOD2, which are primarily responsive to bacterial antigens. The innate activation patterns in autoimmune coagulopathies, myocarditis and Kawasaki disease, or MIS-C, mimic those of severe COVID-19 rather than SARS-CoV-2 alone suggesting that autoimmunity follows combined SARS-CoV-2-bacterial infections. Viral and bacterial receptors are known to synergize to produce the increased inflammation required to support autoimmune disease pathology. Additional studies demonstrate that anti-bacterial antibodies are also required to account for known autoantigen targets in COVID-19 autoimmune complications.
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65
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Candeloro M, Schulman S. Arterial Thrombotic Events in Hospitalized COVID-19 Patients: A Short Review and Meta-Analysis. Semin Thromb Hemost 2023; 49:47-54. [PMID: 35793687 DOI: 10.1055/s-0042-1749661] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
It is well established that the risk of venous thromboembolism is high in coronavirus disease 19 (COVID-19). The frequency of arterial thromboembolic events (ATEs) in hospitalized patients with COVID-19 is unclear, as is the magnitude of these events in comparison with other infections. We searched MEDLINE from February 2020 to February 2022 for prospective or retrospective cohort studies and randomized clinical trials that reported the number of acute myocardial infarction (AMI), acute ischemic stroke (AIS), acute limb ischemia (ALI), or other ATE as defined by the original authors in hospitalized patients with COVID-19. The pooled frequencies were calculated through meta-analysis using random effects model with logit transformation and presented with relative 95% prediction intervals (95% PI). We retrieved a total of 4,547 studies, 36 of which (28 retrospective cohorts, five prospective cohorts and three randomized trials) were finally included in our analysis. The resulting cohort counted 100,949 patients, 2,641 (2.6%) of whom experienced ATE. The pooled ATE frequency was 2.0% (95% PI, 0.4-9.6%). The pooled ATE frequency for AMI, AIS, ALI, and other ATE was 0.8% (95% PI, 0.1-8.1%), 0.9% (95% PI, 0.3-2.9%), 0.2% (95% PI, 0.0-4.2%), and 0.5% (95% PI, 0.1-3.0%), respectively. In comparison with the ATE incidence reported in three studies on non-COVID viral pneumonia, we did not detect a significant difference from the results in our analysis. In conclusion, we found a non-negligible proportion of ATE in patients hospitalized for COVID-19. Our results are similar to those found in hospitalized patients with influenza or with non-COVID viral pneumonia.
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Affiliation(s)
- Matteo Candeloro
- Department of Innovative Technologies in Medicine and Dentistry, "G. D'Annunzio" University, Chieti, Italy.,Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Sam Schulman
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada.,Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
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66
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Outcomes with IV tenecteplase and IV alteplase for acute ischemic stroke with or without thrombectomy in real-world settings in the United States. J Stroke Cerebrovasc Dis 2023; 32:106898. [PMID: 36493706 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106898] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 10/20/2022] [Accepted: 11/10/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND PURPOSE Although many stroke centers in United States are using intravenous (IV) tenecteplase (TNK) for acute ischemic stroke patients, there is paucity of comparative data between IV TNK and IV alteplase from real-world settings. MATERIALS AND METHODS We analyzed the data from 122 healthcare facilities in Cerner Real World Data and included patients admitted between February 2016 to April 2022 to determine the effect of IV TNK (compared with IV alteplase) on occurrence of two outcomes in acute ischemic stroke patients stratified by use of thrombectomy: non-routine discharge or death, and intracranial hemorrhage after adjusting for potential confounders. RESULTS Among 30,643 acute ischemic stroke patients analyzed, 29,480 (96.2%) and 1,163 (3.8%) patients received IV alteplase and IV TNK, respectively. The proportion of patients who received thrombectomy was significantly higher among patients who received IV TNK compared with those who received IV alteplase (16.7% versus 11.0%, p<0.001). Occurrence of intracranial hemorrhage was more common among patients treated with IV TNK in acute ischemic stroke patients who did not receive thrombectomy (7.9% versus 5.1%, p<0.001) but not in those who received thrombectomy (20.1% versus 16.8%, p = 0.234). In the logistic regression analysis, patients treated with IV TNK who did not receive thrombectomy were at higher risk of intracranial hemorrhage (OR, 1.34, 95% CI 1.05-1.72, p = 0.02) after adjusting for age (age strata), gender, race/ethnicity, hypertension, diabetes mellitus, atrial fibrillation, hyperlipidemia, malignancy, nicotine dependence, previous ischemic stroke, previous transient ischemic attack, previous intracerebral hemorrhage, previous subarachnoid hemorrhage, previous acute myocardial infarction, atherosclerosis of aorta, previous AKI, congestive heart failure, peripheral vascular disease, and hospital type, aphasia, hemiplegia, neglect, somnolence, stupor and coma, dysphagia, and homonymous hemianopsia. There was no difference in the rate of non-routine discharge or death between patients treated with IV TNK and those treated with IV alteplase in the multivariate analyses. CONCLUSIONS In an analysis of real-world data, IV TNK was associated with higher rates of intracranial hemorrhage compared with IV alteplase in patients with acute ischemic stroke who did not undergo thrombectomy.
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67
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Stefanou Ε, Karvelas N, Bennett S, Kole C. Cerebrovascular Manifestations of SARS-CoV-2: A Comprehensive Review. Curr Treat Options Neurol 2023; 25:71-92. [PMID: 36950279 PMCID: PMC9984763 DOI: 10.1007/s11940-023-00747-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2023] [Indexed: 03/06/2023]
Abstract
Purpose of review The risks of cerebrovascular manifestations due to SARS-CoV-2 infection are significantly increased within the first 6 months of the infection. Our work aims to give an update on current clinical aspects of diagnosis and treatment of cerebrovascular manifestations during acute and long-term SARS-CoV-2 infection. Recent findings The incidence of acute ischemic stroke and haemorrhagic stroke during acute SARS-CoV-2 patients is estimated at 0.9 to 4.6% and 0.5-0.9%, respectively, and were associated with increased mortality. The majority presented with hemiparesis, dysarthria, sensory deficits, and a NIHSS score within 5-15. In addition, beyond the first 30 days of infection people with COVID-19 exhibited increased risk of stroke. During acute phase, age, hypertension, diabetes, and medical history of vascular disease were increased in patients with COVID-19 with new onset of cerebrovascular manifestations, while during long-COVID-19, the risk of cerebrovascular manifestations were found increased regardless of these factors. The management of patients with large-vessel ischemic stroke fulfilling the intravenous thrombolysis criteria are successfully treated according to the guidelines, while hyperosmolar therapy is typically administered in 4- to 6-h intervals. In addition, prophylaxis of anticoagulation therapy is associated with a better prognosis and low mortality during acute and post hospital discharge of patients with COVID-19. Summary In this work, we provide a comprehensive review of the current literature on acute and post-acute COVID-19 cerebrovascular sequelae, symptomatology, and its pathophysiology mechanisms. Moreover, we discuss therapeutic strategies for these patients during acute and long-term care and point populations at risk. Our findings suggest that older patients with risk factors such as hypertension, diabetes, and medical history of vascular disease are more likely to develop cerebrovascular complications.
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Affiliation(s)
- Εleni Stefanou
- Artificial Kidney Unit, General Hospital of Messinia, Kalamata, Greece
| | - Nikolaos Karvelas
- grid.5216.00000 0001 2155 0800Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Samuel Bennett
- grid.189967.80000 0001 0941 6502Emory University School of Medicine, Atlanta, GA USA
| | - Christo Kole
- grid.5216.00000 0001 2155 0800Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- grid.416018.a0000 0004 0623 0819Cardiology Department, Sismanoglio General Hospital of Attica, Athens, Greece
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68
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Karimi S, Dutra E Oliva LM, Rafiemanesh H, Mendez Capitaine M, Jabre S, Baratloo A. Two-Stage Clinical Model for Screening the Suspected Cases of Acute Ischemic Stroke in Need of Imaging in Emergency Department; a Cross-sectional Study. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2023; 11:e23. [PMID: 36919139 PMCID: PMC10008216 DOI: 10.22037/aaem.v11i1.1941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
Introduction Just as failure to diagnose an acute ischemic stroke (AIS) in a timely manner affects the patient's outcome; an inaccurate and misplaced impression of the AIS diagnosis is not without its drawbacks. Here, we introduce a two-stage clinical tool to aid in the screening of AIS cases in need of imaging in the emergency department (ED). Methods This was a multicenter cross-sectional study, in which suspected AIS patients who underwent a brain magnetic resonance imaging (MRI) were included. The 18 variables from nine existing AIS screening tools were extracted and a two-stage screening tool was developed based on expert opinion (stage-one or rule in stage) and multivariate logistic regression analysis (stage-two or rule out stage). Then, the screening performance characteristics of the two-stage mode was evaluated. Results Data from 803 patients with suspected AIS were analyzed. Among them, 57.4 % were male, and their overall mean age was 66.9 ± 13.9 years. There were 561 (69.9%) cases with a final confirmed diagnosis of AIS. The total sensitivity and specificity of the two-stage screening model were 99.11% (95% CI: 98.33 to 99.89) and 35.95% (95% CI: 29.90 to 42.0), respectively. Also, the positive and negative predictive values of two-stage screening model were 78.20% (95% CI: 75.17 to 81.24) and 94.57% (95% CI: 89.93 to 81.24), respectively. The area under the receiver operating characteristic (ROC) curve of the two-stage screening model for AIS was 67.53% (95% CI: 64.48 to 70.58). Overall, using the two-stage screening model presented in this study, more than 11% of suspected AIS patients were not referred for MRI, and the error of this model is about 5%. Conclusion Here, we proposed a 2-step model for approaching suspected AIS patients in ED for an attempt to safely exclude patients with the least probability of having an AIS as a diagnosis. However, further surveys are required to assess its accuracy and it may even need some modifications.
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Affiliation(s)
- Somayeh Karimi
- Prehospital and Hospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Hosein Rafiemanesh
- Non-communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran.,Department of Epidemiology and Biostatistics, School of Public Health, Alborz University of Medical Sciences, Karaj, Iran
| | - Melissa Mendez Capitaine
- Department of Emergency Medicine, La Villa General Hospital, Health Secretary, Mexico City, Mexico
| | - Sarah Jabre
- Department of Emergency Medicine, Jackson Memorial Hospital, Miami, Florida, USA
| | - Alireza Baratloo
- Research Center for Trauma in Police Operations, Directorate of Health, Rescue & Treatment, Police Headquarter, Tehran, Iran.,Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Katsouras CS, Papafaklis MI, Giannopoulos S, Karapanayiotides T, Tsivgoulis G, Michalis LK. Cerebro-/Cardiovascular Collateral Damage During the COVID-19 Pandemic: Fact or Fiction? J Clin Neurol 2023; 19:1-11. [PMID: 36606641 PMCID: PMC9833878 DOI: 10.3988/jcn.2023.19.1.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 07/20/2022] [Accepted: 07/24/2022] [Indexed: 01/04/2023] Open
Abstract
Numerous observational studies have identified a decline in cerebro-/cardiovascular (CV) admissions during the initial phase of the COVID-19 pandemic. Recent studies and meta-analyses indicated that the overall decrease was smaller than that found in initial studies during the first months of 2020. Two years later we still do not have clear evidence about the potential causes and impacts of the reduction of CV hospitalizations during the COVID-19 pandemic. It has becoming increasingly evident that collateral damage (i.e., incidental damage to the public and patients) from the COVID-19 outbreak is the main underlying cause that at least somewhat reflects the effects of imposed measures such as social distancing and self-isolation. However, a smaller true decline in CV events in the community due to a lack of triggers associated with such acute syndromes cannot be excluded. There is currently indirect epidemiological evidence about the immediate impact that the collateral damage had on excess mortality, but possible late consequences including a rebound increase in CV events are yet to be observed. In the present narrative review, we present the reporting milestones in the literature of the rates of CV admissions and collateral damage during the last 2 years, and discuss all possible factors contributing to the decline in CV hospitalizations during the COVID-19 pandemic. Healthcare systems need to be prepared so that they can cope with the increased hospitalization rates for CV events in the near future.
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Affiliation(s)
- Christos S Katsouras
- 2nd Department of Cardiology, University Hospital of Ioannina, University of Ioannina, Ioannina, Greece
| | - Michail I Papafaklis
- 2nd Department of Cardiology, University Hospital of Ioannina, University of Ioannina, Ioannina, Greece
| | - Sotirios Giannopoulos
- 2nd Department of Neurology, ATTIKON University Hospital, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University Hospital of Ioannina, University of Ioannina, Ioannina, Greece
| | - Theodoros Karapanayiotides
- 2nd Department of Neurology, Faculty of Health Sciences, School of Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Georgios Tsivgoulis
- 2nd Department of Neurology, ATTIKON University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Lampros K Michalis
- 2nd Department of Cardiology, University Hospital of Ioannina, University of Ioannina, Ioannina, Greece
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Mohseni Afshar Z, Sharma A, Babazadeh A, Alizadeh-Khatir A, Sio TT, Taghizadeh Moghadam MA, Tavakolli Pirzaman A, Mojadad A, Hosseinzadeh R, Barary M, Ebrahimpour S. A review of the potential neurological adverse events of COVID-19 vaccines. Acta Neurol Belg 2023; 123:9-44. [PMID: 36385246 PMCID: PMC9668235 DOI: 10.1007/s13760-022-02137-2] [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: 03/17/2022] [Accepted: 10/27/2022] [Indexed: 11/17/2022]
Abstract
Despite the advantages of getting access to the coronavirus disease 2019 (COVID-19) vaccines, their potential ability to induce severe adverse events (AEs) has been a significant concern. Neurological complications are significant among the various adverse events following immunization (AEFI) due to their likely durability and debilitating sequelae. Neurological AEs following COVID-19 vaccination can either exacerbate or induce new-onset neuro-immunologic diseases, such as myasthenia gravis (MG) and Guillain-Barre syndrome (GBS). The more severe spectrum of AEs post-COVID19 vaccines has included seizures, reactivation of the varicella-zoster virus, strokes, GBS, Bell's palsy, transverse myelitis (TM), and acute disseminated encephalomyelitis (ADEM). Here, we discuss each of these neurological adverse effects separately.
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Affiliation(s)
- Zeinab Mohseni Afshar
- grid.412112.50000 0001 2012 5829Clinical Research Development Center, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Akanksha Sharma
- grid.417468.80000 0000 8875 6339Department of Neurology, Mayo Clinic, Scottsdale, AZ USA
| | - Arefeh Babazadeh
- grid.411495.c0000 0004 0421 4102Infectious Diseases and Tropical Medicine Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - Ali Alizadeh-Khatir
- grid.411495.c0000 0004 0421 4102Mobility Impairment Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - Terence T. Sio
- grid.417468.80000 0000 8875 6339Department of Radiation Oncology, Mayo Clinic, Scottsdale, AZ USA
| | | | - Ali Tavakolli Pirzaman
- grid.411495.c0000 0004 0421 4102Student Research Committee, Babol University of Medical Sciences, Babol, Iran
| | - Ahmadreza Mojadad
- grid.411495.c0000 0004 0421 4102Student Research Committee, Babol University of Medical Sciences, Babol, Iran
| | - Rezvan Hosseinzadeh
- grid.411495.c0000 0004 0421 4102Student Research Committee, Babol University of Medical Sciences, Babol, Iran
| | - Mohammad Barary
- Student Research Committee, Virtual School of Medical Education and Management, Shahid Beheshti University of Medical Sciences, Tehran, Iran. .,Students' Scientific Research Center (SSRC), Tehran University of Medical Sciences, Tehran, Iran.
| | - Soheil Ebrahimpour
- Infectious Diseases and Tropical Medicine Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran.
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Meshref M, Hewila IM, Khlidj Y, Korissi R, Shaheen N, Nashwan AJ, Ouerdane Y, Amro Y, Taher KM, Ahmed MG. COVID-19-Associated Cerebrovascular Events: A Case Series Study and a Literature Review of Possible Mechanisms. Case Rep Neurol 2023; 15:11-23. [PMID: 36748059 PMCID: PMC9898811 DOI: 10.1159/000529122] [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: 08/25/2022] [Accepted: 12/29/2022] [Indexed: 02/05/2023] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) affects multiple body systems, including the nervous system. Cerebrovascular accidents can also occur. Patients with comorbid illnesses have severe manifestations and poor outcomes. Despite the proper mechanism of SARS-CoV-2 infection-associated stroke having not yet been settled, various possible mechanisms have been hypothesized. One possibility is that the virus causes endothelial dysfunction and immune-mediated injury. Another possibility is that the trans-neuronal spread of the virus affects brain tissue. In addition, hypercoagulability caused by SARS-CoV-2 infection could lead to a stroke. A virus-induced dysfunction of the renin-angiotensin system could also lead to a stroke. The immune response and vasculitis resulting from SARS-CoV-2 infection are also possible causes via a cytokine storm, immune dysfunction, and various inflammatory responses. SARS-CoV-2 infection may affect calcitonin gene-related peptides and cerebral blood flow and may lead to stroke. Finally, SARS-CoV-2 may cause hemorrhagic strokes via mechanisms stimulated by its interaction with angiotensin-converting enzyme 2 (ACE2), leading to arterial wall damage and blood pressure changes. In this article, we will present seven cases of stroke-associated SARS-CoV-2 infection.
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Affiliation(s)
- Mostafa Meshref
- Neurology Department, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Ibrahim M. Hewila
- Neurology Department, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
- Neurology Department, Worcestershire Royal Hospital, Worcester, UK
| | - Yahia Khlidj
- Faculty of Medicine, University of Algiers Benyoucef Benkhedda, Algiers, Algeria
| | - Rafik Korissi
- Faculty of Medicine, University of Algiers Benyoucef Benkhedda, Algiers, Algeria
| | - Nour Shaheen
- Alexandria Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | | | | | - Yara Amro
- Pharmacist, Ministry of Health, Cairo, Egypt
| | - Khaled M. Taher
- Neurology Department, King Khaled Hospital, Najran, Saudi Arabia
| | - Mahmoud Galal Ahmed
- Neurology Department, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
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Impact of the COVID-19 pandemic lockdown on hospitalizations for cerebrovascular disease and related in-hospital mortality in China: A nationwide observational study. Arch Gerontol Geriatr 2023; 104:104832. [PMID: 36219895 PMCID: PMC9531358 DOI: 10.1016/j.archger.2022.104832] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 09/27/2022] [Accepted: 10/03/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND AND PURPOSE The aim of this nationwide study was to assess the impact of the COVID-19 pandemic on cerebrovascular disease hospitalization rates, out-of-pocket rates, and in-hospital case fatality rates. METHODS All hospitalizations for cerebrovascular disease from 1599 hospitals from 2019 to 2020 were selected using the International Classification of Diseases, 10th revision, in the Hospital Quality Monitoring System (HQMS). We defined 2019 as the pre-pandemic group and 2020 as the post-pandemic group. Multivariate analyses were done to assess the association between the pandemic and patient outcomes and out-of-pocket rate with odds ratios (OR) and 95% CIs presented. RESULTS In total, 9 640 788 patients with the cerebrovascular disease were recruited (mean age was 65.7[SE.0.004] years, and 55.7% were male), and data is available for 5145358 patients in 2019 (pre-epidemic) and 4495430 patients in 2020(post-pandemic), indicating a 12.6% decrease. Out-of-pocket rate increase of 9.3% (2020 vs 2019: 34.1%% vs 31.2% [absolute difference, 2.9% {95% CI, 1.3% to 4.5%}, odd ratio {OR}, 1.1{95% CI, 1.0 to 1.1}]. The epidemic has led to an 18.0% increase in in-hospital mortality (2020 vs 2019: 1.1%% vs 0.9% [absolute difference, 0.2% {95% CI, 0.1% to 0.2%}, odd ratio {OR}, 1.1{95% CI, 1.1 to 1.2}]. The epidemic has led to significantly increased in-hospital mortality for patients with stroke but had no significant impact on other cerebrovascular diseases. CONCLUSIONS During the COVID-19 pandemic lockdown, patients hospitalized for stroke fell by 12.6%, and there were substantial increases in out-of-pocket rates (9.3%) and in-hospital case fatality rates (18.0%).
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Khan M, Hameed S, Soomro BA, Mairaj S, Malik A, Farooq S, Rukn SA, Wasay M. COVID-19 independently predicts poor outcomes in Acute Ischemic Stroke- Insights from a multicenter study from Pakistan and United Arab Emirates. J Stroke Cerebrovasc Dis 2023; 32:106903. [PMID: 36436361 PMCID: PMC9678825 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106903] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 11/05/2022] [Accepted: 11/19/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Ischemic stroke associated with coronavirus 2019 (COVID-19) has been well recognized by now. Few studies have compared COVID related versus unrelated strokes. We intend to report on a large group of Asian patients from two countries and compare COVID with non-COVID strokes admitted during the same time period. METHODS Consecutive cases of acute ischemic stroke either presenting or developing, between March 2020 and December 2021 in four tertiary care hospitals (1 in Dubai, UAE and 3 in Karachi, Pakistan) and testing positive for COVID-19 were included in the study. Patients admitted with ischemic stroke during the same time period and who tested negative for COVID-19 were also randomly selected from the four hospitals. All data was collected from the medical records of the patients and recorded on a standard questionnaire before it was entered in SPSS version 21 for analysis. RESULTS There were 139 COVID positive and 271 COVID negative patients with acute ischemic stroke included in the current study. There were significantly more males (80.6% vs 64.9%, p=0.001) and more large vessel strokes in the COVID positive group (41% vs 21.8%, p<0.001). Being COVID positive was an independent predictor of poor outcome at discharge, defined as a modified Rankin score of 3-6 (OR 3.87, 95% CI 2.21-6.77) after adjusting for country, age, sex, vascular comorbid conditions and stroke subtype. CONCLUSIONS In this largest series of patients with COVID related strokes from Asia, COVID-19 was an independent predictor of poor outcomes at discharge after adjusting for other variables.
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Affiliation(s)
- Maria Khan
- Department of Neurology-Rashid Hospital, Dubai Medical College for Girls, Dubai, UAE
| | - Sajid Hameed
- Department of Neurology, Aga Khan University, Karachi, Pakistan
| | | | - Samar Mairaj
- Dow University of Health sciences, Karachi, Pakistan
| | - Abdul Malik
- Liaquat University of Medicine and Dentistry, Karachi, Pakistan
| | - Saba Farooq
- Department of Neurology-Rashid Hospital, Dubai Medical College for Girls, Dubai, UAE
| | - Suhail Al Rukn
- Department of Neurology-Rashid Hospital, Dubai Medical College for Girls, Dubai, UAE
| | - Mohammad Wasay
- Department of Neurology, Aga Khan University, Karachi, Pakistan,Corresponding author
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Rasyid A, Riyanto DL, Harris S, Kurniawan M, Mesiano T, Hidayat R, Wiyarta E. Association of coagulation factors profile with clinical outcome in patient with COVID-19 and acute stroke: A second wave cohort study. Clin Hemorheol Microcirc 2022; 82:371-377. [PMID: 35871324 DOI: 10.3233/ch-221546] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION The second wave of COVID-19 in Indonesia occurred due to delta variant transmission with up to 2266 cases. This variant could cause higher rate of morbidities and mortalities. This study reported coagulation profile of COVID-19 patients with acute stroke and its association with patients' outcome. METHOD This is a cohort-retrospective study conducted during the second wave of COVID-19, June-August 2021 in Cipto Mangunkusumo General Hospital. Inclusion criteria were adult patients with confirmed COVID-19 and diagnosed with acute stroke confirmed by radiological evidences. Exclusion criteria were COVID-19 patients with prior diagnosis of acute stroke. Coagulation factors were analyzed and presented with tables and graphs. RESULTS A total of 33 patients included in this study with majority experienced ischemic stroke (84.8%), followed by ischemic with haemorrhagic transformation (9.1%), and the rest with haemorrhagic stroke. The median of fibrinogen and D-dimer was 487.1(147-8,943)mg/dL and 2,110(250-35,200)ug/L respectively. Prothrombin time (PT) ratio was 0.95(0.82-1.3) and activated partial thromboplastin time (APTT) ratio was 1.01(0.64-2.72). On observation, 33.3% died during hospitalization, D-dimer value in these patients was significantly higher with 9,940ug/L compared to those who survived with 1,160ug/L(p = 0.009). The highest D-dimer value during hospitalization was also significantly higher with the median of 14,395ug/L compared to 3,740 ug/L (p = 0.014). DISCUSSION D-dimer value on initial assessment and its highest value during hospitalization were significantly higher in patient with poor outcome, showing that D-dimer can be one predictor of mortality in COVID-19 patients with acute stroke.
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Affiliation(s)
- Al Rasyid
- Department of Neurology, Faculty of Medicine, Universitas Indonesia-Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Dinda Larastika Riyanto
- Department of Neurology, Faculty of Medicine, Universitas Indonesia-Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Salim Harris
- Department of Neurology, Faculty of Medicine, Universitas Indonesia-Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Mohammad Kurniawan
- Department of Neurology, Faculty of Medicine, Universitas Indonesia-Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Taufik Mesiano
- Department of Neurology, Faculty of Medicine, Universitas Indonesia-Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Rakhmad Hidayat
- Department of Neurology, Faculty of Medicine, Universitas Indonesia-Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Elvan Wiyarta
- Department of Medical Science, Faculty of Medicine, Universitas Indonesia-Cipto Mangunkusumo Hospital, Jakarta, Indonesia
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Rosenblum JS, Tunacao JM, Nazari MA, Ronk H, Dang DD, Downing C, Zhuang Z, Heiss JD, Smirniotopoulos JG, Bluestone A, Badia J, White J. Acute worsening of CADASIL in a patient with COVID-19 infection: illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2022; 4:CASE22413. [PMID: 36572976 PMCID: PMC9795827 DOI: 10.3171/case22413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 10/19/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND Reports of cerebrovascular ischemia and stroke occurring as predominant neurological sequelae of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, which causes coronavirus disease 2019 (COVID-19), are increasingly evident within the literature. While various pathophysiological mechanisms have been postulated, including hypercoagulability, endothelial invasion, and systemic inflammation, discrete mechanisms for viral neurotropism remain unclear and controversial. OBSERVATIONS The authors present a unique case study of a 64-year-old male with acute COVID-19 infection and acute worsening of previously stable cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL), a rare heritable arteriopathy due to mutation in the Notch3 gene, which is critical for vascular development and tone. Delayed cranial neuropathies, brainstem fluid-attenuated inversion recovery signal, and enhancement of olfactory and vagus nerves on magnetic resonance neurography in this patient further support viral neurotropism via cranial nerves in addition to cerebral vasculature. LESSONS To the authors' knowledge, this is the first case in the literature that not only demonstrates the consequences of COVID-19 infection in a patient with altered cerebrovascular autoregulation such as CADASIL but also highlights the tropism of SARS-CoV-2 for (1) cranial nerves as a mode of entry to the central nervous system and (2) vessels as a cause of cerebrovascular ischemia.
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Affiliation(s)
- Jared S. Rosenblum
- Neuro-Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Jessa M. Tunacao
- Department of Radiology, Stony Brook University Medical Center, Stony Brook, New York
| | - Matthew A. Nazari
- Internal Medicine and Pediatrics, Georgetown Hospital, Washington, District of Columbia
| | - Halle Ronk
- Neuro-Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Danielle D. Dang
- Neuro-Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland,Department of Neurosurgery, Inova Fairfax Medical Campus, Inova Health System, Falls Church, Virginia
| | - Chad Downing
- Department of Radiology, Stony Brook University Medical Center, Stony Brook, New York
| | - Zhengping Zhuang
- Neuro-Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - John D. Heiss
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
| | - James G. Smirniotopoulos
- Department of Radiology, George Washington University, Washington, District of Columbia,MedPix® National Library of Medicine, Bethesda, Maryland; and
| | - Avraham Bluestone
- Department of Radiology, Stony Brook University Medical Center, Stony Brook, New York
| | - James Badia
- Department of Radiology, Stony Brook University Medical Center, Stony Brook, New York
| | - Joseph White
- Department of Family Medicine, Mather Hospital, Northwell Health System, Port Jefferson, New York
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76
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Vuimo TS, Tsarenko SV, Filimonova EV, Seregina EA, Karamzin SS. Correction of Anticoagulant Therapy in Patients with Severe COVID-19 Virus Infection Using a Thrombodynamics Coagulation Assay. Clin Appl Thromb Hemost 2022; 28:10760296221142862. [PMID: 36560917 PMCID: PMC9793037 DOI: 10.1177/10760296221142862] [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] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The average frequency of thrombosis in patients with COVID-19 is still high despite low molecular weight heparin (LMWH) prophylactic. Global hemostasis assays, particularly thrombodynamics (TD), known to be sensitive to both hypercoagulation and heparin effects, could potentially be useful for individual management of anticoagulant therapy. METHODS A total of 74 patients with lung involvement >50% were randomized into two groups: Group A (44 patients) received weight-based dosing of LMWH, and Group B (30 patients) received the first LMWH dose by a weight-based dosing protocol and then received an adjusted dose based on TD daily results. The endpoints of the study were thrombosis and bleeding as well as discharge or death of the patient. RESULTS The incidence of thrombosis was 3 times lower in Group B under TD control compared to Group A without TD control: 7% versus 23 respectively (p = .05). The relative risk of thrombosis if the average clot growth rate V in TD exceeded the threshold value of 25 μm/min was 14.3 (p = .0005, 95% confidence interval 3.2-63.7). There were no clinically significant bleeding episodes in Group B while there were 7% in unregulated Group A. Mortality in Group B under TD control was lower than that in Group A without control: 27% versus 36%, respectively (p = .13). CONCLUSIONS The dosing LMWH under thrombodynamics control in severe patients with COVID-19 allows for a significant reduction in thrombotic complications. Long-term hypercoagulation revealed by thrombodynamics (3 and more days) is a strong predictor of thrombosis (AUC = 0.83).
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Affiliation(s)
- Tatiana S. Vuimo
- Center for Theoretical Problems of
Physicochemical Pharmacology RAS, Moscow, Russia,Dmitry Rogachev National Medical Research
Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Sergey V. Tsarenko
- City Clinical Hospital №52 of Moscow Health care Department, Moscow,
Russia,Faculty of Fundamental Medicine, Moscow State University, Moscow, Russia
| | | | - Elena A. Seregina
- Center for Theoretical Problems of
Physicochemical Pharmacology RAS, Moscow, Russia,Dmitry Rogachev National Medical Research
Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia,Elena A. Seregina, Laboratory of Clinical
Hemostasis, Dmitry Rogachev National Medical Research Center of Pediatric
Hematology, Oncology and Immunology, 117198 Samory Mashela str., 1, Moscow,
Russian Federation.
| | - Sergey S. Karamzin
- Center for Theoretical Problems of
Physicochemical Pharmacology RAS, Moscow, Russia
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77
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Baskett WI, Qureshi AI, Shyu D, Armer JM, Shyu CR. COVID-Specific Long-term Sequelae in Comparison to Common Viral Respiratory Infections: An Analysis of 17 487 Infected Adult Patients. Open Forum Infect Dis 2022; 10:ofac683. [PMID: 36686632 PMCID: PMC9846186 DOI: 10.1093/ofid/ofac683] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
Background A better understanding of long-term health effects after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has become one of the health care priorities in the current pandemic. We analyzed a large and diverse patient cohort to study health effects related to SARS-CoV-2 infection occurring >1 month postinfection. Methods We analyzed 17 487 patients who received diagnoses for SARS-CoV-2 infection in a total of 122 health care facilities in the United States before April 14, 2022. Patients were propensity score-matched with patients diagnosed with the common cold, influenza, or viral pneumonia from March 1, 2020, to April 1, 2021. For each outcome, SARS-CoV-2 was compared with a generic viral respiratory infection (VRI) by predicting diagnoses in the period between 30 and 365 days postinfection. Both coronavirus disease 2019 (COVID-19) and VRI patients were propensity score-matched with patients with no record of COVID-19 or VRI, and the same methodology was applied. Diagnoses where COVID-19 infection was a significant positive predictor in both COVID-19 vs VRI and COVID-19 vs control comparisons were considered COVID-19-specific effects. Results Compared with common VRIs, SARS-CoV-2 was associated with diagnoses of palpitations, hair loss, fatigue, chest pain, dyspnea, joint pain, and obesity in the postinfectious period. Conclusions We identify that some diagnoses commonly described as "long COVID" do not appear significantly more frequent post-COVID-19 infection compared with other common VRIs. We also identify sequelae that are specifically associated with a prior SARS-CoV-2 infection.
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Affiliation(s)
- William I Baskett
- Institute for Data Science and Informatics, University of Missouri, Columbia, Missouri, USA
| | - Adnan I Qureshi
- Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Daniel Shyu
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jane M Armer
- Sinclair School of Nursing, University of Missouri, Columbia, Missouri, USA
| | - Chi-Ren Shyu
- Correspondence: Chi-Ren Shyu, PhD, FAMIA, 22G Heinkel Building, Columbia, MO 65211 ()
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Spence AB, Desale S, Lee J, Kumar P, Huang X, Cooper SE, Fernandez S, Kassaye SG. COVID-19 Outcomes in a US Cohort of Persons Living with HIV (PLWH). REPORTS 2022; 5:41. [PMID: 37063094 PMCID: PMC10104440 DOI: 10.3390/reports5040041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/18/2023] Open
Abstract
Reported coronavirus disease 2019 (COVID-19) outcomes in persons living with HIV (PLWH) vary across cohorts. We examined clinical characteristics and outcomes of PLWH with COVID-19 compared with a matched HIV-seronegative cohort in a mid-Atlantic US healthcare system. Multivariate logistic regression was used to explore factors associated with hospitalization and death/mechanical ventilation among PLWH. Among 281 PLWH with COVID-19, the mean age was 51.5 (SD 12.74) years, 63% were male, 86% were Black, and 87% had a HIV viral load <200 copies/mL. Overall, 47% of PLWH versus 24% (p < 0.001) of matched HIV-seronegative individuals were hospitalized. Rates of COVID-19 associated cardiovascular and thrombotic events, AKI, and infections were similar between PLWH and HIV-seronegative individuals. Overall mortality was 6% (n = 18/281) in PLWH versus 3% (n = 33/1124) HIV-seronegative, p < 0.0001. Among admitted patients, mortality was 14% (n = 18/132) for PLWH and 13% (n = 33/269) for HIV-seronegative, p = 0.75. Among PLWH, hospitalization associated with older age aOR 1.04 (95% CI 1.01, 1.06), Medicaid insurance aOR 2.61 (95% CI 1.39, 4.97) and multimorbidity aOR 2.98 (95% CI 1.72, 5.23). Death/mechanical ventilation associated with older age aOR 1.06 (95% CI 1.01, 1.11), Medicaid insurance aOR 3.6 (95% CI 1.36, 9.74), and multimorbidity aOR 4.4 (95% CI 1.55, 15.9) in adjusted analyses. PLWH were hospitalized more frequently than the HIV-seronegative group and had a higher overall mortality rate, but once hospitalized had similar mortality rates. Older age, multimorbidity and insurance status associated with more severe outcomes among PLWH suggesting the importance of targeted interventions to mitigate the effects of modifiable inequities.
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Affiliation(s)
- Amanda Blair Spence
- Division of Infectious Diseases, Georgetown University Medical Center, Washington, DC 20007, USA
- Correspondence:
| | - Sameer Desale
- MedStar Health Research Institute, Hyattsville, MD 20782, USA
| | - Jennifer Lee
- Division of Infectious Diseases, Georgetown University Medical Center, Washington, DC 20007, USA
| | - Princy Kumar
- Division of Infectious Diseases, Georgetown University Medical Center, Washington, DC 20007, USA
| | - Xu Huang
- MedStar Health Research Institute, Hyattsville, MD 20782, USA
| | - Stanley Evan Cooper
- Department of Medicine, Georgetown University Medical Center, Washington, DC 20007, USA
| | | | - Seble G. Kassaye
- Division of Infectious Diseases, Georgetown University Medical Center, Washington, DC 20007, USA
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Yepes M. Neurological Complications of SARS-CoV-2 Infection and COVID-19 Vaccines: From Molecular Mechanisms to Clinical Manifestations. Curr Drug Targets 2022; 23:1620-1638. [PMID: 36121081 DOI: 10.2174/1389450123666220919123029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 05/31/2022] [Accepted: 07/26/2022] [Indexed: 01/25/2023]
Abstract
Coronavirus Disease 2019 (COVID-19) is an infectious disease, caused by the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), that reached pandemic proportions in 2020. Despite the fact that it was initially characterized by pneumonia and acute respiratory distress syndrome, it is now clear that the nervous system is also compromised in one third of these patients. Indeed, a significant proportion of COVID-19 patients suffer nervous system damage via a plethora of mechanisms including hypoxia, coagulopathy, immune response to the virus, and the direct effect of SARS-CoV-2 on endothelial cells, neurons, astrocytes, pericytes and microglia. Additionally, a low number of previously healthy individuals develop a variety of neurological complications after receiving COVID-19 vaccines and a large proportion of COVID-19 survivors experience longlasting neuropsychiatric symptoms. In conclusion, COVID-19 is also a neurological disease, and the direct and indirect effects of the virus on the nervous system have a significant impact on the morbidity and mortality of these patients. Here we will use the concept of the neurovascular unit, assembled by endothelial cells, basement membrane, perivascular astrocytes, neurons and microglia, to review the effects of SARS-CoV-2 in the nervous system. We will then use this information to review data published to this date on the neurological manifestations of COVID-19, the post- COVID syndrome and COVID-19 vaccines.
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Affiliation(s)
- Manuel Yepes
- Division of Neuropharmacology and Neurologic Diseases, Yerkes National Primate Research Center, Atlanta, GA, USA.,Department of Neurology & Center for Neurodegenerative Disease, Emory University School of Medicine, Atlanta, GA, USA.,Department of Neurology, Veterans Affairs Medical Center, Atlanta, GA, USA
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80
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Horta L, Bakhtyari A, Greige T, Anand P. Challenging Cases in Neurology: Neurologic Complications of COVID-19. Semin Neurol 2022; 42:708-715. [PMID: 36417991 DOI: 10.1055/a-1985-0460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Since the first reported cases of pneumonia in December 2019, coronavirus disease 2019 (COVID-19) has rapidly become recognized as a multisystem illness, with known effects on virtually every organ system. In particular, neurologic complications of COVID-19 have been reported since the beginning of the pandemic in both ambulatory patients with mild disease and critically ill patients. Although it remains unclear whether severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has the potential to directly invade the central nervous system, strokes and other neurovascular complications, sequelae of critical illness and metabolic derangements, parainfectious inflammatory disorders, and a poorly understood post-COVID syndrome have all been reported in patients with COVID-19. Here, we describe cases representing a diverse range of neurologic complications in patients infected with COVID-19.
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Affiliation(s)
- Lucas Horta
- Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Ava Bakhtyari
- Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Tatiana Greige
- Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Pria Anand
- Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
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81
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Yang X, Shi L, Ran D, Li M, Qin C, An Z. The treatment of post-stroke dysarthria with a combination of different acupuncture types and language rehabilitation training: a systematic review and network meta-analysis. ANNALS OF TRANSLATIONAL MEDICINE 2022; 10:1281. [PMID: 36618810 PMCID: PMC9816828 DOI: 10.21037/atm-22-5583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 12/07/2022] [Indexed: 12/23/2022]
Abstract
Background This study used a network meta-analysis to evaluate the efficacy of various different acupuncture types and language rehabilitation training on post-stroke dysarthria (PSD), and examined the possible mechanisms involved. There are often clinical studies comparing the effects of different acupuncture methods on dysarthria after stroke. The efficacy of these methods can be ranked by network meta-analysis. This is necessary for clinical acupoints selection. The results of this study illustrated the comparison of the therapeutic effects of 6 different acupuncture types, which can provide some reference for clinical acupoints selection and research. Methods A comprehensive search for clinical studies related to the use of acupuncture to treat PSD was conducted in eight English and Chinese databases. Patients were divided into six groups based on the acupoints selected, namely, tongue, neck, scalp, body, combination, and traditional acupuncture. The recovery of neurological function in the patients was assessed based on the curative impact and the National Institutes of Health Stroke Scale (NIHSS) score. The quality of the included studies was evaluated using the Cochrane risk bias assessment tool and the STandards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA) criteria. A network meta-analysis was performed using the network-meta package of Stata 15.1 software based on frequency. The heterogeneity test, consistency test, head-to-head mixed comparison, efficacy ranking, and publication bias study were all performed. Results A total of 47 studies were finally included. There was a total of 4,197 patients in the eligible studies. The model for network meta-analysis proved robust, with minimal heterogeneity and high consistency. Combined acupuncture combined with language rehabilitation training was the most effective in treating dysarthria symptoms, followed by tongue acupuncture (TA) and nape acupuncture (NA). In addition, the combined effect of acupuncture and language training was superior to that of acupuncture alone. In terms of recovery of nerve function, traditional acupuncture and body acupuncture were more effective. To facilitate the recovery of nerve function, increasing the frequency of acupoints is necessary. Conclusions Combined acupuncture may have the most beneficial healing effect on PSD, followed by acupuncture of the tongue and the nape of the neck. In terms of recovery of nerve function, traditional acupuncture and body acupuncture may have more effective.
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Affiliation(s)
- Xinming Yang
- Clinical Department of Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
| | - Lei Shi
- Clinical Department of Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
| | - Dawei Ran
- Clinical Department of Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
| | - Menghan Li
- Clinical Department of Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
| | - Chenyang Qin
- Clinical Department of Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
| | - Zimeng An
- Clinical Department of Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
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82
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Vuorio A, Raal F, Kovanen PT. Familial Hypercholesterolemia Patients with COVID-19-Effective Cholesterol-Lowering Therapy is Urgent both during and after Infection. Rev Cardiovasc Med 2022; 23:410. [PMID: 39076654 PMCID: PMC11270387 DOI: 10.31083/j.rcm2312410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 10/16/2022] [Accepted: 11/04/2022] [Indexed: 07/31/2024] Open
Abstract
Heterozygous familial hypercholesterolemia (HeFH) patients are the prime example of subjects who are at high risk for both acute myocardial infarction (AMI) and ischemic stroke during, and post, SARS-CoV-2 infection. HeFH per se, if left untreated, results in premature clinical atherosclerosis often presenting in the fourth or fifth decade of life. The other concern in HeFH is endothelial dysfunction which is already evident from early childhood. In untreated HeFH patients, the severe hypercholesterolemia causes endothelial dysfunction from an early age, and as a result thereof, atherosclerotic lesions develop prematurely, particularly in the coronary arteries, and result in further endothelial dysfunction and inflammation in these critical segments of the arterial tree. As the pre-existing endothelial dysfunction in HeFH patients is most likely sensitive to further direct and indirect SARS-CoV-2 virus-dependent damage, we can infer that HeFH serves as an example of a comorbidity that predicts a poorer prognosis with COVID-19 infection. Indeed, a large US national database study showed that patients diagnosed with HeFH and SARS-CoV-2 infection had significantly increased Annualized Incidence Density Rates (AIDRs) of AMI when compared to matched HeFH controls not having been diagnosed with SARS-CoV-2 infection. Effective cholesterol lowering is essential for the prevention, or at least alleviation, of the detrimental effects of SARS-CoV-2 infection among HeFH patients. Due to the pre-existing subclinical or even clinical atherosclerotic cardiovascular disease in subjects with HeFH, cholesterol-lowering treatment needs to be continued or, better still, intensified during, and for an extended period post, SARS-CoV-2 infection.
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Affiliation(s)
- Alpo Vuorio
- Mehiläinen Airport Health Centre, 01530 Vantaa, Finland
- Department of Forensic Medicine, University of Helsinki, 00100 Helsinki, Finland
| | - Frederick Raal
- Faculty of Health Sciences, University of Witwatersrand, 2193 Johannesburg, South Africa
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83
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Brola W, Wilski M. Neurological consequences of COVID-19. Pharmacol Rep 2022; 74:1208-1222. [PMID: 36180640 PMCID: PMC9524739 DOI: 10.1007/s43440-022-00424-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 09/22/2022] [Accepted: 09/25/2022] [Indexed: 12/13/2022]
Abstract
In December 2019, cases of pneumonia caused by infection with the previously unknown severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), leading to coronavirus disease 2019 (COVID-19), were identified. Typical manifestations of COVID-19 are fever, cough, fatigue and dyspnoea. Initially, it was thought that the mechanism of action of SARS-CoV-2 was only associated with respiratory tract invasion, but it was later revealed that the infection might involve many other organs and systems, including the central and peripheral nervous systems. Neurological complications associated with SARS-CoV-2 infection include encephalopathy, encephalitis, meningitis, acute disseminated encephalomyelitis (ADEM), ischaemic and haemorrhagic stroke and cerebral venous sinus thrombosis. In cases of peripheral nervous system involvement, smell and taste disorders, myopathy or the signs and symptoms of Guillain‒Barré syndrome are observed. The most common early neurological complications, particularly during the first year of the epidemic, were anosmia and taste disorders, which, according to some studies, occurred in over 80 percent of patients with COVID-19. The proportion of patients with serious neurological manifestations was small compared to the global number of patients, but the numbers of SARS-CoV-2 infections and critical patients increased substantially. The experience from 2 years of the pandemic has shown that approximately 13% of infected patients suffer from severe neurological complications. The relationship between SARS-CoV-2 and the nervous system is not only a cause of neurological complications in previously healthy individuals but also directly and indirectly affects the courses of many nervous system diseases.
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Affiliation(s)
- Waldemar Brola
- Collegium Medicum, Jan Kochanowski University, Al. IX Wieków Kielc 19, 25-317, Kielce, Poland.
| | - Maciej Wilski
- Department of Adapted Physical Activity, Poznań University of Physical Education, Poznan, Poland
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84
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Ippolito A, Urban H, Ghoroghi K, Rosbach N, Lingwal N, Adam EH, Friedrichson B, Steinbicker AU, Hattingen E, Wenger KJ. Prevalence of acute neurological complications and pathological neuroimaging findings in critically ill COVID-19 patients with and without VV-ECMO treatment. Sci Rep 2022; 12:17423. [PMID: 36261436 PMCID: PMC9579632 DOI: 10.1038/s41598-022-21475-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 09/27/2022] [Indexed: 01/12/2023] Open
Abstract
Acute brain injuries such as intracerebral hemorrhage (ICH) and ischemic stroke have been reported in critically ill COVID-19 patients as well as in patients treated with veno-venous (VV)-ECMO independently of their COVID-19 status. The purpose of this study was to compare critically ill COVID-19 patients with and without VV-ECMO treatment with regard to acute neurological symptoms, pathological neuroimaging findings (PNIF) and long-term deficits. The single center study was conducted in critically ill COVID-19 patients between February 1, 2020 and June 30, 2021. Demographic, clinical and laboratory parameters were extracted from the hospital's databases. Retrospective imaging modalities included head computed tomography (CT) and magnetic resonance imaging (MRI). Follow-up MRI and neurological examinations were performed on survivors > 6 months after the primary occurrence. Of the 440 patients, 67 patients received VV-ECMO treatment (15%). Sixty-four patients (24 with VV-ECMO) developed acute neurological symptoms (pathological levels of arousal/brain stem function/motor responses) during their ICU stay and underwent neuroimaging with brain CT as the primary modality. Critically ill COVID-19 patients who received VV-ECMO treatment had a significantly lower survival during their hospital stay compared to those without (p < 0.001). Among patients treated with VV-ECMO, 10% showed acute PNIF in one of the imaging modalities during their ICU stay (vs. 4% of patients in the overall COVID-19 ICU cohort). Furthermore, 9% showed primary or secondary ICH of any severity (vs. 3% overall), 6% exhibited severe ICH (vs. 1% overall) and 1.5% were found to have non-hemorrhagic cerebral infarctions (vs. < 1% overall). There was a weak, positive correlation between patients treated with VV-ECMO and the development of acute neurological symptoms. However, the association between the VV-ECMO treatment and acute PNIF was negligible. Two survivors (one with VV-ECMO-treatment/one without) showed innumerable microhemorrhages, predominantly involving the juxtacortical white matter. None of the survivors exhibited diffuse leukoencephalopathy. Every seventh COVID-19 patient developed acute neurological symptoms during their ICU stay, but only every twenty-fifth patient had PNIF which were mostly ICH. VV-ECMO was found to be a weak risk factor for neurological complications (resulting in a higher imaging rate), but not for PNIF. Although logistically complex, repeated neuroimaging should, thus, be considered in all critically ill COVID-19 patients since ICH may have an impact on the treatment decisions and outcomes.
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Affiliation(s)
- Angelo Ippolito
- Institute of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Hans Urban
- Institute of Neurology, University Hospital Frankfurt, Frankfurt, Germany
| | - Kimia Ghoroghi
- Institute of Neuroradiology, University Hospital Frankfurt, Goethe University, Schleusenweg 2-16, 60528, Frankfurt, Germany
| | - Nicolas Rosbach
- Institute of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt, Germany
| | - Neelam Lingwal
- Institute of Biostatistics and Mathematical Modeling, Goethe University, Frankfurt, Germany
| | - Elisabeth H Adam
- Institute of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Benjamin Friedrichson
- Institute of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Andrea U Steinbicker
- Institute of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Elke Hattingen
- Institute of Neuroradiology, University Hospital Frankfurt, Goethe University, Schleusenweg 2-16, 60528, Frankfurt, Germany
| | - Katharina J Wenger
- Institute of Neuroradiology, University Hospital Frankfurt, Goethe University, Schleusenweg 2-16, 60528, Frankfurt, Germany.
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85
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Mariet AS, Duloquin G, Benzenine E, Roussot A, Pommier T, Eicher JC, Baptiste L, Giroud M, Cottin Y, Béjot Y, Quantin C. Impact of the First COVID-19 Wave on French Hospitalizations for Myocardial Infarction and Stroke: A Retrospective Cohort Study. Biomedicines 2022; 10:biomedicines10102501. [PMID: 36289763 PMCID: PMC9598815 DOI: 10.3390/biomedicines10102501] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 09/22/2022] [Accepted: 10/05/2022] [Indexed: 01/09/2023] Open
Abstract
The COVID-19 pandemic modified the management of myocardial infarction (MI) and stroke. We aimed to evaluate the effect of the COVID-19 pandemic on the volume and spatial distribution of hospitalizations for MI and stroke, before, during and after the first nationwide lockdown in France in 2020, compared with 2019. Hospitalization data were extracted from the French National Discharge database. Patient’s characteristics were compared according to COVID-19 status. Changes in hospitalization rates over time were measured using interrupted time series analysis. Possible spatial patterns of over or under-hospitalization rates were investigated using Moran’s indices. We observed a rapid and significant drop in hospitalizations just before the beginning of the lockdown with a nadir at 36.5% for MI and 31.2% for stroke. Hospitalization volumes returned to those seen in 2019 four weeks after the end of the lockdown, except for MI, which rebounded excessively. Older age, male sex, elevated rate of hypertension, diabetes, obesity and mortality characterized COVID-19 patients. There was no evidence of a change in the spatial pattern of over- or under-hospitalization clusters over the three periods. After a steep drop, only MI showed a significant rebound after the first lockdown with no change in the spatial distribution of hospitalizations.
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Affiliation(s)
- Anne-Sophie Mariet
- Biostatistics and Bioinformatics (DIM), University Hospital of Dijon, 21000 Dijon, France
- Clinical Epidemiology/Clinical Trials Unit, Clinical Investigation Center, University Hospital of Dijon, CIC1432, 21000 Dijon, France
| | - Gauthier Duloquin
- Neurology Department, University Hospital of Dijon, 21000 Dijon, France
- Dijon Stroke Registry (Santé Publique France-Inserm), University of Burgundy, UFBC, 21000 Dijon, France
- EA 7460 (Pathophysiology and Epidemiology of Cerebro-CardioVascular Diseases), University of Burgundy, UFBC, 21000 Dijon, France
| | - Eric Benzenine
- Biostatistics and Bioinformatics (DIM), University Hospital of Dijon, 21000 Dijon, France
| | - Adrien Roussot
- Biostatistics and Bioinformatics (DIM), University Hospital of Dijon, 21000 Dijon, France
| | - Thibaut Pommier
- Cardiology Department, University Hospital of Dijon, 21000 Dijon, France
| | | | - Laura Baptiste
- Neurology Department, University Hospital of Dijon, 21000 Dijon, France
- Dijon Stroke Registry (Santé Publique France-Inserm), University of Burgundy, UFBC, 21000 Dijon, France
- EA 7460 (Pathophysiology and Epidemiology of Cerebro-CardioVascular Diseases), University of Burgundy, UFBC, 21000 Dijon, France
| | - Maurice Giroud
- Neurology Department, University Hospital of Dijon, 21000 Dijon, France
- Dijon Stroke Registry (Santé Publique France-Inserm), University of Burgundy, UFBC, 21000 Dijon, France
- EA 7460 (Pathophysiology and Epidemiology of Cerebro-CardioVascular Diseases), University of Burgundy, UFBC, 21000 Dijon, France
| | - Yves Cottin
- Cardiology Department, University Hospital of Dijon, 21000 Dijon, France
- Pathophysiology and Epidemiology of Cerebro-CardioVascular Diseases, University of Burgundy, 21000 Dijon, France
- Registre des Infarctus du Myocarde de Côte d’Or, University Hospital of Dijon, 21000 Dijon, France
| | - Yannick Béjot
- Neurology Department, University Hospital of Dijon, 21000 Dijon, France
- Dijon Stroke Registry (Santé Publique France-Inserm), University of Burgundy, UFBC, 21000 Dijon, France
- EA 7460 (Pathophysiology and Epidemiology of Cerebro-CardioVascular Diseases), University of Burgundy, UFBC, 21000 Dijon, France
| | - Catherine Quantin
- Biostatistics and Bioinformatics (DIM), University Hospital of Dijon, 21000 Dijon, France
- Clinical Epidemiology/Clinical Trials Unit, Clinical Investigation Center, University Hospital of Dijon, CIC1432, 21000 Dijon, France
- Université Paris-Saclay, UVSQ, University of Paris-Sud, Inserm, High-Dimensional Biostatistics for Drug Safety and Genomics, CESP, 94800 Villejuif, France
- Correspondence: ; Tel.: +33-3-80-29-36-29
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86
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Rutović S, Sporiš D, Crnjaković M, Vukorepa G, Deveđija S, Malojčić B. Croatian study on COVID-19-positive stroke patients during the second wave of the pandemic. Croat Med J 2022; 63. [PMID: 36325667 PMCID: PMC9648083 DOI: 10.3325/cmj.2022.63.431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
AIM To investigate stroke characteristics in patients with concomitant coronavirus disease 2019 (COVID-19) infection in Croatia during the second wave of the COVID-19 pandemic. METHODS This retrospective study investigated the characteristics of two groups of ischemic stroke patients: those who developed COVID-19 infection before stroke and those who developed the infection during the hospital stay after stroke onset. Stroke etiology was classified according to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification. RESULTS We analyzed data from 255 stroke patients from 12 Croatian hospitals. The two groups of ischemic stroke patients differed in stroke etiology (P=0.038). Patients with COVID-19 infection before stroke had fewer cardioembolic strokes (46% vs 29.1%), more cryptogenic strokes (32.5% vs 14.3%), and more strokes in multiple vascular territories (12.4% vs 1.8%). The percentage of large-vessel occlusions was high in both groups (49.6% and 44.4%). Median modified Rankin Scale score on discharge was 4 in both groups. Mortality was 36.4% in the group with stroke after COVID-19 and 33.3% in the group with COVID-19 after stroke. CONCLUSION Ischemic stroke after COVID-19 differs in etiology from ischemic stroke complicated by COVID-19 infection. Both patient groups are characterized by severe disability and high mortality. Raising the awareness of prehospital stroke and optimization of clinical workflow are important if we want to improve the stroke outcomes by acute recanalization techniques.
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Affiliation(s)
- Stela Rutović
- Department of Neurology, Dubrava University Hospital, Zagreb, Croatia
| | - Davor Sporiš
- Department of Neurology, Dubrava University Hospital, Zagreb, Croatia
| | | | - Gorana Vukorepa
- Department of Neurology, Dubrava University Hospital, Zagreb, Croatia
| | - Sabina Deveđija
- Department of Neurology, Dubrava University Hospital, Zagreb, Croatia
| | - Branko Malojčić
- Department of Neurology, University Hospital Center Zagreb, Zagreb, Croatia
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87
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SARS-COV-ATE risk assessment model for arterial thromboembolism in COVID-19. Sci Rep 2022; 12:16176. [PMID: 36171201 PMCID: PMC9516525 DOI: 10.1038/s41598-022-18510-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 08/09/2022] [Indexed: 11/09/2022] Open
Abstract
Patients with SARS-CoV-2 infection are at an increased risk of cardiovascular and thrombotic complications conferring an extremely poor prognosis. COVID-19 infection is known to be an independent risk factor for acute ischemic stroke and myocardial infarction (MI). We developed a risk assessment model (RAM) to stratify hospitalized COVID-19 patients for arterial thromboembolism (ATE). This multicenter, retrospective study included adult COVID-19 patients admitted between 3/1/2020 and 9/5/2021. Among 3531 patients from the training cohort, 15.5% developed acute in-hospital ATE, including stroke, MI, and other ATE, compared to 13.4% in the validation cohort. The 16-item final score was named SARS-COV-ATE (Sex: male = 1, Age [40–59 = 2, > 60 = 4], Race: non-African American = 1, Smoking = 1 and Systolic blood pressure elevation = 1, Creatinine elevation = 1; Over the range: leukocytes/lactate dehydrogenase/interleukin-6, B-type natriuretic peptide = 1, Vascular disease (cardiovascular/cerebrovascular = 1), Aspartate aminotransferase = 1, Troponin-I [> 0.04 ng/mL = 1, troponin-I > 0.09 ng/mL = 3], Electrolytes derangement [magnesium/potassium = 1]). RAM had a good discrimination (training AUC 0.777, 0.756–0.797; validation AUC 0.766, 0.741–0.790). The validation cohort was stratified as low-risk (score 0–8), intermediate-risk (score 9–13), and high-risk groups (score ≥ 14), with the incidence of ATE 2.4%, 12.8%, and 33.8%, respectively. Our novel prediction model based on 16 standardized, commonly available parameters showed good performance in identifying COVID-19 patients at risk for ATE on admission.
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88
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Shchukin IA, Fidler MS, Koltsov IA, Suvorov AY. COVID-19-Associated Stroke. NEUROSCIENCE AND BEHAVIORAL PHYSIOLOGY 2022; 52:649-656. [PMID: 36119649 PMCID: PMC9468522 DOI: 10.1007/s11055-022-01291-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 12/22/2021] [Indexed: 11/25/2022]
Abstract
The COVID-19 pandemic has had significant influences on the incidence of acute cerebrovascular accidents and the structure of mortality. SARS-CoV-2 increases the risks of developing both ischemic and hemorrhagic stroke. The key pathogenetic element underlying the development of cerebral stroke in COVID-19 consists of impairments to the operation of angiotensin 2 receptors, which are accompanied by accumulation of excess quantities of angiotensin 2, endothelial dysfunction, hypercoagulation, overproduction of proinflammatory cytokines, and an oxidative storm. In patients with stroke and COVID-19, lesion severity is associated with dual mechanisms of ischemia – systemic and cerebral. The possibilities of medication-based correction of both systemic impairments associated with coronavirus infection and local impairments due to ischemic or hemorrhagic brain damage, are limited. Substances with antioxidant activity may potentially be effective in patients with stroke and COVID-19. Data from a number of clinical rials indicate that Mexidol significantly improves functional outcomes in ischemic stroke. Use of Mexidol in patients with stroke and COVID-19 is advised.
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Affiliation(s)
- I. A. Shchukin
- Pirogov Russian National Research Medical University, Russian Ministry of Health, Moscow, Russia
| | - M. S. Fidler
- Pirogov Russian National Research Medical University, Russian Ministry of Health, Moscow, Russia
| | - I. A. Koltsov
- Pirogov Russian National Research Medical University, Russian Ministry of Health, Moscow, Russia
| | - A. Yu. Suvorov
- Federal Center for the Brain and Neurotechnology, Federal Medical Biological Agency of Russia, Moscow, Russia
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89
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Jamora RDG, Prado MB, Anlacan VMM, Sy MCC, Espiritu AI. Incidence and risk factors for stroke in patients with COVID-19 in the Philippines: An analysis of 10,881 cases. J Stroke Cerebrovasc Dis 2022; 31:106776. [PMID: 36113391 PMCID: PMC9452414 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106776] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/27/2022] [Accepted: 09/06/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND While most large studies on the possible association of COVID-19 and stroke were done in high-income countries, only a few studies consisting of small sample populations have been done in low- to middle-income countries like the Philippines. OBJECTIVES To determine the risk factors of stroke among hospitalized COVID19 patients in the Philippines; to determine the possible association between these risk factors and stroke among the same cohort; and to determine if there is an association between mortality and stroke in this same group. METHODOLOGY We obtained relevant clinical and neurological, including stroke data from the Philippine CORONA study, an observational study involving 10,881 patients with COVID-19 admitted in 37 referral hospitals from all over the Philippines. RESULTS The incidence of stroke among patients with COVID-19 was 3.4% (n = 367). There were more deaths among patients with stroke and COVID-19 than those without stroke and COVID-19 (42.2% vs 14.7%, p < 0.01). In addition, more patients with stroke were admitted in the ICU (43.3% vs 15.0%, p < 0.01) regardless of cause. Smoking (OR: 1.5, 95% CI: 1.3 to 1.7, p < 0.0001), hypertension (OR:1.75, 95% CI:1.53 to 1.97, p < 0.0001), presence of heart failure (OR: 1.4, 95% CI: 1.07 to 1.86, p = 0.01), presence of any neurologic co-morbidities (OR: 1.4, 95% CI:1.11 to 1.46, p = 0.004), and history of stroke (OR:2.3, 95% CI:1.82 to 2.97, p < 0.0001) had direct significant correlation with stroke; while being a health care worker (OR: 0.5, 95% CI: 0.33 to 0.70, p < 0.0004) had an inverse significant association with stroke. CONCLUSION COVID-19 stroke patients in the Philippines have a higher mortality and ICU admission rates than patients with COVID-19 alone or COVID-19 stroke patients from developed countries. Our cohort has similar cardiovascular and metabolic risk factors to western patients with stroke, highlighting that COVID-19 may only have a small contribution to stroke incidence.
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Affiliation(s)
- Roland Dominic G Jamora
- Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines; Institute for Neurosciences, St. Luke's Medical Center, Quezon City and Global City, Philippines.
| | - Mario B Prado
- Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines; Department of Epidemiology and Biostatistics, College of Public Health, University of the Philippines Manila, Manila, Philippines
| | - Veeda Michelle M Anlacan
- Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines; Department of Neurology, Institute of Neurological Sciences, The Medical City, Pasig City, Philippines
| | - Marie Charmaine C Sy
- Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Adrian I Espiritu
- Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines; Department of Clinical Epidemiology, College of Medicine, University of the Philippines Manila, Manila, Philippines; Division of Neurology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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90
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Rubens M, Saxena A, Ramamoorthy V, Ahmed MA, Zhang Z, McGranaghan P, Veledar E, McDermott M, De Los Rios La Rosa F. Hospital Outcomes among COVID-19 Hospitalizations with Acute Ischemic Stroke: Cross-Sectional Study Results from California State Inpatient Database. Brain Sci 2022; 12:brainsci12091177. [PMID: 36138913 PMCID: PMC9496747 DOI: 10.3390/brainsci12091177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/19/2022] [Accepted: 08/25/2022] [Indexed: 11/16/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) could be a risk factor for acute ischemic stroke (AIS) due to the altered coagulation process and hyperinflammation. This study examined the risk factors, clinical profile, and hospital outcomes of COVID-19 hospitalizations with AIS. This study was a retrospective analysis of data from California State Inpatient Database (SID) during 2019 and 2020. COVID-19 hospitalizations with age ≥ 18 years during 2020 and a historical cohort without COVID-19 from 2019 were included in the analysis. The primary outcomes studied were in-hospital mortality and discharge to destinations other than home. There were 91,420 COVID-19 hospitalizations, of which, 1027 (1.1%) had AIS. The historical control cohort included 58,083 AIS hospitalizations without COVID-19. Conditional logistic regression analysis showed that the odds of in-hospital mortality, discharge to destinations other than home, DVT, pulmonary embolism, septic shock, and mechanical ventilation were significantly higher among COVID-19 hospitalizations with AIS, compared to those without AIS. The odds of in-hospital mortality, DVT, pulmonary embolism, septic shock, mechanical ventilation, and respiratory failure were significantly higher among COVID-19 hospitalizations with AIS, compared to AIS hospitalizations without COVID-19. Although the prevalence of AIS was low among COVID-19 hospitalizations, it was associated with higher mortality and greater rates of discharges to destinations other than home.
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Affiliation(s)
- Muni Rubens
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA
| | - Anshul Saxena
- Center for Advanced Analytics, Baptist Health South Florida, Miami, FL 33176, USA
- Department of Neurology, Florida International University, Miami, FL 33199, USA
| | | | - Md Ashfaq Ahmed
- Center for Advanced Analytics, Baptist Health South Florida, Miami, FL 33176, USA
| | - Zhenwei Zhang
- Center for Advanced Analytics, Baptist Health South Florida, Miami, FL 33176, USA
| | - Peter McGranaghan
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA
- Department of Internal Medicine and Cardiology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, 10117 Berlin, Germany
- Correspondence: (P.M.); (F.D.L.R.L.R.); Tel.: +49-030-45050 (P.M.); +1-(786)-596-3876 (F.D.L.R.L.R.)
| | - Emir Veledar
- Center for Advanced Analytics, Baptist Health South Florida, Miami, FL 33176, USA
- Department of Neurology, Florida International University, Miami, FL 33199, USA
| | - Michael McDermott
- Department of Neurology, Florida International University, Miami, FL 33199, USA
- Miami Neuroscience Institute, Baptist Health South Florida, Miami, FL 33176, USA
| | - Felipe De Los Rios La Rosa
- Miami Neuroscience Institute, Baptist Health South Florida, Miami, FL 33176, USA
- Correspondence: (P.M.); (F.D.L.R.L.R.); Tel.: +49-030-45050 (P.M.); +1-(786)-596-3876 (F.D.L.R.L.R.)
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91
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Tang Q, Gao L, Tong Z, Li W. Hyperlipidemia, COVID-19 and acute pancreatitis: A tale of three entities. Am J Med Sci 2022; 364:257-263. [PMID: 35381217 PMCID: PMC8977370 DOI: 10.1016/j.amjms.2022.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 01/04/2022] [Accepted: 03/30/2022] [Indexed: 01/09/2023]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) caused the ongoing pandemic of coronavirus disease 2019 (COVID-19), which presented as not only respiratory symptoms, but various digestive manifestations including pancreatic injury and acute pancreatitis (AP). The underlying mechanism is still unclear. Hypertriglyceridemia has become one of the leading causes of AP in recent years and hyperlipidemia is highly reported in COVID-19 cases. The current narrative review aimed to explore the associations between AP, COVID-19 and hyperlipidemia. Substantial cases of COVID-19 patients complicated with AP were reported, while the incidence of AP in the COVID-19 population was relatively low. Hyperlipidemia was common in COVID-19 patients with a pooled incidence of 32.98%. Hyperlipidemia could be a mediating factor in the pathogenesis of AP in COVID-19 patients. Further studies are warranted to clarify the relationship among AP, lipid metabolism disorders and COVID-19.
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Affiliation(s)
- Qiuyi Tang
- Medical School, Southeast University, Nanjing, Jiangsu, China; Center of Severe Acute Pancreatitis (CSAP), Department of Intensive Care Unit, Jinling Hospital, Nanjing, Jiangsu, China
| | - Lin Gao
- Center of Severe Acute Pancreatitis (CSAP), Department of Intensive Care Unit, Jinling Hospital, Nanjing, Jiangsu, China
| | - Zhihui Tong
- Center of Severe Acute Pancreatitis (CSAP), Department of Intensive Care Unit, Jinling Hospital, Nanjing, Jiangsu, China.
| | - Weiqin Li
- Medical School, Southeast University, Nanjing, Jiangsu, China; Center of Severe Acute Pancreatitis (CSAP), Department of Intensive Care Unit, Jinling Hospital, Nanjing, Jiangsu, China.
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92
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Graham EL, Koralnik IJ, Liotta EM. Therapeutic Approaches to the Neurologic Manifestations of COVID-19. Neurotherapeutics 2022; 19:1435-1466. [PMID: 35861926 PMCID: PMC9302225 DOI: 10.1007/s13311-022-01267-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2022] [Indexed: 02/07/2023] Open
Abstract
As of May 2022, there have been more than 527 million infections with severe acute respiratory disease coronavirus type 2 (SARS-CoV-2) and over 6.2 million deaths from Coronavirus Disease 2019 (COVID-19) worldwide. COVID-19 is a multisystem illness with important neurologic consequences that impact long-term morbidity and mortality. In the acutely ill, the neurologic manifestations of COVID-19 can include distressing but relatively benign symptoms such as headache, myalgias, and anosmia; however, entities such as encephalopathy, stroke, seizures, encephalitis, and Guillain-Barre Syndrome can cause neurologic injury and resulting disability that persists long after the acute pulmonary illness. Furthermore, as many as one-third of patients may experience persistent neurologic symptoms as part of a Post-Acute Sequelae of SARS-CoV-2 infection (Neuro-PASC) syndrome. This Neuro-PASC syndrome can affect patients who required hospitalization for COVID-19 or patients who did not require hospitalization and who may have had minor or no pulmonary symptoms. Given the large number of individuals affected and the ability of neurologic complications to impair quality of life and productivity, the neurologic manifestations of COVID-19 are likely to have major and long-lasting personal, public health, and economic consequences. While knowledge of disease mechanisms and therapies acquired prior to the pandemic can inform us on how to manage patients with the neurologic manifestations of COVID-19, there is a critical need for improved understanding of specific COVID-19 disease mechanisms and development of therapies that target the neurologic morbidities of COVID-19. This current perspective reviews evidence for proposed disease mechanisms as they inform the neurologic management of COVID-19 in adult patients while also identifying areas in need of further research.
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Affiliation(s)
- Edith L Graham
- The Ken and Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, 625 N. Michigan Ave Suite 1150, Chicago, IL, 60611, USA
| | - Igor J Koralnik
- The Ken and Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, 625 N. Michigan Ave Suite 1150, Chicago, IL, 60611, USA
| | - Eric M Liotta
- The Ken and Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, 625 N. Michigan Ave Suite 1150, Chicago, IL, 60611, USA.
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Circulating cell clusters aggravate the hemorheological abnormalities in COVID-19. Biophys J 2022; 121:3309-3319. [PMID: 36028998 PMCID: PMC9420024 DOI: 10.1016/j.bpj.2022.08.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 07/14/2022] [Accepted: 08/22/2022] [Indexed: 11/02/2022] Open
Abstract
Microthrombi and circulating cell clusters (CCCs) are common microscopic findings in patients with COVID-19 at different stages in the disease course, implying that they may function as the primary drivers in disease progression. Inspired by a recent flow imaging cytometry study of the blood samples from patients with COVID-19, we perform computational simulations to investigate the dynamics of different types of CCCs, namely white blood cell (WBC) clusters, platelet clusters and red blood cell (RBC) clusters, over a range of shear flows and quantify their impact on the viscosity of the blood. Our simulation results indicate that the increased level of fibrinogen in patients with COVID-19 can promote the formation of RBC clusters at relatively low shear rates, thereby elevating the blood viscosity, a mechanism that also leads to an increase in viscosity in other blood diseases, such as sickle cell disease and type 2 diabetes mellitus. We further discover that the presence of WBC clusters could also aggravate the abnormalities of local blood rheology. In particular, the extent of elevation of the local blood viscosity is enlarged as the size of the WBC clusters grows. On the other hand, the impact of platelet clusters on the local rheology is found to be negligible, which is likely due to the smaller size of the platelets. The difference in the impact of WBC and platelet clusters on local hemorheology provides a compelling explanation for the clinical finding that the number of WBC clusters is significantly correlated with thrombotic events in COVID-19 whereas platelet clusters do not. Overall, our study demonstrates that our computational models based on dissipative particle dynamics can serve as a powerful tool to conduct quantitative investigation of the mechanism causing the pathological alterations of hemorheology and explore their connections to the clinical manifestations in COVID-19.
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Hidayat R, Widjaya N, Djuliannisaa Z, Mustika AP, Zairinal RA, Diafiri D, Mesiano T, Kurniawan M, Rasyid A, Harris S. Ischemic stroke in COVID-19 patients: a cross-sectional study from an Indonesian COVID-19 referral hospital. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2022; 58:93. [PMID: 35991587 PMCID: PMC9382611 DOI: 10.1186/s41983-022-00528-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 07/25/2022] [Indexed: 11/24/2022] Open
Abstract
Background COVID-19 increases the risk of acute ischemic stroke. The objective of this study is to identify the risk factors, comorbidities, and outcomes in COVID-19 patients with acute ischemic stroke at University of Indonesia Hospital. Results The clinical condition of COVID-19 patients with ischemic stroke is more severe for patients older than 55 years (p < 0.05), patients at the critical COVID-19 clinical stage, and patients with atrial fibrillation (p < 0.05). The level of C-reactive protein (CRP) more than 60 mg/L correlated with the outcome of the patient as well. Conclusion The study concluded that, age, COVID-19 clinical degree, and atrial fibrillation significantly affect the outcome in COVID-19 patients with stroke.
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Brain-Lung Crosstalk: Management of Concomitant Severe Acute Brain Injury and Acute Respiratory Distress Syndrome. Curr Treat Options Neurol 2022; 24:383-408. [PMID: 35965956 PMCID: PMC9363869 DOI: 10.1007/s11940-022-00726-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2022] [Indexed: 12/15/2022]
Abstract
Purpose of Review To summarize pathophysiology, key conflicts, and therapeutic approaches in managing concomitant severe acute brain injury (SABI) and acute respiratory distress syndrome (ARDS). Recent Findings ARDS is common in SABI and independently associated with worse outcomes in all SABI subtypes. Most landmark ARDS trials excluded patients with SABI, and evidence to guide decisions is limited in this population. Potential areas of conflict in the management of patients with both SABI and ARDS are (1) risk of intracranial pressure (ICP) elevation with high levels of positive end-expiratory pressure (PEEP), permissive hypercapnia due to lung protective ventilation (LPV), or prone ventilation; (2) balancing a conservative fluid management strategy with ensuring adequate cerebral perfusion, particularly in patients with symptomatic vasospasm or impaired cerebrovascular blood flow; and (3) uncertainty about the benefit and harm of corticosteroids in this population, with a mortality benefit in ARDS, increased mortality shown in TBI, and conflicting data in other SABI subtypes. Also, the widely adapted partial pressure of oxygen (PaO2) target of > 55 mmHg for ARDS may exacerbate secondary brain injury, and recent guidelines recommend higher goals of 80–120 mmHg in SABI. Distinct pathophysiology and trajectories among different SABI subtypes need to be considered. Summary The management of SABI with ARDS is highly complex, and conventional ARDS management strategies may result in increased ICP and decreased cerebral perfusion. A crucial aspect of concurrent management is to recognize the risk of secondary brain injury in the individual patient, monitor with vigilance, and adjust management during critical time windows. The care of these patients requires meticulous attention to oxygenation and ventilation, hemodynamics, temperature management, and the neurological exam. LPV and prone ventilation should be utilized, and supplemented with invasive ICP monitoring if there is concern for cerebral edema and increased ICP. PEEP titration should be deliberate, involving measures of hemodynamic, pulmonary, and brain physiology. Serial volume status assessments should be performed in SABI and ARDS, and fluid management should be individualized based on measures of brain perfusion, the neurological exam, and cardiopulmonary status. More research is needed to define risks and benefits in corticosteroids in this population.
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Mendonça MM, da Cruz KR, dos Santos Silva FC, Fontes MAP, Xavier CH. Are hemoglobin-derived peptides involved in the neuropsychiatric symptoms caused by SARS-CoV-2 infection? REVISTA BRASILEIRA DE PSIQUIATRIA (SAO PAULO, BRAZIL : 1999) 2022; 44. [PMID: 35896170 PMCID: PMC9375661 DOI: 10.47626/1516-4446-2021-2339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 02/16/2022] [Indexed: 11/29/2022]
Abstract
Follow-up of patients affected by COVID-19 has unveiled remarkable findings. Among the several sequelae caused by SARS-CoV-2 viral infection, it is particularly noteworthy that patients are prone to developing depression, anxiety, cognitive disorders, and dementia as part of the post-COVID-19 syndrome. The multisystem aspects of this disease suggest that multiple mechanisms may converge towards post-infection clinical manifestations. The literature provides mechanistic hypotheses related to changes in classical neurotransmission evoked by SARS-CoV-2 infection; nonetheless, the interaction of peripherally originated classical and non-canonic peptidergic systems may play a putative role in this neuropathology. A wealth of robust findings shows that hemoglobin-derived peptides are able to control cognition, memory, anxiety, and depression through different mechanisms. Early erythrocytic death is found during COVID-19, which would cause excess production of hemoglobin-derived peptides. Following from this premise, the present review sheds light on a possible involvement of hemoglobin-derived molecules in the COVID-19 pathophysiology by fostering neuroscientific evidence that supports the contribution of this non-canonic peptidergic pathway. This rationale may broaden knowledge beyond the currently available data, motivating further studies in the field and paving ways for novel laboratory tests and clinical approaches.
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Affiliation(s)
- Michelle Mendanha Mendonça
- Laboratório de Neurobiologia de Sistemas, Departamento de Ciências Fisiológicas, Instituto de Ciências Biológicas, Universidade Federal de Goiás, Goiânia, GO, Brazil
| | - Kellen Rosa da Cruz
- Laboratório de Neurobiologia de Sistemas, Departamento de Ciências Fisiológicas, Instituto de Ciências Biológicas, Universidade Federal de Goiás, Goiânia, GO, Brazil
| | - Fernanda Cacilda dos Santos Silva
- Laboratório de Fisiologia Cardiovascular, Departamento de Ciências Biológicas, Instituto de Ciências Biológicas, Universidade Federal de Ouro Preto, Ouro Preto, MG, Brazil
| | - Marco Antônio Peliky Fontes
- Laboratório de Hipertensão, Departamento de Fisiologia e Biofísica, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Carlos Henrique Xavier
- Laboratório de Neurobiologia de Sistemas, Departamento de Ciências Fisiológicas, Instituto de Ciências Biológicas, Universidade Federal de Goiás, Goiânia, GO, Brazil
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98
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Abstract
COVID-19 is a primary respiratory illness that is frequently complicated by systemic involvement of the vasculature. Vascular involvement leads to an array of complications ranging from thrombosis to pulmonary edema secondary to loss of barrier function. This review will address the vasculopathy of COVID-19 with a focus on the role of the endothelium in orchestrating the systemic response to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The endothelial receptor systems and molecular pathways activated in the setting of COVID-19 and the consequences of these inflammatory and prothrombotic changes on endothelial cell function will be discussed. The sequelae of COVID-19 vascular involvement at the level of organ systems will also be addressed, with an emphasis on the pulmonary vasculature but with consideration of effects on other vascular beds. The dramatic changes in endothelial phenotypes associated with COVID-19 has enabled the identification of biomarkers that could help guide therapy and predict outcomes. Knowledge of vascular pathogenesis in COVID-19 has also informed therapeutic approaches that may control its systemic sequelae. Because our understanding of vascular response in COVID-19 continues to evolve, we will consider areas of controversy, such as the extent to which SARS-CoV-2 directly infects endothelium and the degree to which vascular responses to SARS-CoV-2 are unique or common to those of other viruses capable of causing severe respiratory disease. This conceptual framework describing how SARS-CoV-2 infection affects endothelial inflammation, prothrombotic transformation, and barrier dysfunction will provide a context for interpreting new information as it arises addressing the vascular complications of COVID-19.
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Affiliation(s)
| | | | - Alec A Schmaier
- Division of Hemostasis and Thrombosis and
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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99
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Belfiore MP, Russo GM, Gallo L, Atripaldi U, Tamburrini S, Caliendo V, Impieri L, Del Canto MT, Ciani G, Parrella P, Mangoni di Santo Stefano ML, Salvia AAH, Urraro F, Nardone V, Coppola N, Reginelli A, Cappabianca S. Secondary Complications in COVID-19 Patients: A Case Series. Tomography 2022; 8:1836-1850. [PMID: 35894019 PMCID: PMC9326591 DOI: 10.3390/tomography8040154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 07/12/2022] [Accepted: 07/14/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction. Coronavirus SARS-CoV-2, the causative agent of COVID-19, primarily causes a respiratory tract infection that is not limited to respiratory distress syndrome, but it is also implicated in other body systems. Systemic complications were reported due to an exaggerated inflammatory response, which involves severe alveolar damage in the lungs and exacerbates the hypercoagulation that leads to venous thrombosis, ischemic attack, vascular dysfunction and infarction of visceral abdominal organs. Some complications are related to anticoagulant drugs that are administrated to stabilize hypercoagulability, but increase the risk of bleeding, hematoma and hemorrhage. The aim of this study is to report the diagnostic role of CT in the early diagnosis and management of patients with severe COVID-19 complications through the most interesting cases in our experience. Material and Methods. The retrospective analysis of patients studied for COVID-19 in our institution and hospitals, which are part of the university training network, was performed. Cases. Pneumomediastinum, cortical kidney necrosis, splenic infarction, cerebral ischemic stroke, thrombosis of the lower limb and hematomas are the most major complications that are reviewed in this study. Conclusions. Since the onset of the COVID-19 pandemic, the CT imaging modality with its high sensitivity and specificity remains the preferred imaging choice to diagnose early the different complications associated with COVID-19, such as thrombosis, ischemic stroke, infarction and pneumomediastinum, and their management, which significantly improved the outcomes.
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Affiliation(s)
- Maria Paola Belfiore
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, Piazza Luigi Miraglia, 80138 Naples, Italy; (M.P.B.); (L.G.); (U.A.); (V.C.); (L.I.); (M.T.D.C.); (G.C.); (P.P.); (A.A.H.S.); (F.U.); (V.N.); (N.C.); (A.R.); (S.C.)
| | - Gaetano Maria Russo
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, Piazza Luigi Miraglia, 80138 Naples, Italy; (M.P.B.); (L.G.); (U.A.); (V.C.); (L.I.); (M.T.D.C.); (G.C.); (P.P.); (A.A.H.S.); (F.U.); (V.N.); (N.C.); (A.R.); (S.C.)
- Correspondence: ; Tel.: +39-3495838248
| | - Luigi Gallo
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, Piazza Luigi Miraglia, 80138 Naples, Italy; (M.P.B.); (L.G.); (U.A.); (V.C.); (L.I.); (M.T.D.C.); (G.C.); (P.P.); (A.A.H.S.); (F.U.); (V.N.); (N.C.); (A.R.); (S.C.)
| | - Umberto Atripaldi
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, Piazza Luigi Miraglia, 80138 Naples, Italy; (M.P.B.); (L.G.); (U.A.); (V.C.); (L.I.); (M.T.D.C.); (G.C.); (P.P.); (A.A.H.S.); (F.U.); (V.N.); (N.C.); (A.R.); (S.C.)
| | - Stefania Tamburrini
- Department of Radiology, Ospedale del Mare, Via Enrico Russo, 80147 Naples, Italy;
| | - Valentina Caliendo
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, Piazza Luigi Miraglia, 80138 Naples, Italy; (M.P.B.); (L.G.); (U.A.); (V.C.); (L.I.); (M.T.D.C.); (G.C.); (P.P.); (A.A.H.S.); (F.U.); (V.N.); (N.C.); (A.R.); (S.C.)
| | - Luigi Impieri
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, Piazza Luigi Miraglia, 80138 Naples, Italy; (M.P.B.); (L.G.); (U.A.); (V.C.); (L.I.); (M.T.D.C.); (G.C.); (P.P.); (A.A.H.S.); (F.U.); (V.N.); (N.C.); (A.R.); (S.C.)
| | - Maria Teresa Del Canto
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, Piazza Luigi Miraglia, 80138 Naples, Italy; (M.P.B.); (L.G.); (U.A.); (V.C.); (L.I.); (M.T.D.C.); (G.C.); (P.P.); (A.A.H.S.); (F.U.); (V.N.); (N.C.); (A.R.); (S.C.)
| | - Giovanni Ciani
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, Piazza Luigi Miraglia, 80138 Naples, Italy; (M.P.B.); (L.G.); (U.A.); (V.C.); (L.I.); (M.T.D.C.); (G.C.); (P.P.); (A.A.H.S.); (F.U.); (V.N.); (N.C.); (A.R.); (S.C.)
| | - Pasquale Parrella
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, Piazza Luigi Miraglia, 80138 Naples, Italy; (M.P.B.); (L.G.); (U.A.); (V.C.); (L.I.); (M.T.D.C.); (G.C.); (P.P.); (A.A.H.S.); (F.U.); (V.N.); (N.C.); (A.R.); (S.C.)
| | | | - Antonio Alessandro Heliot Salvia
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, Piazza Luigi Miraglia, 80138 Naples, Italy; (M.P.B.); (L.G.); (U.A.); (V.C.); (L.I.); (M.T.D.C.); (G.C.); (P.P.); (A.A.H.S.); (F.U.); (V.N.); (N.C.); (A.R.); (S.C.)
| | - Fabrizio Urraro
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, Piazza Luigi Miraglia, 80138 Naples, Italy; (M.P.B.); (L.G.); (U.A.); (V.C.); (L.I.); (M.T.D.C.); (G.C.); (P.P.); (A.A.H.S.); (F.U.); (V.N.); (N.C.); (A.R.); (S.C.)
| | - Valerio Nardone
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, Piazza Luigi Miraglia, 80138 Naples, Italy; (M.P.B.); (L.G.); (U.A.); (V.C.); (L.I.); (M.T.D.C.); (G.C.); (P.P.); (A.A.H.S.); (F.U.); (V.N.); (N.C.); (A.R.); (S.C.)
| | - Nicola Coppola
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, Piazza Luigi Miraglia, 80138 Naples, Italy; (M.P.B.); (L.G.); (U.A.); (V.C.); (L.I.); (M.T.D.C.); (G.C.); (P.P.); (A.A.H.S.); (F.U.); (V.N.); (N.C.); (A.R.); (S.C.)
| | - Alfonso Reginelli
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, Piazza Luigi Miraglia, 80138 Naples, Italy; (M.P.B.); (L.G.); (U.A.); (V.C.); (L.I.); (M.T.D.C.); (G.C.); (P.P.); (A.A.H.S.); (F.U.); (V.N.); (N.C.); (A.R.); (S.C.)
| | - Salvatore Cappabianca
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, Piazza Luigi Miraglia, 80138 Naples, Italy; (M.P.B.); (L.G.); (U.A.); (V.C.); (L.I.); (M.T.D.C.); (G.C.); (P.P.); (A.A.H.S.); (F.U.); (V.N.); (N.C.); (A.R.); (S.C.)
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Md Noh MSF, Yusof Khan AHK, Mohd Sabri MN, Kamis MFAK, Mohd Yaakob MN, Rahim EA, Muda AS. Vessel wall imaging in COVID-19 associated carotid atherothrombosis and stroke: a case report and literature review. J Cent Nerv Syst Dis 2022; 14:11795735221112589. [PMID: 35832610 PMCID: PMC9272477 DOI: 10.1177/11795735221112589] [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: 03/07/2022] [Accepted: 06/10/2022] [Indexed: 11/21/2022] Open
Abstract
COVID-19 associated neurological syndromes, including acute ischemic stroke, pose a
challenge to treating physicians. The role of MRI in aiding diagnosis and further
management is indispensable. The advent of new MRI sequences such as vessel wall imaging
(VWI) allows an avenue in which these patients could be better investigated and treated.
We describe our experience in managing a patient with COVID-19 associated atherothrombosis
and stroke, focusing on the VWI imaging findings.
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Affiliation(s)
- Mohamad Syafeeq Faeez Md Noh
- Department of Radiology, Faculty of Medicine and Health Sciences & Universiti Putra Malaysia Teaching Hospital, Selangor, Malaysia
| | - Abdul Hanif Khan Yusof Khan
- Department of Radiology, Faculty of Medicine and Health Sciences & Universiti Putra Malaysia Teaching Hospital, Selangor, Malaysia
| | - Mohd Naqib Mohd Sabri
- Department of Radiology, Faculty of Medicine and Health Sciences & Universiti Putra Malaysia Teaching Hospital, Selangor, Malaysia
| | | | - Mohd Naim Mohd Yaakob
- Department of Radiology, Faculty of Medicine and Health Sciences & Universiti Putra Malaysia Teaching Hospital, Selangor, Malaysia
| | - Ezamin Abdul Rahim
- Department of Radiology, Faculty of Medicine and Health Sciences & Universiti Putra Malaysia Teaching Hospital, Selangor, Malaysia
| | - Ahmad Sobri Muda
- Department of Radiology, Faculty of Medicine and Health Sciences & Universiti Putra Malaysia Teaching Hospital, Selangor, Malaysia
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