COVID-19 and ischemic stroke: a systematic review and meta-summary of the literature

Longitudinal bi-criteria framework for assessing national healthcare responses to pandemic outbreaks

Pandemics like COVID-19 have illuminated the significant disparities in the performance of national healthcare systems (NHCSs) during rapidly evolving crises. The challenge of comparing NHCS performance has been a difficult topic in the literature. To address this gap, our study introduces a bi-criteria longitudinal algorithm that merges fuzzy clustering with Data Envelopment Analysis (DEA). This new approach provides a comprehensive and dynamic assessment of NHCS performance and efficiency during the early phase of the pandemic. By categorizing each NHCS as an efficient performer, inefficient performer, efficient underperformer, or inefficient underperformer, our analysis vividly represents performance dynamics, clearly identifying the top and bottom performers within each cluster of countries. Our methodology offers valuable insights for performance evaluation and benchmarking, with significant implications for enhancing pandemic response strategies. The study's findings are discussed from theoretical and practical perspectives, offering guidance for future health system assessments and policy-making.

An immunology model for accelerated coronary atherosclerosis and unexplained sudden death in the COVID-19 era

The immunological basis for cardiac deaths remote from potential triggering viral infection, including SARS-CoV-2 infection, remains enigmatic. Cardiac surface inflammation, including the pericardium, epicardium and superficial myocardium with associated coronary artery vasculitis in infant Kawasaki Disease (KD) and multisystem inflammatory syndrome in children (MIS-C) is well recognised. In this perspective, we review the evidence pointing towards prominent post-viral infection related epicardial inflammation in older subjects, resulting in atherosclerotic plaque destabilisation with seemingly unrelated myocardial infarction that may be temporally distant from the actual infectious triggers. Cardiac surface inflammation in the relatively immune cell rich tissues in the territory though where the coronary arteries traverse is common in the adult post-COVD pneumonic phase and is also well described after vaccination including pre-COVID era vaccinations. Immunologically, the pericardium/epicardium tissue was known to be critical for coronary artery territory atherosclerotic disease prior to the COVID-19 era and may be linked to the involvement of the coronary artery vasa vasorum that physiologically oxygenates the coronary artery walls. We highlight how viral infection or vaccination-associated diffuse epicardial tissue inflammation adjacent to the coronary artery vasa vasorum territory represents a critical unifying concept for seemingly unrelated fatal coronary artery atherosclerotic disease, that could occur soon after or remote from infection or vaccination in adults. Mechanistically, such epicardial inflammation impacting coronary artery vasa vasorum immunity acts as gateways towards the slow destabilisation of pre-existing atherosclerotic plaques, with resultant myocardial infarction and other cardiac pathology. This model offers immunologists and academic cardiologists an immunopathological roadmap between innocuous viral infections or vaccinations and seemingly temporally remote "unrelated" atherosclerotic disease with excess cardiac deaths.

Neurological complications caused by SARS-CoV-2

SUMMARYSARS-CoV-2 can not only cause respiratory symptoms but also lead to neurological complications. Research has shown that more than 30% of SARS-CoV-2 patients present neurologic symptoms during COVID-19 (A. Pezzini and A. Padovani, Nat Rev Neurol 16:636-644, 2020, https://doi.org/10.1038/s41582-020-0398-3). Increasing evidence suggests that SARS-CoV-2 can invade both the central nervous system (CNS) (M.S. Xydakis, M.W. Albers, E.H. Holbrook, et al. Lancet Neurol 20: 753-761, 2021 https://doi.org/10.1016/S1474-4422(21)00182-4 ) and the peripheral nervous system (PNS) (M.N. Soares, M. Eggelbusch, E. Naddaf, et al. J Cachexia Sarcopenia Muscle 13:11-22, 2022, https://doi.org/10.1002/jcsm.12896), resulting in a variety of neurological disorders. This review summarized the CNS complications caused by SARS-CoV-2 infection, including encephalopathy, neurodegenerative diseases, and delirium. Additionally, some PNS disorders such as skeletal muscle damage and inflammation, anosmia, smell or taste impairment, myasthenia gravis, Guillain-Barré syndrome, ICU-acquired weakness, and post-acute sequelae of COVID-19 were described. Furthermore, the mechanisms underlying SARS-CoV-2-induced neurological disorders were also discussed, including entering the brain through retrograde neuronal or hematogenous routes, disrupting the normal function of the CNS through cytokine storms, inducing cerebral ischemia or hypoxia, thus leading to neurological complications. Moreover, an overview of long-COVID-19 symptoms is provided, along with some recommendations for care and therapeutic approaches of COVID-19 patients experiencing neurological complications.

COVID-19 Diagnosis, Oral Anticoagulation, and Stroke Risk in Patients with Atrial Fibrillation

BACKGROUND

Coronavirus disease 2019 (COVID-19) has been associated with an increased risk of stroke. It remains unclear whether the risk of stroke associated with a diagnosis of COVID-19 differed with oral anticoagulation (OAC) use. The aim of this study was to evaluate the association between COVID-19 infection, OAC use, and stroke in patients with atrial fibrillation (AF).

METHODS

A retrospective cohort study was conducted in individuals with established AF using data from Optum's deidentified Clinformatics® Data Mart Database. Cox proportional hazard models with time-dependent variables were employed to assess the association between possession of OAC, COVID-19 diagnosis in both inpatient and outpatient setting, and time to ischemic stroke.

RESULTS

A total of 561,758 individuals aged 77 ± 10 were included in the study, with a mean follow up time of 1.3 years. OAC use was associated with a reduced stroke risk [hazard ratio (HR) 0.85, 95% confidence interval (CI) 0.82-0.88]. COVID-19 infection was associated with an increased risk of stroke (HR 2.11, 95% CI 1.87-2.38); this increased risk was particularly pronounced for patients diagnosed with an inpatient diagnosis of COVID-19 (HR 3.95, 95% CI 3.33-4.68). There was no significant interaction between OAC use and COVID-19 diagnosis (p value = 0.96). As a result, the relative increase in stroke risk associated with COVID-19 did not differ between patients on OAC (HR 2.12; 95% CI 1.71-2.62) and those not on OAC (HR 2.11; 95% CI 1.83-2.43).

CONCLUSION

In a nationwide sample of patients with established AF, we found the relative increase in stroke risk associated with COVID-19 was independent of OAC use.

Stroke and COVID-19: An Umbrella Review

Introduction

Acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH) are among the acute cerebrovascular diseases (CVDs) that have been reported as a result of COVID-19. It will be a significant step forward if our research helps improve the compilation and analysis of existing data from other studies.

Methods

The study is registered on PROSPERO with an ID of CRD42023464058. It encompasses articles published until December 2023 and involves searching databases such as PubMed, Scopus, Web of Knowledge, Embase, and Cochrane. Additionally, we conducted manual searches in respected publications within this discipline, utilized the Google Scholar search engine, and conducted reference checks, citation checks, and study of gray literature. The publications' reporting quality was assessed using the "Assessment of Multiple Systematic Reviews" (AMSTAR) checklist. The meta-analysis was conducted using Stata software (StataCorp, version 16).

Results

We analyzed the findings of 23 meta-analyses, which included 795 articles and encompassed 5,937 patients who had previously experienced a stroke. The average age of these patients was 62.3 years, and 68.3% were male. The findings indicated that the collective incidence of stroke among individuals with COVID-19 is roughly 1.75% [95% confidence interval (CI): 0.4%-3.03], with 1.59% for ischemic strokes and 0.3% for hemorrhagic strokes. 32.3% (95% CI: 27.8%-36.9%) of COVID-19 patients with stroke passed away, approximately 27% were discharged from the hospital with very mild or no complications, and around 28.1% (95% CI: 14.1%-42.1%) were referred for rehabilitation.

Conclusions

The overall rate of stroke in COVID-19 patients was approximately 1.75%, with a higher incidence in males and those with an average age of 62.3 years. Almost 80% of the strokes were ischemic, and the mortality rate was approximately 32%. Finally, 27% of the patients were discharged without complications, and 28% required rehabilitation.

Effectiveness of Physiotherapy for Improving Functionality, Participation, and Quality of Life after a Stroke: Study Protocol for a Randomized Controlled Clinical Trial

BACKGROUND

Stroke survivors experience significant alterations in their daily functionality that has a negative impact on their functionality, participation, and quality of life. Person-centered approaches in Physical Therapy interventions that are focused on functional and meaningful goals help to minimize the impact of the alterations. Therefore, the aim of this study is to assess the effectiveness of a Physical Therapy intervention based on a goal-oriented approach with task-specific training for improving functionality, participation, and quality of life for people with Stroke.

METHODS

A single-blinded randomized controlled clinical trial will be developed. Adults over 50 years old diagnosed with Stroke over 6 months will be included in this study. Participants (n = 62) will be randomly allocated into two groups: The experimental group (n = 31) will receive 30 sessions, three per week during 10 weeks, of Physical Therapy sessions of goal-directed and task-specific training. The control group (n = 31) will follow the same intervention intensity of their usual Physical Therapy treatment. The primary outcome variables quality of life (NewsQol), participation (Ox-PAQ), and gait functionality (FAC) and the secondary outcome variables functional disability (BI), postural control (PASS), dynamic trunk balance (TIS), and functional goals (GAS) will be measured at baseline, after group interventions (10 weeks), and 6 months after the baseline. Statistical analyses will include repeated-measures ANOVA, Student's t-test, or the Mann-Whitney U-test, with a 95% confidence interval and significance level of p < 0.05.

CONCLUSION

Person-centered approaches in Physical Therapy interventions may yield better outcomes in functionality, participation, and quality of life for Stroke patients compared to standardized interventions.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT06165666 (December 2023).

The Influence of SARS-CoV-2 Infection on the Development of Selected Neurological Diseases

In 2024, over 775 million cases of COVID-19 were recorded, including approximately 7 million deaths, indicating its widespread and dangerous nature. The disease is caused by the SARS-CoV-2 virus, which can manifest a wide spectrum of symptoms, from mild infection to respiratory failure and even death. Neurological symptoms, such as headaches, confusion, and impaired consciousness, have also been reported in some COVID-19 patients. These observations suggest the potential of SARS-CoV-2 to invade the central nervous system and induce neuroinflammation during infection. This review specifically explores the relationship between SARS-CoV-2 infection and selected neurological diseases such as multiple sclerosis (MS), ischemic stroke (IS), and Alzheimer's disease (AD). It has been observed that the SARS-CoV-2 virus increases the production of cytokines whose action can cause the destruction of the myelin sheaths of nerve cells. Subsequently, the body may synthesize autoantibodies that attack nerve cells, resulting in damage to the brain's anatomical elements, potentially contributing to the onset of multiple sclerosis. Additionally, SARS-CoV-2 exacerbates inflammation, worsening the clinical condition in individuals already suffering from MS. Moreover, the secretion of pro-inflammatory cytokines may lead to an escalation in blood clot formation, which can result in thrombosis, obstructing blood flow to the brain and precipitating an ischemic stroke. AD is characterized by intense inflammation and heightened oxidative stress, both of which are exacerbated during SARS-CoV-2 infection. It has been observed that the SARS-CoV-2 demonstrates enhanced cell entry in the presence of both the ACE2 receptor, which is already elevated in AD and the ApoE ε4 allele. Consequently, the condition worsens and progresses more rapidly, increasing the mortality rate among AD patients. The above information underscores the numerous connections between SARS-CoV-2 infection and neurological diseases.

Incidence and Features of Acute Ischemic Stroke in Patients Hospitalized with COVID-19: A Multi-center Study in Turkey

Introduction

Acute ischemic stroke (AIS) is a devastating complication of COVID-19 with high morbidity and mortality. In this study, we reported the frequency, characteristics, and outcome of AIS in patients with COVID-19.

Methods

This multicenter and cross-sectional study was conducted between April 2020 and February 2021. Among the hospitalized patients with COVID-19, the detailed characteristics of those with and without AIS were recorded and compared.

Results

Six hundred ninety-three patients were included in the study. Acute ischemic stroke was detected in 16 (2.31%) patients, the median age was 77 (range, 48-91) years, and 10 (62.5%) were female. The median NIHSS score at admission was 9 (range, 3-17). Total anterior circulation infarction (TACI) was the most common (37.5%) type and cardioembolism was the most common etiology (37.5%). Nine patients (56.25%) developed AIS within 24 hours of having COVID-19. COVID-19 severity was severe or critical in seven patients (43.75%). Eight patients died, and eight were discharged. Patients with AIS had a higher rate of hypertension, coronary artery disease, heart failure, a history of myocardial infarction, a history of cerebrovascular disease, severe and critical COVID-19, a higher mean age, and a longer ICU stay compared with those without AIS (p<0.001 for each).

Conclusions

AIS can occur in patients with COVID-19 and is associated with mortality. Acute ischemic stroke is encountered at any stage of COVID-19, especially within the first 72 hours of the diagnosis, in older patients with comorbidities and severe COVID-19. There is an increased risk of AIS in patients with COVID-19 with a history of stroke.

Cardiovascular disease risk after a SARS-CoV-2 infection: A systematic review and meta-analysis

OBJECTIVES

To our knowledge, there is no systematic review examining CVD risks after a SARS-CoV-2 infection over time, while also taking into account disease severity. All evidence on the risk for pulmonary embolism (PE), myocardial infarction (MI), ischaemic stroke (IS), haemorrhagic stroke (HS), and arterial thrombosis following infection was evaluated.

METHODS

The protocol was registered with PROSPERO. We searched Pubmed, Embase, MedRxiv and screened the titles/abstracts and full texts. We extracted the included studies, assessed their quality, and estimated pooled risks by time after infection and according to disease severity.

RESULTS

Risks were highest in the acute phase [PE: 27.1 (17.8-41.10); MI: 4.4 (1.6-12.4); stroke: 3.3 (2.1-5.2); IS: 5.6 (2.1-14.8); HS: 4.0 (0.1-326.2)] compared to the post-acute phase [PE: 2.9 (2.6-3.3); MI: 1.4 (1.1-1.9); stroke: 1.4 (1.0-2.0); IS: 1.6 (0.9-2.7)]. Highest risks were observed after infection confirmation, dropping during the first month post-infection (e.g. PE: RR(7 days) = 31; RR(1 month) = 8.1). A doubled risk was still observed until 4.5 months for PE, one month for MI and two months for IS. Risks decreased with decreasing disease severity.

CONCLUSIONS

Because of increased risk of CVD outcomes, management of persons who survived a severe SARS-CoV-2 infection is required, especially during the first nine months post-infection.

Comparison of radiological and clinical characteristics of COVID-19 positive and negative ischemic stroke patients undergoing revascularization: A single-centre Turkish study

OBJECTIVE

We aimed to compare the radiological and clinical characteristics of COVID-19-positive and -negative acute ischemic stroke (AIS) patients who underwent revascularization and to evaluate whether COVID-19 has an effect on revascularization and outcome in AIS patients with COVID-19 infection.

METHODS

Consecutive COVID-19 positive and negative AIS patients who underwent intravenous thrombolysis and/or endovascular therapy in our hospital between March 2020 and February 2022 were included in this study. Our study is retrospective and 23 COVID-19 positive patients and 108 COVID-19 negative patients were compared in terms of radiological and clinical characteristics.

RESULTS

Hypertension was lower in the COVID-19 positive ischemic stroke group (p=0.029). Admission NIHSS score was higher in COVID-19 positive patients (p=0.041). ASPECTS was found to be lower in COVID-19 positive ischemic stroke patients (p=0.019). The rate of hyperdense artery sign differed between groups (p=0.014) and was higher in the COVID-19 positive ischemic stroke group. The incidence of multi-vessel occlusion was found to be significantly higher in the COVID-19-positive ischemic stroke group (p=0.002). In terms of prognostic features, only the 3-month good outcome rate was statistically significantly lower in the COVID-19-positive ischemic stroke group (p=0.011).

CONCLUSION

This study found that radiologically, COVID-19 may be associated with lower ASPECTS in ischemic stroke patients receiving revascularization treatment and may predispose to multivessel occlusion and hyperdense artery sign. Clinically, COVID-19 may be associated with a more severe initial presentation and worse prognosis at 3 months in ischemic stroke patients undergoing revascularization, but may not affect long-term mortality.

A systematic review of thromboembolic complications and outcomes in hospitalised COVID-19 patients

Thromboembolic (TE) complications [myocardial infarction (MI), stroke, deep vein thrombosis (DVT), and pulmonary embolism (PE)] are common causes of mortality in hospitalised COVID-19 patients. Therefore, this review was undertaken to explore the incidence of TE complications and mortality associated with TE complications in hospitalised COVID-19 patients from different studies. A literature search was performed using ScienceDirect and PubMed databases using the MeSH term search strategy of "COVID-19", "thromboembolic complication", "venous thromboembolism", "arterial thromboembolism", "deep vein thrombosis", "pulmonary embolism", "myocardial infarction", "stroke", and "mortality". There were 33 studies included in this review. Studies have revealed that COVID-19 patients tend to develop venous thromboembolism (PE:1.0-40.0% and DVT:0.4-84%) compared to arterial thromboembolism (stroke:0.5-15.2% and MI:0.8-8.7%). Lastly, the all-cause mortality of COVID-19 patients ranged from 4.8 to 63%, whereas the incidence of mortality associated with TE complications was between 5% and 48%. A wide range of incidences of TE complications and mortality associated with TE complications can be seen among hospitalized COVID-19 patients. Therefore, every patient should be assessed for the risk of thromboembolic complications and provided with an appropriate thromboprophylaxis management plan tailored to their individual needs.

Temporal trends of ambulance time intervals for suspected stroke/transient ischaemic attack (TIA) before and during the COVID-19 pandemic in Ireland: a quasi-experimental study

OBJECTIVES

Time is a fundamental component of acute stroke and transient ischaemic attack (TIA) care, thus minimising prehospital delays is a crucial part of the stroke chain of survival. COVID-19 restrictions were introduced in Ireland in response to the pandemic, which resulted in major societal changes. However, current research on the effects of the COVID-19 pandemic on prehospital care for stroke/TIA is limited to early COVID-19 waves. Thus, we aimed to investigate the effect of the COVID-19 pandemic on ambulance time intervals and suspected stroke/TIA call volume for adults with suspected stroke and TIA in Ireland, from 2018 to 2021.

DESIGN

We conducted a secondary data analysis with a quasi-experimental design.

SETTING

We used data from the National Ambulance Service in Ireland. We defined the COVID-19 period as '1 March 2020-31 December 2021' and the pre-COVID-19 period '1 January 2018-29 February 2020'.

PRIMARY AND SECONDARY OUTCOME MEASURES

We compared five ambulance time intervals: 'allocation performance', 'mobilisation performance', 'response time', 'on scene time' and 'conveyance time' between the two periods using descriptive and regression analyses. We also compared call volume for suspected stroke/TIA between the pre-COVID-19 and COVID-19 periods using interrupted time series analysis.

PARTICIPANTS

We included all suspected stroke/TIA cases ≥18 years who called the National Ambulance Service from 2018 to 2021.

RESULTS

40 004 cases were included: 19 826 in the pre-COVID-19 period and 19 731 in the COVID-19 period. All ambulance time intervals increased during the pandemic period compared with pre-COVID-19 (p<0.001). Call volume increased during the COVID-19-period compared with the pre-COVID-19 period (p<0.001).

CONCLUSIONS

A 'shock' like a pandemic has a negative impact on the prehospital phase of care for time-sensitive conditions like stroke/TIA. System evaluation and public awareness campaigns are required to ensure maintenance of prehospital stroke pathways amidst future healthcare crises. Thus, this research is relevant to routine and extraordinary prehospital service planning.

Extracellular Vesicles: The Invisible Heroes and Villains of COVID-19 Central Neuropathology

Acknowledging the neurological symptoms of COVID-19 and the long-lasting neurological damage even after the epidemic ends are common, necessitating ongoing vigilance. Initial investigations suggest that extracellular vesicles (EVs), which assist in the evasion of the host's immune response and achieve immune evasion in SARS-CoV-2 systemic spreading, contribute to the virus's attack on the central nervous system (CNS). The pro-inflammatory, pro-coagulant, and immunomodulatory properties of EVs contents may directly drive neuroinflammation and cerebral thrombosis in COVID-19. Additionally, EVs have attracted attention as potential candidates for targeted therapy in COVID-19 due to their innate homing properties, low immunogenicity, and ability to cross the blood-brain barrier (BBB) freely. Mesenchymal stromal/stem cell (MSCs) secreted EVs are widely applied and evaluated in patients with COVID-19 for their therapeutic effect, considering the limited antiviral treatment. This review summarizes the involvement of EVs in COVID-19 neuropathology as carriers of SARS-CoV-2 or other pathogenic contents, as predictors of COVID-19 neuropathology by transporting brain-derived substances, and as therapeutic agents by delivering biotherapeutic substances or drugs. Understanding the diverse roles of EVs in the neuropathological aspects of COVID-19 provides a comprehensive framework for developing, treating, and preventing central neuropathology and the severe consequences associated with the disease.

Post-stroke rehabilitation in the peri-pandemic COVID-19 era

The coronavirus disease 2019 (COVID-19), which arose in late 2019, caused extensive destruction, impacting a substantial proportion of the worldwide population and leading to millions of deaths. Although COVID-19 is mainly linked to respiratory and pulmonary complications, it has the potential to affect neurologic structures as well. Neurological involvement may manifest as minimal and reversible; however, a notable proportion of cases have exhibited pronounced neurological consequences, such as strokes. Endothelial inflammation, hypercoagulation, renin-angiotensin-aldosterone system alterations, and cardiogenic embolism are the pathophysiological mechanisms of stroke under COVID-19 circumstances. Physical activity and exercise have improved several aspects of post-stroke recovery, including cardiovascular health, walking capacity, and upper limb strength. They are commonly used to assist stroke survivors in overcoming their motor restrictions. Furthermore, stroke rehabilitation can incorporate a range of specific techniques, including body-weight-supported treadmill applications, constraint-induced movement therapy, robotic rehabilitation interventions, transcranial direct current stimulation, transcranial magnetic stimulation, and prism adaptation training. Under pandemic conditions, there were several barriers to neurological rehabilitation. The most significant of these were individual's fear of infection, which caused them to postpone their rehabilitation applications and rehabilitation areas being converted into COVID-19 units. The primary emphasis had turned to COVID-19 treatment. Several valuable data and views were gained in reorganizing rehabilitation during the pandemic, contributing to establishing future views in this regard.

New Directions in Infection-Associated Ischemic Stroke

The relationship between infections and stroke has not been fully characterized, probably delaying the development of specific treatments. This narrative review addresses mechanisms of stroke linked to infections, including hypercoagulability, endothelial dysfunction, vasculitis, and impaired thrombolysis. SARS-CoV-2, the virus that causes COVID-19, may promote the development of stroke, which may represent its most severe neurological complication. The development of specific therapies for infection-associated stroke remains a profound challenge. Perhaps the most important remaining issue is the distinction between infections that trigger a stroke versus infections that are truly incidental. This distinction likely requires the establishment of appropriate biomarkers, candidates of which are elevated levels of fibrin D-dimer and anticardiolipin/antiphospholipid antibodies. These candidate biomarkers might have potential use in identifying pathogenic infections preceding stroke, which is a precursor to establishing specific therapies for this syndrome.

Clinical characteristics of stroke in SARS-CoV-2 infected patients in Japan: A prospective nationwide study

INTRODUCTION

We investigated the clinical characteristics and outcomes of stroke in SARS-CoV-2 infected patients in Japan.

METHODS

This prospective, multicenter observational study of stroke in patients with SARS-CoV-2 infection involving 563 primary stroke centers across Japan was conducted between July 2020, and May 2022. We included 159 stroke cases (131 ischemic stroke, 2 transient ischemic attack (TIA), 21 intracranial hemorrhage, and 5 subarachnoid hemorrhage) and collected their clinical characteristics. Ischemic stroke and TIA (n = 133) were analyzed separately.

RESULTS

The mean age of the 159 patients was 70.6 years, with 66% being men. Poor outcomes (modified Rankin Scale score 5-6) occurred in 40% (63/159) at discharge. Among patients with ischemic stroke and TIA, 30%, 18%, 10%, and 42% had cardioembolism, large-artery atherosclerosis, small-vessel occlusion, and cryptogenic stroke or embolic stroke of undetermined source, respectively. One-third (34%) presented with large vessel occlusion (LVO) of the internal carotid, middle cerebral M1, or basilar arteries. Poor outcomes included age (adjusted odds ratio (aOR): 1.06, 95%CI: 1.01-1.12), ischemic heart disease (IHD) history (aOR: 13.00, 95%CI: 1.51-111.70), moderate to severe pneumonia (aOR: 7.78, 95%CI: 1.18-51.42), an National Institutes of Health Stroke Scale score at baseline (aOR: 1.10, 95%CI: 1.03-1.17), LVO (aOR: 14.88, 95%CI: 2.33-94.97), and log10 D-dimer (aOR: 3.38, 95%CI: 1.01-11.26).

CONCLUSION

Upon discharge, 40% of SARS-CoV-2 infected patients with ischemic stroke and TIA had poor outcomes. Poor outcomes were associated with older age, IHD history, moderate to severe pneumonia, higher NIHSS scores, LVO, and higher log10 D-dimer.

REGISTRATION

UMIN Clinical Trials Registry: https://www.umin.ac.jp/ctr/. Unique identifier: UMIN000041226.

Epidemiology, pathogenesis, and management of Coronavirus disease 2019-associated stroke

The Coronavirus disease 2019 (COVID-19) epidemic has triggered a huge impact on healthcare, socioeconomics, and other aspects of the world over the past three years. An increasing number of studies have identified a complex relationship between COVID-19 and stroke, although active measures are being implemented to prevent disease transmission. Severe COVID-19 may be associated with an increased risk of stroke and increase the rates of disability and mortality, posing a serious challenge to acute stroke diagnosis, treatment, and care. This review aims to provide an update on the influence of COVID-19 itself or vaccines on stroke, including arterial stroke (ischemic stroke and hemorrhagic stroke) and venous stroke (cerebral venous thrombosis). Additionally, the neurovascular mechanisms involved in SARS-CoV-2 infection and the clinical characteristics of stroke in the COVID-19 setting are presented. Evidence on vaccinations, potential therapeutic approaches, and effective strategies for stroke management has been highlighted.

Antithrombotic Therapy in Arterial Thrombosis and Thromboembolism in COVID-19: An American College of Chest Physicians Expert Panel Report

BACKGROUND

Evidence increasingly shows that the risk of thrombotic complications in COVID-19 is associated with a hypercoagulable state. Several organizations have released guidelines for the management of COVID-19-related coagulopathy and prevention of VTE. However, an urgent need exists for practical guidance on the management of arterial thrombosis and thromboembolism in this setting.

RESEARCH QUESTION

What is the current available evidence informing the prevention and management of arterial thrombosis and thromboembolism in patients with COVID-19?

STUDY DESIGN AND METHODS

A group of approved panelists developed key clinical questions by using the Population, Intervention, Comparator, and Outcome (PICO) format that address urgent clinical questions regarding prevention and management of arterial thrombosis and thromboembolism in patients with COVID-19. Using MEDLINE via PubMed, a literature search was conducted and references were screened for inclusion. Data from included studies were summarized and reviewed by the panel. Consensus for the direction and strength of recommendations was achieved using a modified Delphi survey.

RESULTS

The review and analysis of the literature based on 11 PICO questions resulted in 11 recommendations. Overall, a low quality of evidence specific to the population with COVID-19 was found. Consequently, many of the recommendations were based on indirect evidence and prior guidelines in similar populations without COVID-19.

INTERPRETATION

The existing evidence and panel consensus do not suggest a major departure from the management of arterial thrombosis according to recommendations predating the COVID-19 pandemic. Data on the optimal strategies for prevention and management of arterial thrombosis and thromboembolism in patients with COVID-19 are sparse. More high-quality evidence is needed to inform management strategies in these patients.

Intracranial hemorrhages in patients with COVID-19: a systematic review of the literature, regarding six cases in an Amazonian population

BACKGROUND

 Coronavirus disease 2019 (COVID-19) has emerged as a public health emergency worldwide, predominantly affecting the respiratory tract. However, evidence supports the involvement of extrapulmonary sites, including reports of intracranial hemorrhages.

OBJECTIVE

 To describe six original cases and review the literature on intracranial hemorrhages in patients diagnosed with COVID-19 by molecular methods.

METHODS

 A systematic literature review was performed on MEDLINE, PubMed, and NCBI electronic databases to identify eligible studies. Of the total 1,624 articles retrieved, only 53 articles met the inclusion criteria.

RESULTS

 The overall incidence of intracranial hemorrhage in patients hospitalized for COVID-19 was 0.26%. In this patient group, the mean age was 60 years, and the majority were male (68%) with initial respiratory symptoms (73%) and some comorbidity. Before the diagnosis of hemorrhage, 43% of patients were using anticoagulants, 47.3% at therapeutic doses. The intraparenchymal (50%) was the most affected compartment, followed by the subarachnoid (34%), intraventricular (11%), and subdural (7%). There was a predominance of lobar over non-lobar topographies. Multifocal or multicompartmental hemorrhages were described in 25% of cases. Overall mortality in the cohort studies was 44%, while around 55% of patients were discharged from hospital.

CONCLUSION

 Despite the unusual association, the combination of these two diseases is associated with high rates of mortality and morbidity, as well as more severe clinicoradiological presentations. Further studies are needed to provide robust evidence on the exact pathophysiology behind the occurrence of intracranial hemorrhages after COVID-19 infection.

Correlation Between Hypercoagulable State and Severity Level of Ischemic Stroke With Covid-19 Infection

Background

Hypercoagulable state in acute ischemic stroke patients with COVID-19, was found to occur in most cases, may affect the severity and clinical outcome of acute ischemic stroke with COVID-19. Ischemic stroke patients with COVID-19 infection have worsen prognosis in mortality regarding hypercoagulable state condition.

Objective

The study aims to determine the relationship between the hypercoagulable state and the severity of acute ischemic stroke patients with COVID-19.

Methods

This study is a retrospective analytic study using a cross-sectional method in acute ischemic stroke who meet the criteria must have focal clinical symptoms or global dysfunction lasting more than 24 hours, be caused by vascular factors, be confirmed positive for COVID-19, NIHSS (admission and discharge), and have an examination of D-dimer and/or fibrinogen. Chi-Square is used for data processing relationship analysis.

Results

A total of 32 patients met the inclusion and exclusion criteria of this study. Elevated D-dimer and/or fibrinogen were found in 28 patients (87.5%), confirming a hypercoagulable state. In this study, the average value of D-dimer was 5.3 mg/mL, and fibrinogen was 479 mg/dL. Based on the admission NIHSS score, it was found that most of the patients had moderate strokes with an average NIHSS score of 12. The chi-square test results showed no relationship between the hypercoagulable state and the severity of acute ischemic stroke as measured by NIHSS admission (p=0.333), but it was closely related to NIHSS exit (p=0.02). The finding supports that 40.62% of acute ischemic stroke patients with COVID-19 confirmed to have a hypercoagulable state had a death discharge status.

Conclusion

There is no significant relationship between hypercoagulable state and stroke severity on admission, but it closely related to NIHSS on discharge and high mortality in acute ischemic stroke patients with COVID-19.

From Emergence to Endemicity: A Comprehensive Review of COVID-19

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), later renamed coronavirus disease 2019 (COVID-19), was first identified in Wuhan, China, in early December 2019. Initially, the China office of the World Health Organization was informed of numerous cases of pneumonia of unidentified etiology in Wuhan, Hubei Province at the end of 2019. This would subsequently result in a global pandemic with millions of confirmed cases of COVID-19 and millions of deaths reported to the WHO. We have analyzed most of the data published since the beginning of the pandemic to compile this comprehensive review of SARS-CoV-2. We looked at the core ideas, such as the etiology, epidemiology, pathogenesis, clinical symptoms, diagnostics, histopathologic findings, consequences, therapies, and vaccines. We have also included the long-term effects and myths associated with some therapeutics of COVID-19. This study presents a comprehensive assessment of the SARS-CoV-2 virology, vaccines, medicines, and significant variants identified during the course of the pandemic. Our review article is intended to provide medical practitioners with a better understanding of the fundamental sciences, clinical treatment, and prevention of COVID-19. As of May 2023, this paper contains the most recent data made accessible.

Thromboembolic Presentations among Patients Hospitalized to the Intensive Care Unit for Coronavirus Disease 2019 (COVID-19) - A Northern Taiwan Single Center Experience

Coronavirus Disease 2019 (COVID-19) has been associated with a high thromboembolic risk among patients in intensive care units. Asian populations may share a similar thromboembolic risk, but with a higher prevalence of arterial thromboembolism than venous thromboembolism. To clarify this risk in Taiwan, this single-center retrospective study collected 27 consecutive intensive care unit patients with COVID-19 confirmed by polymerase chain reaction, with a median age of 67.6 years (male 81.5%). Twenty-three patients received prophylactic anticoagulation (85.2%), and there were four bleeding events (14.8%). Nine patients had thromboembolism (33.3%), including three with deep vein thrombosis, two with peripheral artery thromboembolism, and four with ischemic stroke. There were no significant clinical differences between the patients with or without thromboembolism. Initial serum ferritin [adjusted odds ratio (OR): 13.19, 95% confidence interval (CI): 1.01-172.07] and peak serum procalcitonin (adjusted OR: 18.93, 95% CI: 1.08-330.91) were associated with a higher risk of thromboembolism. Furthermore, prophylactic anticoagulation (adjusted OR: 0.01, 95% CI: < 0.001-0.55) was associated with a lower risk of thromboembolism. All cases of deep vein thrombosis and one peripheral artery thromboembolism occurred at intravascular catheter locations. No association between thromboembolism and survival was found (age-adjusted hazard ratio: 0.55, 95% CI: 0.10-2.95). In conclusion, the prevalence of COVID-19 thromboembolism among Taiwanese patients in intensive care units was high, even with prophylactic anticoagulation. Serum ferritin and procalcitonin may identify high-risk populations. Prophylactic anticoagulation may reduce the risk of thromboembolism with a manageable bleeding risk. Larger prospective studies are needed to clarify the risk of COVID-19 thromboembolism and its risk factors in the post-Omicron era.

Ischemic strokes in COVID-19: risk factors, obesity paradox, and distinction between trigger and causal association

Background and purpose

Stroke has been described as a COVID-19 complication. However, its occurrence rate, risk factors, and causal relationships are still not well established.

Methods

We describe the characteristics of confirmed COVID-19-related strokes among all cases of COVID-19 hospitalized in our health network, from November 1, 2020 to April 30, 2021. Risk factor analysis has been conducted for ischemic stroke (IS), which represents 92% of all confirmed cases of Covid-19-related strokes, and a "causal attribution to infection" classification is provided.

Results

In all, 62/4105 hospitalized COVID-19 patients had an acute stroke (1.51%). Severe COVID-19 (OR 2.27-CI 1.06-4.77; p = 0.032), atrial fibrillation (OR 3.65-CI 1.63-7.98; p = 0.001), and ischemic heart disease (OR 4.590-CI 1.714-12.137; p = 0.002) proved to be independent risk factors for IS, while obesity was a protective factor (OR 0.90-CI 0.82-0.97; p = 0.012). COVID-19 had a causal role in 32.1% of IS cases, was a relevant cofactor in 28.6% of cases of IS, and was a possible trigger in 39.3% of events.

Conclusion

Our stroke occurrence rate is consistent with other population-based reports (range 0.34-2.7%). Prespecified peculiar clinical and radiological features allow the distinction between "IS caused by COVID-19" and "IS triggered by COVID-19." Clinical history of vascular diseases and risk factors is crucial in determining the risk of IS in patients with COVID-19. However, the protective effect of a BMI > 30 kg/m2 seems to suggest an obesity paradox.

Abnormalities of brain imaging in COVID-19 patients with neurological symptoms

Background: Coronavirus disease 2019 (COVID-19) is a multisystem disease, manifested by several symptoms of various degrees. Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) can affect the central nervous system (CNS) through several mechanisms and brain imaging plays an essential role in the diagnosis and evaluation of the neurological involvement of COVID-19. Moreover, brain imaging of patients with COVID-19 would result in a better understanding of SARS-CoV-2 neuro-pathophysiology. In this study, we evaluated the brain imaging findings of patients with COVID-19 in Shohada-e Tajrish Hospital, Tehran, Iran. Methods: This was a single-center, retrospective, and observational study. The hospital records and chest and brain computed tomography (CT) scans of patients with confirmed COVID-19 were reviewed. Results: 161 patients were included in this study (39.1% women, mean age: 60.84). Thirteen patients (8%) had ischemic strokes identified by brain CT. Subdural hematoma, subdural effusion, and subarachnoid hemorrhage were confirmed in three patients. Furthermore, there were four cases of intracranial hemorrhage (ICH) and intraventricular hemorrhage (IVH). Patients with and without abnormal brain CTs had similar average ages. The rate of brain CT abnormalities in both genders did not differ significantly. Moreover, abnormal brain CT was not associated with increased death rate. There was no significant difference in lung involvement (according to lung CT scan) between the two groups. Conclusion: Our experience revealed a wide range of imaging findings in patients with COVID-19 and these findings were not associated with a more severe lung involvement or increased rate of mortality.

Severe Acute Respiratory Syndrome Associated Infections

Viral infections are some of the most common sources of respiratory illness in pediatric and adult populations worldwide. Influenza and coronaviruses are viral pathogens that could lead to severe respiratory illness and death. More recently, respiratory illness from coronaviruses, accounts for more than 1 million deaths in the United States alone. This article will explore the epidemiology, pathogenesis, diagnosis, treatment, and prevention of severe acute respiratory syndrome caused by coronavirus-2, and Middle Eastern respiratory syndrome.

Epidemiology of Stroke 2 Years Before and During COVID-19 Pandemic in Kerman (south of Iran): a Hospital-Based Study

INTRODUCTION

Stroke is the second leading cause of death worldwide. Recent studies have shown that the COVID-19 pandemic has been associated with a higher frequency of stroke. This study aimed to investigate the epidemiologic aspects of stroke two years before and during the COVID-19 pandemic in Kerman.

METHOD

This cross-sectional study was conducted in Kerman. The participants included all patients with a confirmed diagnosis of stroke. COVID-19 confirmation was based on a positive PCR test. The data was analyzed with SPSS.V24 software.

RESULTS

In this study, 4152 patients with stroke were evaluated. The frequency of stroke before and during the COVID-19 pandemic was the same. The total number of stroke patients with COVID-19 was 298 (8.16%). The frequency of ischemic stroke patients before the COVID-19 pandemic was 1751 and during the pandemic was 1770. Before and after the pandemic, the mean age of ischemic stroke patients was 67.42±14.14 and 64.49±14.46 respectively, which showed a statistically significant difference (P>0.001). Our findings showed a significant difference between the NIHSS of ischemic stroke before and after the pandemic (P<0.001). The mortality rate of stroke patients was 111 before COVID-19 and 115 patients in the first two years of COVID-19. Except for the mortality rate (P<0.001), there was no significant difference in other demographic variables between ischemic stroke patients with and without COVID-19.

CONCLUSION

The patients with ischemic stroke during the COVID-19 pandemic were younger and had more neurological deficits than the ischemic stroke patients before the pandemic. COVID-19 was associated with higher mortality in patients with ischemic stroke.

Ischaemic Stroke Occurring in a Patient Treated with Monoclonal Antibodies for COVID-19

Since the COVID-19 outbreak began, an association between COVID-19 and thrombotic diseases has been underlined. Although this association is more frequent with venous thromboembolism, ischaemic stroke has also been reported as a thrombotic complication in several cohorts of affected patients. Furthermore, the association between ischaemic stroke and COVID-19 has been considered a risk factor for early mortality. On the other hand, after the successful vaccination campaign, the incidence and the virulence of SARS-CoV-2 decreased, though it has been observed that COVID-19 may induce a severe infection in specific cohorts of frail subjects. For this reason, different drugs have been introduced of an antiviral action in order to improve the disease outcome of frail patients. In this field, with the arrival of a neutralizing monoclonal antibody against SARS-CoV-2, in particular, sotrovimab, a further chance to treat high-risk patients with mild-to-moderate COVID-19 arrived, achieving a concrete reduction in the risk of disease progression. We here report our clinical experience of an ischaemic stroke occurring a few minutes after the administration of sotrovimab for the treatment of moderate COVID-19 in a frail patient with chronic lymphocytic leukaemia. Other causes of ischaemic stroke were ruled out, and in order to evaluate the probability of a rare side effect, the Naranjo probability scale has also been utilized. In conclusion, among several side effects that have been described during the treatment of COVID-19 with sotrovimab, ischaemic stroke was not reported. Therefore, we here report a rare case of ischaemic stroke with early clinical manifestation after the administration of sotrovimab for the treatment of moderate COVID-19 in an immunocompromised patient for the first time.

COVID-19, Blood Lipid Changes, and Thrombosis

Although there is increasing evidence that oxidative stress and inflammation induced by COVID-19 may contribute to increased risk and severity of thromboses, the underlying mechanism(s) remain to be understood. The purpose of this review is to highlight the role of blood lipids in association with thrombosis events observed in COVID-19 patients. Among different types of phospholipases A₂ that target cell membrane phospholipids, there is increasing focus on the inflammatory secretory phospholipase A₂ IIA (sPLA₂-IIA), which is associated with the severity of COVID-19. Analysis indicates increased sPLA₂-IIA levels together with eicosanoids in the sera of COVID patients. sPLA₂ could metabolise phospholipids in platelets, erythrocytes, and endothelial cells to produce arachidonic acid (ARA) and lysophospholipids. Arachidonic acid in platelets is metabolised to prostaglandin H2 and thromboxane A₂, known for their pro-coagulation and vasoconstrictive properties. Lysophospholipids, such as lysophosphatidylcholine, could be metabolised by autotaxin (ATX) and further converted to lysophosphatidic acid (LPA). Increased ATX has been found in the serum of patients with COVID-19, and LPA has recently been found to induce NETosis, a clotting mechanism triggered by the release of extracellular fibres from neutrophils and a key feature of the COVID-19 hypercoagulable state. PLA2 could also catalyse the formation of platelet activating factor (PAF) from membrane ether phospholipids. Many of the above lipid mediators are increased in the blood of patients with COVID-19. Together, findings from analyses of blood lipids in COVID-19 patients suggest an important role for metabolites of sPLA₂-IIA in COVID-19-associated coagulopathy (CAC).

Recombinant tissue plasminogen activator (rTPA) management for first onset acute ischemic stroke with covid -19 and non-covid -19 patients

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.

Acute stroke in COVID-19 patients: A first year experience in a Colombian hospital

Background

COVID-19 may be a new risk factor for stroke. Stroke in COVID-19 varies from 1.1 to 8.1%. Various pathophysiological pathways predispose SARS-CoV-2 infected patients to stroke.

Aim

To describe COVID-19 patients with acute stroke in one Colombian Center.

Methods

From March 6 2020 and March 6 2021 records of patients with acute stroke and in-hospital positive PCR (Polymerase Chain Reaction) test for Sars-CoV-2 infection were reviewed. Demographic, stroke and COVID-19 characteristics were extracted. Continuous variables were reported in means and ranges. Categorical variables were presented in frequencies and percentage. A descriptive narrative was performed.

Results

Of 328 acute stroke patients 14 (4.2%) tested positive for PCR SARS-CoV-2. Mean age 56.4 years with 57% males. Five were (35.7%) without vascular risk factors but 9 (64.3%) overweight. Brain infarct diagnosed in 11 (78.5%), 53% with anterior circulation syndromes. Mean NIHSS score 11.8 and 7 (63%) received intravenous thrombolysis. Acute inflammatory blood biomarkers (D-dimer, ferritin, LDH elevated) were positive in all. 11 (78.5%) had symptomatic COVID-19 before stroke with a mean latency of 7 days. 12 (85.7%) had severe COVID-19 and 6 (42.8%) required mechanical ventilation. Outcome was unfavorable in 9 (64.3%) (The Modified Rankin Scale (mRS) > 2), mean hospital stay was 21.8 days and in-hospital case fatality rate was 14.2%.

Conclusion

In susceptible individuals COVID-19 predisposes to stroke. Hypercoagulation and immune thrombosis may be at the culprit for this state. In Colombia, COVID-19 patients with stroke have similar characteristics to the described worldwide.

Chest computed tomography findings typical of COVID-19 pneumonia in Germany as early as 30 December 2019: a case report

BACKGROUND

The first cases of coronavirus disease 2019 were officially confirmed in Germany and its European neighbors in late January 2020. In France and Italy, there is evidence that coronavirus disease 2019 was spreading as early as December 2019.

CASE PRESENTATION

We report on a 71-year-old male patient from Germany who was admitted to our hospital on 30 December 2019 with pneumonia of unclear etiology and chest computed tomography findings typical of COVID-19 pneumonia.

CONCLUSION

This case may indicate that coronavirus disease 2019 was already spreading in Germany as early as December 2019.

The impact of SARS-CoV-2 infection on the outcome of acute ischemic stroke-A retrospective cohort study

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.

COVID-19 and Acute Ischemic Stroke Mortality and Clinical Outcomes among Hospitalized Patients in the United States: Insight from National Inpatient Sample

Coronavirus-19, primarily a respiratory virus, also affects the nervous system. Acute ischemic stroke (AIS) is a well-known complication among COVID-19 infections, but large-scale studies evaluating AIS outcomes related to COVID-19 infection remain limited. We used the National Inpatient Sample database to compare acute ischemic stroke patients with and without COVID-19. A total of 329,240 patients were included in the study: acute ischemic stroke with COVID-19 (n = 6665, 2.0%) and acute ischemic stroke without COVID-19 (n = 322,575, 98.0%). The primary outcome was in-hospital mortality. Secondary outcomes included mechanical ventilation, vasopressor use, mechanical thrombectomy, thrombolysis, seizure, acute venous thromboembolism, acute myocardial infarction, cardiac arrest, septic shock, acute kidney injury requiring hemodialysis, length of stay, mean total hospitalization charge, and disposition. Acute ischemic stroke patients who were COVID-19-positive had significantly increased in-hospital mortality compared to acute ischemic stroke patients without COVID-19 (16.9% vs. 4.1%, aOR: 2.5 [95% CI 1.7-3.6], p < 0.001). This cohort also had significantly increased mechanical ventilation use, acute venous thromboembolism, acute myocardial infarction, cardiac arrest, septic shock, acute kidney injury, length of stay, and mean total hospitalization charge. Further research regarding vaccination and therapies will be vital in reducing worse outcomes in patients with acute ischemic stroke and COVID-19.

Is a high chest CT severity score a risk factor for an increased incidence of long-term neuroimaging findings after COVID-19?

OBJECTIVES

We aimed to determine the incidences of neuroimaging findings (NIF) and investigate the relationship between the course of pneumonia severity and neuroimaging findings.

MATERIALS AND METHODS

Our study was a retrospective analysis of 272 (>18 years) COVID-19 patients who were admitted between "March 11, 2021, and September 26, 2022". All patients underwent both chest CT and neuroimaging. The patient's chest CTs were evaluated for pneumonia severity using a severity score system (CT-SS). The incidence of NIF was calculated. NIF were categorized into two groups; neuroimaging positive (NIP) and neuroimaging negative (NIN). Consecutive CT-SS changes in positive and negative NIF patients were analyzed.

RESULTS

The median age of total patients was 71; IQR, 57-80. Of all patients, 56/272 (20.6%) were NIP. There was no significant relationship between NIP and mortality (p = 0.815) and ICU admission (p = 0.187). The incidences of NIF in our patients were as follows: Acute-subacute ischemic stroke: 47/272 (17.3%); Acute spontaneous intracranial hemorrhage: 13/272 (4.8%); Cerebral microhemorrhages: 10/272 (3.7%) and Cerebral venous sinus thrombosis: 3/25 (10.7%). Temporal change of CT-SSs, there was a statistically significant increase in the second and third CT-SSs compared to the first CT-SS in both patients with NIP and NIN.

CONCLUSION

Our results showed that since neurological damage can be seen in the late period and neurological damage may develop regardless of pneumonia severity.

Arterial Thrombotic Events in Hospitalized COVID-19 Patients: A Short Review and Meta-Analysis

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.

Evaluation of patients with antiphospholipid syndrome subsequently COVID-19 vaccinations: A retrospective cohort study

The aim of this study is to evaluate development of side effects, thrombotic or obstetric complications in our antiphospholipid syndrome (APS) patient group, after vaccination against coronavirus disease 2019 (COVID-19). A cohort was formed from patients who have previously been followed up with a diagnosis of APS. The patients of the cohort were evaluated retrospectively to find out if they were vaccinated with CoronaVac and/or BNT162b2 vaccines which are being used in our country. To evaluate the side effects seen after the vaccination, the information was collected by the patients in their outpatient appointments or making a phone call. Thirty-five APS patients who had received at least 1 dose of any of the COVID-19 vaccines were included in the study. Median (min-max) number of vaccine doses per patient was 2 (1-3). Eleven patients had a booster dose after primary vaccination. Twenty patients were ever vaccinated with BNT162b2 and 18 with CoronaVac. Among BNT162b2 recipients, 9 (45.0%) and among CoronaVac recipients 15 (42.9%) reported an adverse event after a vaccine administration. The most common adverse events were myalgia and malaise after any dose of both vaccines. No vaccine-related new thrombotic events or APS flares were observed. Our results were comparable with those reported in the literature. Comprehensive large-scale studies are needed for more accurate results on the evaluation of side effects after COVID-19 vaccination in APS patients.

Characteristics of subarachnoid hemorrhage associated with COVID-19 infection: A systematic review and descriptive analysis

OBJECTIVE

Subarachnoid hemorrhage (SAH) has been reported as a neurological manifestation in 0.1% of COVID-19 patients. This systematic review investigated the outcomes and predictive factors of SAH in patients with COVID-19.

MATERIALS AND METHODS

An electronic literature search was conducted on PubMed, Embase, and Scopus from inception to 10th September 2021. Studies reporting SAH in COVID-19 patients were included. Demographic characteristics, risk factors for disease, severity of COVID-19, and mortality of SAH in COVID-19 patients were analyzed. Subgroup analyses stratified by COVID-19 severity and mortality were conducted.

RESULTS

17 case reports, 11 case series, and 2 retrospective cohort studies, with a total of 345 cases of SAH in COVID-19 patients, were included for analysis. Most published cases were reported in the US. Mean age was 55±18.4 years, and 162 patients (48.5%) were female. 242 patients (73.8%) had severe-to-critical COVID-19, 56.7% had aneurysmal SAH, 71.4% were on anticoagulation, and 10.8% underwent surgical treatment. 136 out of 333 patients (40.8%) died. Among patients with severe-to-critical COVID-19, 11 out of 18 (61.1%) died, and 8 out of 8 (100.0%) were non-aneurysmal SAH.

CONCLUSIONS

SAH is a rare but morbid occurrence in COVID-19. The mortality rate of COVID-SAH patients was 40.8%, with a higher prevalence of severe-to-critical COVID-19 (100% versus 53.8%) and non-aneurysmal SAH (85.7% versus 44.6%) among COVID-SAH deaths. Given the changing landscape of COVID-19 variants, further studies investigating the association between COVID-19 and SAH may be warranted to identify the long-term effects of COVID-19.

Multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD) following COVID-19 vaccines: A systematic review

BACKGROUND

The global COVID-19 pandemic began in March 2019, and given the number of casualties and adverse effects on the economy, society, and all aspects of the health system, efforts have been made to develop vaccines from the beginning of the pandemic. Numerous vaccines against COVID-19 infection have been developed in several technologies and have spread rapidly. There have been reported multiple complications of the COVID-19 vaccines as with other vaccines. A number of studies have reported multiple sclerosis (MS ) and neuromyelitis optica spectrum disorder (NMOSD) as complications of COVID-19 vaccines.

METHODS

First, we found 954 studies from 4 databases (PubMed, Embase, Scopus, and Web of Science) from inception to March 1^st, 2022. Next, duplicate articles were eliminated, and 476 studies remained. Then 412 studies were removed according to inclusion and exclusion criteria. After obtaining the full text of 64 articles, 12 studies were selected finally.

RESULTS

The data were extracted from included studies in a table. Our data includes demographic data, comorbidities, vaccines information and side effects, NMOSD and MS symptoms, laboratory and cerebrospinal fluid (CSF) findings, magnetic resonance imaging (MRI) results, treatment, and outcome of all cases.

CONCLUSION

MS and NMOSD are two neuroinflammatory disorders that arise in the CNS. Cases of MS and NMOSD have been reported following COVID-19 vaccination. Nevertheless, more studies with more subjects are needed to assess any possible relationship between the COVID-19 vaccine and central nervous system demyelination.

[The Respiratory Therapist in Neurology An Evolving Specialization in Germany]

In Germany, nurses, physiotherapists and speech and language therapists follow a qualifying training for about 1,5 years to become respiratory therapists (RTs). With respect to neurological illness, RTs diagnose and treat disorders of respiration, cough and swallowing as well as a retention of tracheobronchial secretions. There is an increasing demand for RTs in neurology, in neurointensive care and in neurological and neurosurgical early rehabilitation. The certification of specialized centers for weaning in neurological and neurosurgical early rehabilitation was introduced by the German Society for Neurorehabilitation (DGNR) in 2021. As a certification criterion it includes the employment of a respiratory therapists. In neurological organizations treating critically and severely ill patients, RTs work at an important interdisciplinary intersection of physicians, nurses and therapists. RTs are qualified to train teams, patients and family caregivers and to establish care structures for critically and severely ill neurological patients. Due to the complexity of neurological illnesses RTs working in neurological institutions need specific qualification. Specific training for RTs in neurology and neurorehabilitation might improve care for critically and severely ill neurological patients. Further professionalization of RT in Germany requires standardizing curricula, a professional society for RTs and, finally, academization.

Cardioembolic stroke, the most common subtype of stroke in COVID 19: A single center experience from Isfahan, Iran

Background

Some studies showed the cerebrovascular manifestation in patients with recently pandemic coronavirus 2 named the coronavirus disease 2019 (COVID-19). However, there are rare reports about stroke subtypes in these patients. Here, we reported the stroke subtype in patients with laboratory-confirmed diagnosis of COVID-19 and treated at our hospitals, which are located in Isfahan, Iran.

Materials and Methods

This is a retrospective, observational case series. Data were collected from March 01, 2020, to May 20, 2020, at three designated special care centers for COVID-19 of Isfahan University of Medical Sciences. The study included 1188 consecutive hospitalized patients with laboratory-confirmed diagnosis of COVID-19.

Results

Of 1188 COVID-19 patients, 7 (0.5%) patients developed stroke. Five (0.4%) had ischemic arterial stroke, 1 (0.08%) hemorrhagic stroke and 1(0.08 %) cerebral venous and sinus thrombosis. Sixty percent of ischemic stroke were cardioembolic stroke (CE) and the rest 2 (40%) were embolic stroke of undetermined source. Three male patients (40%) had stroke as a presenting and admitted symptom of COVID-19. Four patients (57%) had severe COVID-19.

Conclusion

Stroke was an uncommon manifestation in COVID-19 patients. CE was a common subtype of stroke in COVID-19 patients in our centers.

COVID-19-Associated Cerebrovascular Events: A Case Series Study and a Literature Review of Possible Mechanisms

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.

Chronic Subdural Hematoma, Caused by Disseminated Intravascular Coagulation and/or Anticoagulation Therapy, after COVID-19

Chronic subdural hematoma (CSDH) typically develops in the supratentorial region in elderly patients. We treated a case of unilateral supratentorial and bilateral infratentorial CSDH, whereby the patient had a coronavirus disease 2019 (COVID-19) infection combined with disseminated intravascular coagulation 2 months earlier. The patient had not experienced any head trauma before the onset of the CSDH. The postoperative course was uneventful, and the patient experienced no neurological deficit. We propose that we should be aware not only of acute ischemic or hemorrhagic diseases after COVID-19 infection but also of chronic subdural hematoma caused by coagulopathy after a COVID-19 infection.

An update on angiotensin-converting enzyme 2 structure/functions, polymorphism, and duplicitous nature in the pathophysiology of coronavirus disease 2019: Implications for vascular and coagulation disease associated with severe acute respiratory syndrome coronavirus infection

It has been known for many years that the angiotensin-converting enzyme 2 (ACE2) is a cell surface enzyme involved in the regulation of blood pressure. More recently, it was proven that the severe acute respiratory syndrome coronavirus (SARS-CoV-2) interacts with ACE2 to enter susceptible human cells. This functional duality of ACE2 tends to explain why this molecule plays such an important role in the clinical manifestations of coronavirus disease 2019 (COVID-19). At the very start of the pandemic, a publication from our Institute (entitled "ACE2 receptor polymorphism: susceptibility to SARS-CoV-2, hypertension, multi-organ failure, and COVID-19 disease outcome"), was one of the first reviews linking COVID-19 to the duplicitous nature of ACE2. However, even given that COVID-19 pathophysiology may be driven by an imbalance in the renin-angiotensin system (RAS), we were still far from understanding the complexity of the mechanisms which are controlled by ACE2 in different cell types. To gain insight into the physiopathology of SARS-CoV-2 infection, it is essential to consider the polymorphism and expression levels of the ACE2 gene (including its alternative isoforms). Over the past 2 years, an impressive amount of new results have come to shed light on the role of ACE2 in the pathophysiology of COVID-19, requiring us to update our analysis. Genetic linkage studies have been reported that highlight a relationship between ACE2 genetic variants and the risk of developing hypertension. Currently, many research efforts are being undertaken to understand the links between ACE2 polymorphism and the severity of COVID-19. In this review, we update the state of knowledge on the polymorphism of ACE2 and its consequences on the susceptibility of individuals to SARS-CoV-2. We also discuss the link between the increase of angiotensin II levels among SARS-CoV-2-infected patients and the development of a cytokine storm associated microvascular injury and obstructive thrombo-inflammatory syndrome, which represent the primary causes of severe forms of COVID-19 and lethality. Finally, we summarize the therapeutic strategies aimed at preventing the severe forms of COVID-19 that target ACE2. Changing paradigms may help improve patients' therapy.

Portal vein thrombosis in patients with COVID-19: A systematic review

Several studies have proven that COVID-19 is linked to a higher incidence of different thrombotic events. Thrombosis of the portal vein can result in portal hypertension and can extend to the mesenteric vein resulting in intestinal ischemia. A search of PubMed, Web of Science, and Scopus for relevant studies revealed an association between PVT and COVID-19. This review is structured according to PRISMA guidelines. Thirty-three studies met the inclusion criteria. Twenty-nine case studies/series and four cohort/cross-sectional studies were included. Age at diagnosis was lower when compared to PVT due to cirrhosis. In cohort/cross-sectional studies, males comprised 54.83% of subjects, whereas in case reports/series, males comprised 62.1%. Obesity, asthma, hypertension, and diabetes were the most common comorbidities identified. The majority of the thrombotic events occurred within two weeks. The treatment aimed to prevent thrombus progression and improve recanalization. According to the evidence, early intervention prevents the poor prognosis of intestinal ischemia and its propagation.

Endothelial Dysfunction in COVID-19: Potential Mechanisms and Possible Therapeutic Options

SARS-CoV-2, a novel coronavirus found in Wuhan (China) at the end of 2019, is the etiological agent of the current pandemic that is a heterogeneous disease, named coronavirus disease 2019 (COVID-19). SARS-CoV-2 affects primarily the lungs, but it can induce multi-organ involvement such as acute myocardial injury, myocarditis, thromboembolic eventsandrenal failure. Hypertension, chronic kidney disease, diabetes mellitus and obesity increase the risk of severe complications of COVID-19. There is no certain explanation for this systemic COVID-19 involvement, but it could be related to endothelial dysfunction, due to direct (endothelial cells are infected by the virus) and indirect damage (systemic inflammation) factors. Angiotensin-converting enzyme 2 (ACE2), expressed in human endothelium, has a fundamental role in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. In fact, ACE2 is used as a receptor by SARS-CoV-2, leading to the downregulation of these receptors on endothelial cells; once inside, this virus reduces the integrity of endothelial tissue, with exposure of prothrombotic molecules, platelet adhesion, activation of coagulation cascades and, consequently, vascular damage. Systemic microangiopathy and thromboembolism can lead to multi-organ failure with an elevated risk of death. Considering the crucial role of the immunological response and endothelial damage in developing the severe form of COVID-19, in this review, we will attempt to clarify the underlying pathophysiological mechanisms.

Multiple ischemic stroke with pulmonary embolism revealing severe COVID-19 infection in a young healthy patient

Coronavirus 2019 (COVID-19) disease has caused significant morbidity and mortality worldwide since its emergence in December 2019. Despite its respiratory tropism; there is a nontrivial relationship between this virus and the neurovascular system exposing patients to higher morbidity and mortality. We report the case of a young patient admitted for hemiplegia with acute respiratory failure, in whom imaging found multiple ischemic strokes with pulmonary embolism and severe involvement suggestive of COVID-19 pneumopathy. Stroke in the context of COVID-19 infection has distinct characteristics in terms of disease mechanism, patient demographics, but also clinical, biological, and neuroradiological specificities. The pathogenesis and optimal management of COVID-19-associated ischemic stroke remain unclear, but the coagulopathy and endotheliopathy triggered by the cytokine storm represent possible target mechanisms.

Impact of the COVID-19 pandemic on changes in temperature-sensitive cardiovascular and respiratory disease mortality in Japan

Some cardiovascular and respiratory diseases are triggered by changes in ambient temperature or extremes of temperature. This study aimed to clarify the changes in mortality associated with temperature-sensitive diseases in Japan during the COVID-19 pandemic. We used data from three major cities (Sapporo City, Tokyo 23 wards, and Osaka City) from 2010 to 2019 to determine disease mortality rates and monthly mean temperatures from April to December. If the pandemic had not occurred in 2020, the results showed that temperature-sensitive disease death counts would have increased from 324 to 980, based on a 95% confidence interval estimated from the past 10 years in Sapporo (19-56% increase in actual deaths from 2020), from 651 to 2,653 in Tokyo (10-39% increase), and from 235 to 1,343 in Osaka (8-48% increase). Analyses of meshed population data during the COVID-19 pandemic indicated that inhibiting people's behaviour and outdoor mobility, especially in older men, caused a decrease in mortality.

Croatian study on COVID-19-positive stroke patients during the second wave of the pandemic

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.

SARS-COV-ATE risk assessment model for arterial thromboembolism in COVID-19

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.

COVID-19 neuropsychiatric repercussions: Current evidence on the subject

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has affected the entire world, causing the coronavirus disease 2019 (COVID-19) pandemic since it was first discovered in Wuhan, China in December 2019. Among the clinical presentation of the disease, in addition to fever, fatigue, cough, dyspnea, diarrhea, nausea, vomiting, and abdominal pain, infected patients may also experience neurological and psychiatric repercussions during the course of the disease and as a post-COVID-19 sequelae. Thus, headache, dizziness, olfactory and gustatory dysfunction, cerebrovascular disorders, neuromuscular abnormalities, anxiety, depression, and post-traumatic stress disorder can occur both from the infection itself and from social distancing and quarantine. According to current evidence about this infection, the virus has the ability to infect the central nervous system (CNS) via angiotensin-converting enzyme 2 (ACE2) receptors on host cells. Several studies have shown the presence of ACE2 in nerve cells and nasal mucosa, as well as transmembrane serine protease 2, key points for interaction with the viral Spike glycoprotein and entry into the CNS, being olfactory tract and blood-brain barrier, through hematogenous dissemination, potential pathways. Thus, the presence of SARS-CoV-2 in the CNS supports the development of neuropsychiatric symptoms. The management of these manifestations seems more complex, given that the dense parenchyma and impermeability of brain tissue, despite protecting the brain from the infectious process, may hinder virus elimination. Still, some alternatives used in non-COVID-19 situations may lead to worse prognosis of acute respiratory syndrome, requiring caution. Therefore, the aim of this review is to bring more current points related to this infection in the CNS, as well as the repercussions of the isolation involved by the pandemic and to present perspectives on interventions in this scenario.