Missed cerebrovascular events during prolonged sedation for COVID-19 pneumonia

Topographical Distribution of Neuroanatomical Abnormalities Following COVID-19 Invasion : A Systematic Literature Review

PURPOSE

This systematic review is aimed at synthesising the literature base to date on the frequency and topographical distribution of neuroanatomical changes seen on imaging following COVID-19 invasion with a focus on both the acute and chronic phases of the disease.

METHODS

In this study, 8 databases were systematically searched to identify relevant articles published from December 2019 to March 2022 and supplemented with a manual reference search. Data were extracted from the included studies and narrative synthesis was employed to integrate the findings.

RESULTS

A total of 110 studies met the inclusion criteria and comprised 119,307 participants (including 31,073 acute and 143 long COVID-19 patients manifesting neurological alterations) and controls. Considerable variability in both the localisation and nature of neuroanatomical abnormalities are noted along the continuum with a wide range of neuropathologies relating to the cerebrovascular/neurovascular system, (sub)cortical structures (including deep grey and white matter structures), brainstem, and predominant regional and/or global alterations in the cerebellum with varying degrees of spinal involvement.

CONCLUSION

Structural regional alterations on neuroimaging are frequently demonstrated in both the acute and chronic phases of SARS-CoV‑2 infection, particularly prevalent across subcortical, prefrontal/frontal and cortico-limbic brain areas as well as the cerebrovascular/neurovascular system. These findings contribute to our understanding of the acute and chronic effects of the virus on the nervous system and has the potential to provide information on acute and long-term treatment and neurorehabilitation decisions.

Strokes in Critically Ill COVID-19 Patients Diagnosed After Deep Sedation: A Single-Center Case Series

In the Philippines, acute cerebrovascular disease is a common neurologic complication in coronavirus disease 2019 (COVID-19) patients. Because of sedation and limited neurological examination, the diagnosis of stroke in critically ill patients with COVID-19 may be delayed. This retrospective analysis was done on the medical records of adult patients with critical COVID-19 in 2021-2022 who were brought to a tertiary hospital in the Philippines, placed on mechanical ventilation, and later discovered to have had an ischemic or hemorrhagic stroke while under deep sedation. The study aimed to explore the delayed diagnosis of cerebrovascular disease clinically concealed by deep sedation and emphasizes the importance of a collaborative, multi-specialty approach to managing such patients. There were nine patients with strokes discovered on imaging after deep sedation due to severe COVID-19 infection. The median age of the cases was 63 years, and 55.5% (n=5) were males. Three of the nine patients had an ischemic stroke with hemorrhagic conversion, three with ischemic infarction, and the other three had a primary intracerebral hemorrhage. This series shows a pattern of delayed diagnosis of cerebrovascular disease clinically concealed by deep sedation that was essential in managing acute respiratory distress syndrome in the background of severe COVID-19 infection before the emergence of severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2) variants and the discovery of COVID-19 vaccines. The study demonstrates the significance of managing this unique population of patients in a collaborative and multi-specialty manner. With the continuing threat of SARS-CoV-2 and its variants, there is a need to strike a balance between the risks of ischemic and hemorrhagic stroke in COVID-19 infection and the care of this patient population.

Monitoring of sedation in mechanically ventilated patients using remote technology

PURPOSE OF REVIEW

Two years of coronavirus disease 2019 (COVID-19) pandemic highlighted that excessive sedation in the ICU leading to coma and other adverse outcomes remains pervasive. There is a need to improve monitoring and management of sedation in mechanically ventilated patients. Remote technologies that are based on automated analysis of electroencephalogram (EEG) could enhance standard care and alert clinicians real-time when severe EEG suppression or other abnormal brain states are detected.

RECENT FINDINGS

High rates of drug-induced coma as well as delirium were found in several large cohorts of mechanically ventilated patients with COVID-19 pneumonia. In patients with acute respiratory distress syndrome, high doses of sedatives comparable to general anesthesia have been commonly administered without defined EEG endpoints. Continuous limited-channel EEG can reveal pathologic brain states such as burst suppression, that cannot be diagnosed by neurological examination alone. Recent studies documented that machine learning-based analysis of continuous EEG signal is feasible and that this approach can identify burst suppression as well as delirium with high specificity.

SUMMARY

Preventing oversedation in the ICU remains a challenge. Continuous monitoring of EEG activity, automated EEG analysis, and generation of alerts to clinicians may reduce drug-induced coma and potentially improve patient outcomes.

Stroke Treatment in the Era of COVID-19: a Review

Purpose of Review

To describe a comprehensive review of the epidemiology, pathophysiology, and treatment of stroke in the era of COVID-19.

Recent Findings

COVID-19 is associated with myriad neurological disorders, including cerebrovascular disease. While ischemic stroke is the most common, COVID-19 is associated with an increased risk of intracranial hemorrhage, arterial dissection, posterior reversible encephalopathy syndrome, and cerebral venous sinus thrombosis. In this review, we discuss the epidemiology, pathophysiology, and treatment of stroke due to COVID-19. In addition, we describe how COVID-19 has changed the landscape of stroke systems of care and the effect this has had on patients with cerebrovascular disease.

Summary

While COVID-19 is associated with a heightened risk of stroke, the pandemic has led to advances in stroke systems of care that may reduce the long-term burden of stroke.

Severe stroke in patients admitted to intensive care unit after COVID-19 infection: Pictorial essay of a case series

Patients infected by COVID-19 could require intensive care unit admission especially due to acute respiratory failure. However, neurological manifestations are very common. Among these, ischemic stroke or cerebral hemorrhage may have unfavorable outcome. The mechanisms leading to cerebral damage by SARS-CoV2 are still under debate. One of the most accepted theories implies an endothelial activation which in turns increase the risk of thrombus formation with the development of stroke, either ischemic or hemorrhagic. The more severe the COVID-19 disease, the higher the risk of stroke. Stroke in ICU patients are not frequent, but cerebral hemorrhage has devastating effects with high mortality. In these pictorial essay of case reports, main clinical aspects are discussed, along with a summary of the evidence about pathophysiology and treatment of these patients.

Associated Factors of High Sedative Requirements within Patients with Moderate to Severe COVID-19 ARDS

The coronavirus pandemic continues to challenge global healthcare. Severely affected patients are often in need of high doses of analgesics and sedatives. The latter was studied in critically ill coronavirus disease 2019 (COVID-19) patients in this prospective monocentric analysis. COVID-19 acute respiratory distress syndrome (ARDS) patients admitted between 1 April and 1 December 2020 were enrolled in the study. A statistical analysis of impeded sedation using mixed-effect linear regression models was performed. Overall, 114 patients were enrolled, requiring unusual high levels of sedatives. During 67.9% of the observation period, a combination of sedatives was required in addition to continuous analgesia. During ARDS therapy, 85.1% (n = 97) underwent prone positioning. Veno-venous extracorporeal membrane oxygenation (vv-ECMO) was required in 20.2% (n = 23) of all patients. vv-ECMO patients showed significantly higher sedation needs (p < 0.001). Patients with hepatic (p = 0.01) or renal (p = 0.01) dysfunction showed significantly lower sedation requirements. Except for patient age (p = 0.01), we could not find any significant influence of pre-existing conditions. Age, vv-ECMO therapy and additional organ failure could be demonstrated as factors influencing sedation needs. Young patients and those receiving vv-ECMO usually require increased sedation for intensive care therapy. However, further studies are needed to elucidate the causes and mechanisms of impeded sedation.

Sedation, Analgesia, and Muscle Relaxation During VV-ECMO Therapy in Patients With Severe Acute Respiratory Syndrome Coronavirus Type 2 (SARS-CoV-2): A Single-Center, Retrospective, Observational Study

Objective: The pharmacokinetics and pharmacodynamics of ECMO-supported sedative, analgesic, and muscle relaxants have changed, but there are insufficient data to determine the optimal dosing strategies for these agents. Sedation, analgesia and muscle relaxation therapy for patients with severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) receiving ECMO support are more specific and have not been fully reported. This study observed and evaluated the use of sedative and analgesic drugs and muscle relaxants in SARS-CoV-2 patients treated with VV-ECMO.

Methods: This study was a single-center, retrospective and observational study. Our study includes 8 SARS-CoV-2 patients treated with VV-ECMO in an intensive care unit at Shanghai Public Health Center from February to June 2020. We collected the demographic data from these patients and the dose and course of sedation, analgesia, and muscle relaxants administered during ECMO treatment.

Results: The doses of sedative, analgesic and muscle relaxant drugs used in patients with VV-ECMO were significant. Over time, the doses of drugs that were used were increased, and the course of muscle relaxant treatment was extended.

Conclusion: Sedation, analgesia, and muscle relaxant use require individualized titration in patients with SARS-CoV-2 who have respiratory failure and who are receiving VV-ECMO.