Cerebrovascular Manifestations of SARS-CoV-2: A Comprehensive Review

Trends in the Diagnosis of Pediatric Venous Thromboembolism and Arterial Ischemic Stroke during the COVID-19 Pandemic: An Administrative Database Study

OBJECTIVE

To investigate trends in the diagnosis of venous thromboembolism (VTE) and arterial ischemic stroke (AIS), and examine the use of pharmacological thromboprophylaxis during the COVID-19 pandemic.

STUDY DESIGN

This retrospective cohort study used the Pediatric Health Information Systems database to investigate patients admitted to a participating hospital between January 1, 2018, and December 31, 2021. International Classification of Diseases, 10th edition codes were used to identify VTE, AIS, and COVID-19. Pharmacy billing codes were used to investigate pharmacological thromboprophylaxis use.

RESULTS

1 759 701 unique patients underwent 2 234 135 inpatient admissions. Rate of VTE increased from 84 cases per 10 000 admissions in 2018-2019 to 108 cases per 10 000 admissions in 2020-2021, representing a 28.6% increase (P < .001). In contrast, the rate of AIS remained stable through the study period. When compared with 2018-2019, children diagnosed with VTE during 2020-2021 had longer hospitalizations and were more likely to be admitted to the intensive care unit. When analysis was limited to 2020-2021, a diagnosis code of COVID-19 was associated with a 1.35-fold (95% CI: 1.24-1.45) increase in the odds of VTE diagnosis, but not AIS. Use of pharmacologic thromboprophylaxis increased from 1.5% of hospitalizations in 2018-2019 to 3.0% of hospitalizations in 2020-2021 (P < .001). When evaluating thromboprophylaxis during 2020-2021, a diagnosis code for COVID-19 was associated with an 11-fold (95% CI: 10.86-11.49; P < .001) increase in the utilization of pharmacological thromboprophylaxis.

CONCLUSIONS

This study found an increase in the rate of VTE among hospitalized children during the pandemic. A diagnosis of COVID-19 was associated with a modest increase in odds of VTE diagnosis, which occurred despite increased use of pharmacological thromboprophylaxis.

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.

COVID-19 Infection Is Associated With Poor Outcomes in Patients With Intracerebral Hemorrhage

BACKGROUND

Patients with ischemic stroke and concomitant COVID-19 infection have worse outcomes than those without this infection, but the impact of COVID-19 on hemorrhagic stroke remains unclear. We aimed to assess if COVID-19 worsens outcomes in intracerebral hemorrhage (ICH).

METHODS AND RESULTS

We conducted an observational study of ICH outcomes using Get With The Guidelines Stroke data. We compared patients with ICH who were COVID-19 positive and negative during the pandemic (March 2020-February 2021) and prepandemic (March 2019-February 2020). Main outcomes were poor functional outcome (defined as a modified Rankin scale score of 4 to 6 at discharge), mortality, and discharge to a skilled nursing facility or hospice. The first stage included 60 091 patients with ICH who were COVID-19 negative and 1326 COVID-19 positive. In multivariable analyses, patients with ICH with versus without COVID-19 infection had 68% higher odds of poor outcome (odds ratio [OR], 1.68 [95% CI, 1.41-2.01]), 51% higher odds of mortality (OR, 1.51 [95% CI, 1.33-1.71]), and 66% higher odds of being discharged to a skilled nursing facility/hospice (OR, 1.66 [95% CI, 1.43-1.93]). The second stage included 62 743 prepandemic and 64 681 intrapandemic cases with ICH. In multivariable analyses, patients with ICH admitted during versus before the COVID-19 pandemic had 10% higher odds of poor outcomes (OR, 1.10 [95% CI, 1.07-1.14]), 5% higher mortality (OR, 1.05 [95% CI, 1.02-1.08]), and no significant difference in the risk of being discharged to a skilled nursing facility/hospice (OR, 0.93 [95% CI, 0.90-0.95]).

CONCLUSIONS

The pathophysiology of the COVID-19 infection and changes in health care delivery during the pandemic played a role in worsening outcomes in the patient population with ICH.

Association between SARS-CoV-2 Seropositivity and Severity of Out-of-Hospital Acute Ischemic Stroke Following Asymptomatic/Mild COVID-19 in Children

Objective This article investigates the frequency of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) seropositivity and its association with the severity of new-onset acute ischemic stroke (AIS) among previously healthy children with asymptomatic/mild coronavirus disease 2019 (COVID-19).

Methods A case–control study that included children < 18 years with out-of-hospital AIS of undetermined etiology and a control group of healthy children. Exclusion criteria were current respiratory symptoms, previous COVID-19 diagnosis, prior COVID-19 vaccination, active SARS-CoV-2 infection, history of hospital admission in the last 6 months, and having a stroke predisposition. We screened children for SARS-CoV-2 immunoglobulin G antibodies using enzyme-linked immunosorbent assay. The severity of stroke was evaluated using the Pediatric National Institutes of Health Stroke Scale (PedNIHSS).

Results The current study included 25 children (15 males and 10 females; median age 24 months) with out-of-hospital AIS and 25 healthy controls (11 males and 14 females; median age 24 months). SARS-CoV-2 seropositivity was detected in 15 (60%) of AIS children and 11 (44%) among controls (p = 0.258). Compared with seronegative AIS children, those seropositive for SARS-CoV-2 had higher PedNIHSS scores (median 19 vs. 8.5; p = 0.001), pediatric intensive care unit admission (93.3% vs. 40%; p = 0.007), need for mechanical ventilation (53.3% vs. 10%; p = 0.040), and D-dimer levels (median 3.5 vs. 1.75 μg/mL; p < 0.001).

Conclusion SARS-CoV-2 seropositivity may be associated with more severe AIS affecting previously healthy children during the postacute phase of asymptomatic/mildly symptomatic COVID-19.

Thrombotic complications in children with Coronavirus disease 2019 and Multisystem Inflammatory Syndrome of Childhood

Coronavirus disease 2019 (COVID-19) associated coagulopathy is multifactorial and involves inflammation driven hypercoagulability, endothelial dysfunction, platelet activation, and impaired fibrinolysis. Hospitalized adults with COVID-19 are at an increased risk of both venous thromboembolism and ischemic stroke, resulting in adverse outcomes, including increased mortality. Although COVID-19 in children follows a less severe course, both arterial and venous thromboses have been reported in hospitalized children with COVID-19. Additionally, some children develop a postinfectious, hyperinflammatory illness termed multisystem inflammatory syndrome of childhood (MIS-C), which is also associated with hypercoagulability and thrombosis. Several randomized trials have evaluated the safety and efficacy of antithrombotic therapy in adults with COVID-19, although similar pediatric data are lacking. In this narrative review, we discuss the postulated pathophysiology of COVID-19 coagulopathy and summarize principal findings of the recently completed adult trials of antithrombotic therapy. We provide an up-to-date summary of pediatric studies investigating the rate of venous thromboembolism and ischemic stroke in COVID-19 and multisystem inflammatory syndrome of childhood in addition to reviewing the findings of the single, nonrandomized pediatric trial investigating the safety of prophylactic anticoagulation. Lastly, we outline adult and pediatric consensus guidelines on the use of antithrombotic therapy in this cohort. A detailed discussion of the practical implementation and current limitations of published data will hopefully address the knowledge deficits surrounding the use of antithrombotic therapy in children with COVID-19 and generate hypotheses for future research.

Age and sex-specific stroke epidemiology in COVID-19

Background

COVID-19 has emerged as an independent risk factor for stroke. We aimed to determine age and sex-specific stroke incidence and risk factors with COVID-19 in the US using a large electronic health record (EHR) that included both inpatients and outpatients.

Methods

A retrospective cohort study was conducted using individual-level data from Optum® de-identified COVID-19 EHR. A total of 387,330 individuals aged ≥18 with laboratory-confirmed COVID-19 between March 1, 2020 and December 31, 2020 were included. The primary outcome was cumulative incidence of stroke after COVID-19 confirmation within 180 days of follow-up or until death. Kaplan-Meier cumulative incidence curves for acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), and a composite outcome of all strokes were stratified by sex and age, and the differences in curves were assessed using a log-rank test. The relative risk of stroke by demographics and risk factors was estimated using multivariable Cox-proportional hazards regressions and adjusted hazard ratios (aHRs).

Results

Of 387,330 COVID-19 patients, 2,752 patients (0.71%, 95% CI 0.68-0.74) developed stroke during the 180-day follow-up, AIS in 0.65% (95% CI 0.62-0.67), and ICH in 0.11% (95% CI 0.10-0.12). Of strokes among COVID-19 patients, 57% occurred within 3 days. Advanced age was associated with a substantially higher stroke risk, with aHR 6.92 (5.72-8.38) for ages 65-74, 9.42 (7.74-11.47) for ages 75-84, and 11.35 (9.20-14.00) for ages 85 and older compared to ages 18-44 years. Men had a 32% higher risk of stroke compared to women. African-American [aHR 1.78 (1.61-1.97)] and Hispanic patients [aHR 1.48 (1.30-1.69)] with COVID-19 had an increased risk of stroke compared to white patients.

Conclusion

This study has several important findings. AIS and ICH risk in patients with COVID-19 is highest in the first 3 days of COVID-19 positivity; this risk decreases with time. The incidence of stroke in patients with COVID-19 (both inpatient and outpatient) is 0.65% for AIS and 0.11% for ICH during the 180-day follow-up. Traditional stroke risk factors increase the risk of stroke in patients with COVID-19. Male sex is an independent risk factor for stroke in COVID-19 patients across all age groups. African-American and Hispanic patients have a higher risk of stroke from COVID-19.