Stroke as a Neurological Complication of COVID-19: A Systematic Review and Meta-Analysis of Incidence, Outcomes and Predictors

COVID-19: Post infection implications in different age groups, mechanism, diagnosis, effective prevention, treatment, and recommendations

SARS-CoV-2 is a highly contagious pathogen that predominantly caused the COVID-19 pandemic. The persistent effects of COVID-19 are defined as an inflammatory or host response to the virus that begins four weeks after initial infection and persists for an undetermined length of time. Chronic effects are more harmful than acute ones thus, this review explored the long-term effects of the virus on various human organs, including the pulmonary, cardiovascular, and neurological, reproductive, gastrointestinal, musculoskeletal, endocrine, and lymphoid systems and found that SARS-CoV-2 adversely affects these organs of older adults. Regarding diagnosis, the RT-PCR is a gold standard method of diagnosing COVID-19; however, it requires specialized equipment and personnel for performing assays and a long time for results production. Therefore, to overcome these limitations, artificial intelligence employed in imaging and microfluidics technologies is the most promising in diagnosing COVID-19. Pharmacological and non-pharmacological strategies are the most effective treatment for reducing the persistent impacts of COVID-19 by providing immunity to post-COVID-19 patients by reducing cytokine release syndrome, improving the T cell response, and increasing the circulation of activated natural killer and CD8 T cells in blood and tissues, which ultimately reduces fever, nausea, fatigue, and muscle weakness and pain. Vaccines such as inactivated viral, live attenuated viral, protein subunit, viral vectored, mRNA, DNA, or nanoparticle vaccines significantly reduce the adverse long-term virus effects in post-COVID-19 patients; however, no vaccine was reported to provide lifetime protection against COVID-19; consequently, protective measures such as physical separation, mask use, and hand cleansing are promising strategies. This review provides a comprehensive knowledge of the persistent effects of COVID-19 on people of varying ages, as well as diagnosis, treatment, vaccination, and future preventative measures against the spread of SARS-CoV-2.

Management, risk factors and treatment outcomes of rhegmatogenous retinal detachment associated with giant retinal tears: scoping review

BACKGROUND

Rhegmatogenous retinal detachment (RRD) is a serious condition that occurs when the retina detaches from its underlying retinal pigment epithelium. RRDs associated with giant retinal tears (GRTs) are caused by retinal tears at least 90° or one-quarter of the circumferential extent. This scoping review systematically identifies and summarizes clinical studies evaluating surgical techniques for the management of GRT-related RRDs, discusses functional and visual outcomes and the risk factors affecting treatment outcomes.

METHODS

This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Scopus, Google Scholar, and Springer Link databases were searched for relevant papers (from January 2001 to March 2023). Studies that were published in the English language and reported the risk factors, management, and treatment outcomes of GRT-related RRDs were included in the review. The outcome measures included anatomic success rates, changes in BCVA (logMAR) from baseline to the final follow-up, and adverse events.

RESULTS

A total of 11,982 articles were identified. After the title and abstract review, 71 studies were deemed eligible for full-text review. Thirty-six studies that met the eligibility criteria were included in the final review. Four surgical techniques were identified: pars plana vitrectomy (PPV), combined PPV and scleral buckling, scleral buckling alone, and pneumatic retinopexy. Various types of tamponades, including gas, silicone oil, and air, have been used. PPV was the most commonly used surgical technique in 33.1-100% of patients. Among the 20 studies that used PPV alone, 17 were associated with preoperative PVR. In addition, scleral buckling alone or in combination with PPV was reported as a treatment option in 10 studies, with 2-100% of patients experiencing scleral buckling alone and 13.6-100% experiencing combined PPV and complementary scleral buckling. Primary anatomic success (PAS) was achieved with retinal reattachment via a single operation with no residual tamponade, whereas final anatomic success (FAS) was achieved via more than one operation with no residual tamponade. Reported single surgery anatomic success (SSAS) rates range from 65.51 to 100%. The preoperative best-corrected visual acuity (BCVA) ranged from 0.067 to 2.47 logMAR, whereas the postoperative BCVA ranged from 0.08 to 2.3 logMAR. An improvement in visual acuity was observed in 29 studies. Cataracts (3.9-28.3%) were the most common postoperative complication, followed by high IOP (0.01-51.2%) and PVR (0.8-31.57%).

CONCLUSION

PPV is the most common surgical technique, and currently microincision vitrectomy surgery (MIVS) systems are commonly employed. Silicone oil is the most frequently used tamponade in RRD repair. Risk factors for GRT-related RRD include age, sex, lens status, high myopia status, proliferative vitreoretinopathy (PVR), presenting visual acuity, the extent of the GRT and retinal detachment, and macular involvement. Future research areas include guidelines to reduce variability in the reporting of surgical methodology, choice of tamponades, and reporting of functional and visual outcomes to inform the best therapeutic interventions in GRT-related RRD.

Acute ischemic stroke outcomes in patients with COVID-19: a systematic review and meta-analysis

BACKGROUND

Although patients with COVID-19 have a higher risk of acute ischemic stroke (AIS), the impact on stroke outcomes remains uncertain.

AIMS

To determine the clinical outcomes of patients with AIS and COVID-19 (AIS-COVID+).

METHODS

We performed a systematic review and meta-analysis following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Our protocol was registered with the International Prospective Register of Systematic Reviews (CRD42020211977). Systematic searches were last performed on June 3, 2021 in EMBASE, PubMed, Web-of-Science, Scopus, and CINAHL Databases.

INCLUSION CRITERIA

(1) studies reporting outcomes on AIS-COVID+; (2) original articles published in 2020 or later; (3) study participants aged ≥18 years.

EXCLUSION CRITERIA

(1) case reports with <5 patients, abstracts, review articles; (2) studies analyzing novel interventions. Risk of bias was assessed using the Mixed Methods Appraisal Tool. Random-effects models estimated the pooled OR and 95% confidence intervals (95% CI) for mortality, modified Rankin Scale (mRS) score, length of stay (LOS), and discharge disposition.

RESULTS

Of the 43 selected studies, 46.5% (20/43) reported patients with AIS without COVID-19 (AIS-COVID-) for comparison. Random-effects model included 7294 AIS-COVID+ and 158 401 AIS-COVID-. Compared with AIS-COVID-, AIS-COVID+ patients had higher in-hospital mortality (OR=3.87 (95% CI 2.75 to 5.45), P<0.001), less mRS scores 0-2 (OR=0.53 (95% CI 0.46 to 0.62), P<0.001), longer LOS (mean difference=4.21 days (95% CI 1.96 to 6.47), P<0.001), and less home discharge (OR=0.31 (95% CI 0.21 to 0.47), P<0.001).

CONCLUSIONS

Patients with AIS-COVID had worse outcomes, with almost fourfold increased mortality, half the odds of mRS scores 0-2, and one-third the odds of home discharge. These findings confirm the significant impact of COVID-19 on early stroke outcomes.

Degree of COVID-19 severity and mortality in stroke: correlation of clinical and laboratory parameters

BACKGROUND

Stroke is one of the neurological manifestations of COVID-19, leading to a significant risk of morbidity and mortality. Clinical manifestations and laboratory parameters were investigated to determine mortality predictors in this case.

METHOD

The case control study was conducted at Dr. Sardjito General Hospital,Yogyakarta, Indonesia, with data collected between July 2020 and August 2021. All recorded clinical and laboratory data from acute stroke patients with confirmed COVID-19 were collected. Baseline characteristics, bivariate, and multivariate analyses were assessed to determine significant predictors for mortality.

RESULT

This study involved 72 subjects with COVID-19 and stroke. The majority experienced ischemic stroke, with hypertension as the most prevalent comorbidity. Notably, 45.8% of subjects (p < 0.05) loss of consciousness and 72.2% of exhibited motor deficits (p < 0.05). Severe degree of COVID-19 was observed in 52.8% of patients, with respiratory distress and death rates of 56.9% and 58.3%. Comparison of surviving and deceased groups highlighted significant differences in various clinical and laboratory characteristics differences. Hazard ratio (HR) analysis identified loss of consciousness (HR = 2.68; p = 0.01), motor deficit (HR = 2.34; p = 0.03), respiratory distress (HR = 81.51; p < 0.001), and monocyte count (HR:1.002; p = 0.04) as significant predictors of mortality.

CONCLUSION

Mortality in COVID-19 patients with stroke was significantly associated with loss of consciousness, motor deficit, respiratory distress, and raised monocyte count. The risk of mortality is heightened when multiple factors coexist.

A Systematic Review Unraveling the Intricate Neurological Spectrum of COVID-19: Manifestations, Complications, and Transformative Insights for Patient Care

The coronavirus disease 2019 (COVID-19) pandemic has strained global healthcare and financial infrastructures. Neurological manifestations of COVID-19 have gained recognition, emphasizing the need for comprehensive research in this area. This systematic review aims to comprehensively examine the neurological manifestations and complications associated with COVID-19 and assess their prevalence, impact on patient outcomes, and potential relationships with comorbidities, while emphasizing the significance of ongoing research in this field. We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) 2020 guidelines. A comprehensive search of PubMed, Google Scholar, Science Direct, and ResearchGate databases was conducted to identify eligible studies focusing on COVID-19 patients, reporting neurological symptoms or complications, and published between 2020 and 2022 in English. The data extracted is performed in a Microsoft Excel spreadsheet. Two independent reviewers assessed study quality and bias using the AMSTAR 2 scale before inclusion. This systematic includes 12 systematic reviews and meta-analysis with 191,412 participants and average age of 60 years. Neurological symptoms included headaches, dizziness, anosmia, and ageusia. Complications ranged from cerebrovascular events to Guillain-Barré syndrome. Comorbidities, such as hypertension and diabetes, exacerbated severity. Mortality rates associated with neurological manifestations varied from 29.1% to 84.8%. The study underscores the complex neurological impact of COVID-19, affecting patients across age groups. Ongoing research is vital to understand mechanisms and develop targeted interventions, improving patient care and addressing pandemic consequences. This review provides a holistic view of COVID-19's neurological effects, emphasizing the need for sustained research efforts and collaborative endeavors to combat the neurological issues.

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.

The Potential Role of Gender in the Incidence, Management, and Outcomes of Stroke in Patients Suffering From COVID-19: A Brief Review

Gender-disaggregated data are continuously needed in all aspects of the coronavirus disease 2019 (COVID-19) pandemic, including cerebrovascular disease in patients infected with SARS-CoV-2. This brief review was conducted to summarize available evidence and highlight potential sex differences regarding the incidence, applied therapies, and outcomes of stroke in patients with COVID-19. Local and global registries of such patients were included, where comparisons with historical (pre-pandemic era) and contemporary (stroke patients negative for SARS-CoV-2) cohorts formed the basis of the analysis. According to the herein reported evidence, the frequency of stroke under COVID-19 does not seem to vary according to gender, although a tendency toward male predominance cannot be excluded. In terms of management and outcomes, more advanced therapies are used in men. Follow-up data on gender differences are needed, as the pandemic is evolving (no lockdowns; new strains; vaccinated or naturally immune populations).

Effects of bundle-care interventions on pressure ulcers in patients with stroke: A meta-analysis

We conducted a meta-analysis to assess the effects of bundle-care interventions on pressure ulcers in patients with stroke to provide a basis for clinical work. Randomised controlled trials on the effects of bundle-care interventions in patients with stroke were identified using computerised searches of the PubMed, Embase, Cochrane Library, Chinese National Knowledge Infrastructure, VIP and Wanfang databases, from the time of inception of each database to July 2023, supplemented by manual literature searches. Two researchers independently retrieved and screened the articles, extracted the data and evaluated the quality of the included studies. After reaching consensus, meta-analysis was performed using RevMan 5.4. Twenty-four papers were included, involving 3330 patients of whom 1679 were in the intervention group and 1651 were in the control group. The results showed that, compared with standard care, bundle-care interventions significantly reduced the incidence of pressure ulcers (3.28% vs. 14.84%, odds ratio [OR]: 0.19, 95% confidence interval [CI]: 0.14-0.26, p < 0.001), and aspiration (5.60% vs. 18.84%, OR: 0.25, 95% CI: 0.17-0.39, p < 0.001), and improved patient satisfaction with nursing care (96.59% vs. 84.43%, OR. 5.45, 95% CI: 3.76-7.90, p < 0.001). Current evidence suggests that care bundles are significantly better than conventional nursing measures in preventing pressure ulcers and aspiration, and improving patient satisfaction with nursing care in patients with stroke, and are worthy of clinical promotion and application.

Application of the ICF and OTPF-4 to Conceptualize the Dual Diagnosis of COVID-19 and Stroke: Implications for Occupational Therapy Practice in Acute and Inpatient Rehabilitation

There is mounting evidence that the vascular manifestations associated with COVID-19 are linked to ischemic strokes. The emergence of patients with both COVID-19 and cerebrovascular accidents (COV-CVA) has created a need to adjust occupational therapy service delivery for inpatients with this dual diagnosis. This clinical perspective paper conceptualizes COV-CVA as a health condition using the International Classification of Functioning, Disability and Health Framework (ICF). The Occupational Therapy Practice Framework-4 was used to guide clinical considerations and recommendations for the evaluation, intervention, and discharge planning of patients with COV-CVA.

Alexander M, A. Campbell R, Grandhi R. Endovascular mechanical thrombectomy in a child with COVID-19: Clot analysis reveals a novel pathway in the neuroinflammatory cascade resulting in large-vessel occlusion

Large-vessel occlusion is rare in children, but its results can be devastating and may lead to recurrent strokes, persistent neurological deficits, and decreased quality of life. Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has yielded extrapulmonary effects and multiorgan diseases, many of which are neurological manifestations. There is a paucity of literature in pediatric patients about large-vessel occlusion in the setting of COVID-19 infection. We discuss a nine-year-old child who presented with a left middle cerebral artery occlusion and underwent revascularization with a Thrombolysis in Cerebral Infarction grade 3 reperfusion approximately three weeks after COVID-19 diagnosis. The patient harbored concerning signs and symptoms of multisystem inflammatory syndrome in children. This case emphasizes the importance of recognizing SARS-CoV-2 and the propensity for thrombosis in a delayed fashion, which can lead to severe stroke in young people.

Mortality and Outcomes in Cerebrovascular Disease Patients With Emphasis on COVID-19: A Cross-Sectional Analysis of the National Inpatient Sample 2020

Background COVID-19-related pulmonary complications have been explored extensively in the recent past. There is also a significant amount of literature on the neurological manifestations of COVID-19. However, there exists an unmet need to assess the impact of COVID-19 on patients with cerebrovascular diseases and its role in affecting mortality in such patients. Methods In this cross-sectional study, we analyzed 401,318 hospitalized patients with cerebrovascular diseases using the discharge data from the National Inpatient Sample 2020 to assess the association of COVID-19 with multiple clinical conditions, along with additional factors, such as length of stay in the hospital, total charges incurred, region and type of hospital, and primary insurance/payer in the United States of America. We used a multivariable logistic regression model to predict factors relating to mortality in such patients. Results The mortality during hospitalization in patients with cerebrovascular disease who were also diagnosed with COVID-19 was significantly higher than the patients without COVID-19 (22.50% vs 5.44%, p-value <0.0001). COVID-19 independently increased the odds of death significantly in patients with cerebrovascular diseases (adjusted OR = 4.81, p-value <0.0001). Other statistically and clinically significant factors that contributed to increased odds of mortality in such patients were comorbidities such as moderate/severe liver disease, myocardial infarction, congestive heart failure, and complications such as the development of a saddle pulmonary embolus. Conclusion COVID-19 was associated with higher mortality in patients with cerebrovascular diseases. It also significantly increased the duration of hospital stay and odds of mortality in such patients.

An Increased Risk for Ischemic Stroke in the Short-Term Period following COVID-19 Infection: A Nationwide Population-Based Study

INTRODUCTION

The association disclosed between coronavirus disease 2019 (COVID-19) infection and ischemic stroke (IS) raises concern. The exact risk periods, which were not consistent between studies, require further investigation.

METHODS

We linked two national databases: the COVID-19 database and the Israeli National Stroke Registry. The self-controlled case series method was used to estimate the association between COVID-19 infection and a first IS. The study population included all Israeli residents who had both a first IS event and a first COVID-19 diagnosis during 2020. The date of the PCR test served to define the day of exposure, and the 28 days following it were categorized into three risk periods: days 1-7, 8-14, and 15-28. A relative incidence (RI) with a 95% confidence interval (95% CI) was calculated based on the incidence rate of events in a post-exposure period, compared to the incidence rate in a control period.

RESULTS

From January 1, 2020, to December 31, 2020, 308,015 Israelis aged 18+ were diagnosed with COVID-19 and 9,535 were diagnosed with a first IS. Linking the two databases, 555 persons had both diagnoses during 2020. The mean age of the study population was 71.5 ± 13.7, 55.1% were males, 77.8% had hypertension, 73.7% had hyperlipidemia, 51.9% had diabetes, and 28.5% had ischemic heart disease. Comparing the risk period and the control period, we found a very similar distribution of the cardiovascular risk factors. The risk for an acute IS was 3.3-fold higher in the first week following COVID-19 diagnosis, compared with a control period (RI = 3.3; 95% CI: 2.3-4.6). The RI among males (RI = 4.5; 95% CI: 2.9-6.8) was 2.2-fold higher compared to females. The increased risk did not last beyond the first week following exposure.

CONCLUSION

Physicians should be aware of the elevated risk for IS among patients experiencing COVID-19, particularly among men with high burden of cardiovascular risk factors.

Post-COVID-19 Syndrome Mechanisms, Prevention and Management

As the population of patients recovering from COVID-19 grows, post COVID-19 challenges are recognizing by ongoing evidences at once. Long COVID is defined as a syndrome with a range of persistent symptoms that remain long after (beyond 12 weeks) the acute SARS-CoV-2 infection. Studies have shown that long COVID can cause multi-organ damages with a wide spectrum of manifestations. Many systems, but not limited to, including respiratory, cardiovascular, nervous, gastrointestinal, and musculoskeletal systems, are involved in long COVID. Fatigue and dyspnea are the most common symptoms of long COVID. Long COVID-19 may be driven by tissue damage caused by virus-specific pathophysiologic changes or secondary to pathological long-lasting inflammatory response because of viral persistence, immune dysregulation, and autoimmune reactions. Some risk factors like sex and age, more than five early symptoms, and specific biomarkers have been revealed as a probable long COVID predicator discussed in this review. It seems that vaccination is the only way for prevention of long COVID and it can also help patients who had already long COVID. Managing long COVID survivors recommended being in a multidisciplinary approach, and a framework for identifying those at high risk for post-acute COVID-19 must be proposed. Possible therapeutic options and useful investigation tools for follow-up are suggested in this review. In sum, as evidence and researches are regularly updated, we provide the current understanding of the epidemiology, clinical manifestation, suspected pathophysiology, associated risk factors, and treatment options of long COVID in this review.

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).

Prevalence and Mortality Risk of Neurological Disorders during the COVID-19 Pandemic: An Umbrella Review of the Current Evidence

INTRODUCTION

Coronavirus disease 2019 (COVID-19), a global pandemic, has infected approximately 10% of the world's population. This comprehensive review aimed to determine the prevalence of various neurological disorders in COVID-19 without overlapping meta-analysis errors.

METHODS

We searched for meta-analyses on neurological disorders following COVID-19 published up to March 14, 2023. We obtained 1,184 studies, of which 44 meta-analyses involving 9,228,588 COVID-19 patients were finally included. After confirming the forest plot of each study and removing overlapping individual studies, a re-meta-analysis was performed using the random-effects model.

RESULTS

The summarized combined prevalence of each neurological disorder is as follows: stroke 3.39% (95% confidence interval, 1.50-5.27), dementia 6.41% (1.36-11.46), multiple sclerosis 4.00% (2.50-5.00), epilepsy 5.36% (-0.60-11.32), Parkinson's disease 0.67% (-1.11-2.45), encephalitis 0.66% (-0.44-1.77), and Guillain-Barré syndrome 3.83% (-0.13-7.80). In addition, the mortality risk of patients with comorbidities of COVID-19 is as follows: stroke OR 1.63 (1.23-2.03), epilepsy OR 1.71 (1.00-2.42), dementia OR 1.90 (1.31-2.48), Parkinson's disease OR 3.94 (-2.12-10.01).

CONCLUSION

Our results show that the prevalence and mortality risk may increase in some neurological diseases during the COVID-19 pandemic. Future studies should elucidate the precise mechanisms for the link between COVID-19 and neurological diseases, determine which patient characteristics predispose them to neurological diseases, and consider potential global patient management.

Extracardiac Prothrombotic Effects of COVID-19

COVID-19 infection triggers a heightened inflammatory response which in turn, increases thrombosis and thromboembolism. Microvascular thrombosis has been detected in various tissue beds which may account for some of the multi-system organ dysfunction associated with COVID-19. Additional research is needed to understand which prophylactic and therapeutic drug regimens are best for the prevention and treatment of thrombotic complications of COVID-19.

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.

Neurologic Complications of Patients With COVID-19 Requiring Extracorporeal Membrane Oxygenation: A Systematic Review and Meta-Analysis

In COVID-19 patients requiring extracorporeal membrane oxygenation (ECMO), our primary objective was to determine the frequency of intracranial hemorrhage (ICH). Secondary objectives were to estimate the frequency of ischemic stroke, to explore association between higher anticoagulation targets and ICH, and to estimate the association between neurologic complications and in-hospital mortality.

DATA SOURCES

We searched MEDLINE, Embase, PsycINFO, Cochrane, and MedRxiv databases from inception to March 15, 2022.

STUDY SELECTION

We identified studies that described acute neurological complications in adult patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection requiring ECMO.

DATA EXTRACTION

Two authors independently performed study selection and data extraction. Studies with 95% or more of its patients on venovenous or venoarterial ECMO were pooled for meta-analysis, which was calculated using a random-effects model.

DATA SYNTHESIS

Fifty-four studies (n = 3,347) were included in the systematic review. Venovenous ECMO was used in 97% of patients. Meta-analysis of ICH and ischemic stroke on venovenous ECMO included 18 and 11 studies, respectively. The frequency of ICH was 11% (95% CI, 8-15%), with intraparenchymal hemorrhage being the most common subtype (73%), while the frequency of ischemic strokes was 2% (95% CI, 1-3%). Higher anticoagulation targets were not associated with increased frequency of ICH (p = 0.06). In-hospital mortality was 37% (95% CI, 34-40%) and neurologic causes ranked as the third most common cause of death. The risk ratio of mortality in COVID-19 patients with neurologic complications on venovenous ECMO compared with patients without neurologic complications was 2.24 (95% CI, 1.46-3.46). There were insufficient studies for meta-analysis of COVID-19 patients on venoarterial ECMO.

CONCLUSIONS

COVID-19 patients requiring venovenous ECMO have a high frequency of ICH, and the development of neurologic complications more than doubled the risk of death. Healthcare providers should be aware of these increased risks and maintain a high index of suspicion for ICH.

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.

[The alleged mechanisms of olfactory disorders in the new coronavirus infection]

In March 2020, the World Health Organization (WHO) announced the beginning of the COVID-19 pandemic, which continues to the present. A change in the sense of smell, up to the complete disappearance of odors, is regarded as one of the early symptoms of the disease. Sometimes anosmia was the only sign of infection of the patient. As is known, a disturbance of the sense of smell indicates a serious pathology of the brain, such as the consequences of traumatic brain injuries, strokes, Alzheimer's disease, Parkinson's disease, autoimmune diseases, a side-effect of drug therapy. The review is dedicated to the pathogenesis of anosmia in COVID-19. For a better understanding of the pathogenesis, the article presents a brief anatomy and physiology of the olfactory organ as well as the probable mechanisms of anosmia: encephalitis, inflammatory edema of the olfactory cleft, olfactory epithelium damage, apoptosis of bipolar neurons, damage of olfactory cell cilia and damage of olfactory bulbs. Because of the rapid accumulation of information on this topic, there is a need to structure, periodic systematization and presentation to a wide range of specialists.

Comparative features and outcomes of major neurological complications of COVID-19

BACKGROUND AND PURPOSE

The aim of this study was to assess the neurological complications of SARS-CoV-2 infection and compare phenotypes and outcomes in infected patients with and without selected neurological manifestations.

METHODS

The data source was a registry established by the European Academy of Neurology during the first wave of the COVID-19 pandemic. Neurologists collected data on patients with COVID-19 seen as in- and outpatients and in emergency rooms in 23 European and seven non-European countries. Prospective and retrospective data included patient demographics, lifestyle habits, comorbidities, main COVID-19 complications, hospital and intensive care unit admissions, diagnostic tests, and outcome. Acute/subacute selected neurological manifestations in patients with COVID-19 were analysed, comparing individuals with and without each condition for several risk factors.

RESULTS

By July 31, 2021, 1523 patients (758 men, 756 women, and nine intersex/unknown, aged 16-101 years) were registered. Neurological manifestations were diagnosed in 1213 infected patients (79.6%). At study entry, 978 patients (64.2%) had one or more chronic general or neurological comorbidities. Predominant acute/subacute neurological manifestations were cognitive dysfunction (N = 449, 29.5%), stroke (N = 392, 25.7%), sleep-wake disturbances (N = 250, 16.4%), dysautonomia (N = 224, 14.7%), peripheral neuropathy (N = 145, 9.5%), movement disorders (N = 142, 9.3%), ataxia (N = 134, 8.8%), and seizures (N = 126, 8.3%). These manifestations tended to differ with regard to age, general and neurological comorbidities, infection severity and non-neurological manifestations, extent of association with other acute/subacute neurological manifestations, and outcome.

CONCLUSIONS

Patients with COVID-19 and neurological manifestations present with distinct phenotypes. Differences in age, general and neurological comorbidities, and infection severity characterize the various neurological manifestations of COVID-19.

Mechanisms, Effects, and Management of Neurological Complications of Post-Acute Sequelae of COVID-19 (NC-PASC)

With a growing number of patients entering the recovery phase following infection with SARS-CoV-2, understanding the long-term neurological consequences of the disease is important to their care. The neurological complications of post-acute sequelae of SARS-CoV-2 infection (NC-PASC) represent a myriad of symptoms including headaches, brain fog, numbness/tingling, and other neurological symptoms that many people report long after their acute infection has resolved. Emerging reports are being published concerning COVID-19 and its chronic effects, yet limited knowledge of disease mechanisms has challenged therapeutic efforts. To address these issues, we review broadly the literature spanning 2020-2022 concerning the proposed mechanisms underlying NC-PASC, outline the long-term neurological sequelae associated with COVID-19, and discuss potential clinical interventions.

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.

COVID-19 independently predicts poor outcomes in Acute Ischemic Stroke- Insights from a multicenter study from Pakistan and United Arab Emirates

BACKGROUND

Ischemic stroke associated with coronavirus 2019 (COVID-19) has been well recognized by now. Few studies have compared COVID related versus unrelated strokes. We intend to report on a large group of Asian patients from two countries and compare COVID with non-COVID strokes admitted during the same time period.

METHODS

Consecutive cases of acute ischemic stroke either presenting or developing, between March 2020 and December 2021 in four tertiary care hospitals (1 in Dubai, UAE and 3 in Karachi, Pakistan) and testing positive for COVID-19 were included in the study. Patients admitted with ischemic stroke during the same time period and who tested negative for COVID-19 were also randomly selected from the four hospitals. All data was collected from the medical records of the patients and recorded on a standard questionnaire before it was entered in SPSS version 21 for analysis.

RESULTS

There were 139 COVID positive and 271 COVID negative patients with acute ischemic stroke included in the current study. There were significantly more males (80.6% vs 64.9%, p=0.001) and more large vessel strokes in the COVID positive group (41% vs 21.8%, p<0.001). Being COVID positive was an independent predictor of poor outcome at discharge, defined as a modified Rankin score of 3-6 (OR 3.87, 95% CI 2.21-6.77) after adjusting for country, age, sex, vascular comorbid conditions and stroke subtype.

CONCLUSIONS

In this largest series of patients with COVID related strokes from Asia, COVID-19 was an independent predictor of poor outcomes at discharge after adjusting for other variables.

Outcome and characteristics of COVID-19 patients associated with stroke: a multicenter hospital-based study in Egypt

Background

 Nearly 55 percent of patients are said to be affected by the neurological effects of COVID-19. COVID-19 was shown to be related with stroke in 0.9 to 5% of people. It's critical to assess the impact of COVID-19 on the outcomes of acute ischemic stroke. The goal of this study was to look at the outcomes and characteristics of patients who had an acute ischemic stroke due to covid-19 infection.

Results

 The participants in this study were 399 people who had had a stroke. COVID-19 positivity was confirmed in 77 cases, while COVID-19 negativity was confirmed in 322. In the COVID-19 and control groups, the average age of the patients was 65.4 ± 10.2 and 65.3 ± 11.8, respectively. The Covid-19 and control groups had a mean stroke onset of 5.2 ± 2.1 and 5.7 ± 3.8 h, respectively (P = 0.12). There was a high in-hospital mortality rate among patients with COVID-19 with a rate of 11.7% compared to 4.04% among the control group (P = 0.02). At discharge, the number of patients with mRS > 2 was higher (P = 0.001) among the COVID-19. There was a correlation between the mean levels of D-Dimer (r = 0.668, P < 0.001), the severity of COVID-19 (r = 0.802, P < 0.001), and mRS > 2.

Conclusion

Despite receiving equal acute care as non-COVID-19 patients, COVID-19 patients had more severe strokes and had worse outcomes. This includes a high chance of death while in the hospital as well as a significant level of disability. Neurologists should use timely and effective therapies, particularly for patients who are at a higher risk of having a stroke. This includes elderly patients, patients with severe COVID-19, patients with high levels of D-Dimer, and those with high NIHSS.

Does COVID-19 Escalate Aging Process? A Possible Concern

A key challenge after the COVID-19 pandemic will be managing the long-term sequelae for the millions of individuals who recover from the disease. Based on the available evidence, our hypothesis is that the SARS-CoV-2 pandemic and its long-term complications will lead to premature aging (in terms of health) of many people in the world. Obviously, to maintain appropriate public health and prevent poor health-care services, countries should think and plan about the health problems and the long-term consequences of SARS-CoV-2 after controlling the COVID-19 pandemic.

Is Myasthenia Gravis a Real Complication of the COVID-19 Vaccine? A Case Report-Based Systematic Review

Background

Myasthenia gravis (MG) is a neuromuscular, autoimmune disease that causes weakness by impairing neuromuscular transmission. According to reports, vaccines can lead to autoimmunity in different ways, and COVID-19 vaccines are suggested to trigger MG. We conducted this systematic review to assess MG patients after the COVID-19 vaccination.

Methods

We collected 231 studies from four databases from inception to 26 March 2022.

Results

4 case studies were selected from 231 research studies, and data were extracted based on inclusion criteria. In all cases, MG was reported following COVID-19 vaccination. Symptoms such as muscle weakness, numbness, and ptosis were common. The MG was confirmed through RNST, MRC, NCS, and AchR-binding antibody titer tests.

Conclusion

Although all cases of MG were diagnosed following appropriate tests, the sample size was small; therefore, further investigation is required to demonstrate the possible association between MG and COVID-19 vaccination.

Oculomotor, vestibular, reaction time, and cognitive tests as objective measures of neural deficits in patients post COVID-19 infection

Objective

An alarming proportion (>30%) of patients affected by SARS-CoV-2 (COVID-19) continue to experience neurological symptoms, including headache, dizziness, smell and/or taste abnormalities, and impaired consciousness (brain fog), after recovery from the acute infection. These symptoms are self-reported and vary from patient to patient, making it difficult to accurately diagnose and initiate a proper treatment course. Objective measures to identify and quantify neural deficits underlying the symptom profiles are lacking. This study tested the hypothesis that oculomotor, vestibular, reaction time, and cognitive (OVRT-C) testing using eye-tracking can objectively identify and measure functional neural deficits post COVID-19 infection.

Methods

Subjects diagnosed with COVID-19 (n = 77) were tested post-infection with a battery of 20 OVRT-C tests delivered on a portable eye-tracking device (Neurolign Dx100). Data from 14 tests were compared to previously collected normative data from subjects with similar demographics. Post-COVID subjects were also administered the Neurobehavioral Symptom Inventory (NSI) for symptom evaluation.

Results

A significant percentage of post COVID-19 patients (up to 86%) scored outside the norms in 12 out of 14 tests, with smooth pursuit and optokinetic responses being most severely affected. A multivariate model constructed using stepwise logistic regression identified 6 metrics as significant indicators of post-COVID patients. The area under the receiver operating characteristic curve (AUC) was 0.89, the estimated specificity was 98% (with cutoff value of 0.5) and the sensitivity was 88%. There were moderate but significant correlations between NSI domain key variables and OVRT-C tests.

Conclusions

This study demonstrates the feasibility of OVRT-C testing to provide objective measures of neural deficits in people recovering from COVID-19 infection. Such testing may serve as an efficient tool for identifying hidden neurological deficits post COVID-19, screening patients at risk of developing long COVID, and may help guide rehabilitation and treatment strategies.

Efficacy and safety of recanalization therapy for acute ischemic stroke with COVID-19: A systematic review and meta-analysis

Background

The novel coronavirus disease 2019 (COVID-19) has rapidly spread worldwide and created a tremendous threat to global health. Growing evidence suggests that patients with COVID-19 have more severe acute ischemic stroke (AIS). However, the overall efficacy and safety of recanalization therapy for AIS patients infected by the SARS-CoV-2 virus is unknown.

Methods

The PRISMA guideline 2020 was followed. Two independent investigators systematically searched databases and ClinicalTrials.gov to identify relevant studies published up to 31 March 2022. AIS patients who received any recanalization treatments were categorized into those with COVID-19 and those without COVID-19. The main efficacy outcomes were patients' functional independence on discharge and successful recanalization, and the safety outcomes were in-hospital mortality and symptomatic intracranial hemorrhage. Subgroup analyses were implemented to assess the influence of admission National Institutes of Health Stroke Scale and different recanalization treatments on the outcomes. STATA software 12.0 was used for the statistical analysis.

Results

This systematic review and meta-analysis identified 10 studies with 7,042 patients, including 596 COVID-19 positive patients and 6,446 COVID-19 negative patients. Of the total patients, 2,414 received intravenous thrombolysis while 4,628 underwent endovascular thrombectomy. COVID-19 positive patients had significantly lower rates of functional independence at discharge [odds ratio (OR) 0.30, 95% confidence interval (CI) 0.15 to 0.59, P = 0.001], lower rates of successful recanalization (OR 0.40, 95% CI 0.24 to 0.68, P = 0.001), longer length of hospital stay (weighted mean difference 5.09, 95% CI 1.25 to 8.94, P = 0.009) and higher mortality rates (OR 3.38, 95% CI 2.43 to 4.70, P &lt; 0.0001). Patients with COVID-19 had a higher risk of symptomatic intracranial hemorrhage than the control group, although the difference did not reach statistical significance (OR 2.34, 95% CI 0.99 to 5.54, P = 0.053).

Conclusions

Compared with COVID-19 negative AIS patients who received recanalization treatments, COVID-19 positive patients turned out to have poorer outcomes. Particular attention needs to be paid to the treatments for these COVID-19 patients to decrease mortality and morbidity. Long-term follow-up is necessary to evaluate the recanalization treatments for AIS patients with COVID-19.

Systematic review registration

https://inplasy.com/inplasy-2022-4-0022/, identifier: INPLASY202240022.

Vessel wall imaging in COVID-19 associated carotid atherothrombosis and stroke: a case report and literature review

COVID-19 associated neurological syndromes, including acute ischemic stroke, pose a challenge to treating physicians. The role of MRI in aiding diagnosis and further management is indispensable. The advent of new MRI sequences such as vessel wall imaging (VWI) allows an avenue in which these patients could be better investigated and treated. We describe our experience in managing a patient with COVID-19 associated atherothrombosis and stroke, focusing on the VWI imaging findings.

The impact of COVID 19 on the outcomes of thrombectomy in stroke patients: A systematic review and meta-analysis

We aimed to conduct the current meta-analysis to provide better insight into the efficacy of mechanical thrombectomy (MT) in managing COVID-19 patients suffering from a stroke. An electronic search was conducted through eight databases for collecting the current evidence about the efficacy of MT in stroke patients with COVID-19 until 18 December 2021. The results were reported as the pooled prevalence rates and the odds ratios (ORs), with their corresponding 95% confidence intervals (CI). Out of 648 records, we included nine studies. The prevalence of stroke patients with COVID-19 who received MT treatment was with TICI ≥2b 79% (95%CI: 73-85), symptomatic intracranial haemorrhage 6% (95%CI: 3-11), parenchymal haematoma type 1, 11.1% (95%CI: 5-23), and mortality 29% (95%CI: 24-35). On further comparison of MT procedure between stroke patients with COVID 19 to those without COVID-19, we found no significant difference in terms of TICI ≥2b score (OR: 0.85; 95%CI: 0.03-23; p = 0.9). However, we found that stroke patients with COVID-19 had a significantly higher mortality rate than stroke patients without COVID-19 after MT procedure (OR: 2.99; 95%CI: 2.01-4.45; p < 0.001). Stroke patients with COVID-19 can be safely and effectively treated with MT, with comparable reperfusion and complication rates to those without the disease.

SARS-CoV-2 Brain Regional Detection, Histopathology, Gene Expression, and Immunomodulatory Changes in Decedents with COVID-19

Brains of 42 COVID-19 decedents and 107 non-COVID-19 controls were studied. RT-PCR screening of 16 regions from 20 COVID-19 autopsies found SARS-CoV-2 E gene viral sequences in 7 regions (2.5% of 320 samples), concentrated in 4/20 subjects (20%). Additional screening of olfactory bulb (OB), amygdala (AMY) and entorhinal area for E, N1, N2, RNA-dependent RNA polymerase, and S gene sequences detected one or more of these in OB in 8/21 subjects (38%). It is uncertain whether these RNA sequences represent viable virus. Significant histopathology was limited to 2/42 cases (4.8%), one with a large acute cerebral infarct and one with hemorrhagic encephalitis. Case-control RNAseq in OB and AMY found more than 5000 and 700 differentially expressed genes, respectively, unrelated to RT-PCR results; these involved immune response, neuronal constituents, and olfactory/taste receptor genes. Olfactory marker protein-1 reduction indicated COVID-19-related loss of OB olfactory mucosa afferents. Iba-1-immunoreactive microglia had reduced area fractions in cerebellar cortex and AMY, and cytokine arrays showed generalized downregulation in AMY and upregulation in blood serum in COVID-19 cases. Although OB is a major brain portal for SARS-CoV-2, COVID-19 brain changes are more likely due to blood-borne immune mediators and trans-synaptic gene expression changes arising from OB deafferentation.

Blockchain Assisted Disease Identification of COVID-19 Patients with the Help of IDA-DNN Classifier

Globally, millions of people were affected by the Corona-virus disease-2019 (COVID-19) causing loads of deaths. Most COVID-19 affected people recover in a few spans of weeks. However, certain people even those with a milder variant of the disease persist in experiencing symptoms subsequent to their initial recuperation. Here, a novel Block-Chain (BC)-assisted optimized deep learning algorithm, explicitly improved dragonfly algorithm based Deep Neural Network (IDA-DNN), is proposed for detecting the different diseases of the COVID-19 patients. Initially, the input data of the COVID-19 recovered patients are gathered centered on their post symptoms and their data is amassed as a BC for rendering security to the patient's data. After that, the disease identification of the patient's data is performed with the aid of system training. The training includes '4' disparate datasets for data collection, and then, performs preprocessing, Feature Extraction (FE), Feature Reduction (FR), along with classification utilizing ID-DNN on the gathered inputted data. The IDA-DNN classifies '2' classes (presence of disease and absence of disease) for every type of data. The proposed method's outcomes are examined as well as contrasted with the other prevailing techniques to corroborate that the proposed IDA-DNN detects the COVID-19 more efficiently.

Prognostic indicators and outcomes of hospitalised COVID-19 patients with neurological disease: An individual patient data meta-analysis

Background

Neurological COVID-19 disease has been reported widely, but published studies often lack information on neurological outcomes and prognostic risk factors. We aimed to describe the spectrum of neurological disease in hospitalised COVID-19 patients; characterise clinical outcomes; and investigate factors associated with a poor outcome.

Methods

We conducted an individual patient data (IPD) meta-analysis of hospitalised patients with neurological COVID-19 disease, using standard case definitions. We invited authors of studies from the first pandemic wave, plus clinicians in the Global COVID-Neuro Network with unpublished data, to contribute. We analysed features associated with poor outcome (moderate to severe disability or death, 3 to 6 on the modified Rankin Scale) using multivariable models.

Results

We included 83 studies (31 unpublished) providing IPD for 1979 patients with COVID-19 and acute new-onset neurological disease. Encephalopathy (978 [49%] patients) and cerebrovascular events (506 [26%]) were the most common diagnoses. Respiratory and systemic symptoms preceded neurological features in 93% of patients; one third developed neurological disease after hospital admission. A poor outcome was more common in patients with cerebrovascular events (76% [95% CI 67–82]), than encephalopathy (54% [42–65]). Intensive care use was high (38% [35–41]) overall, and also greater in the cerebrovascular patients. In the cerebrovascular, but not encephalopathic patients, risk factors for poor outcome included breathlessness on admission and elevated D-dimer. Overall, 30-day mortality was 30% [27–32]. The hazard of death was comparatively lower for patients in the WHO European region.

Interpretation

Neurological COVID-19 disease poses a considerable burden in terms of disease outcomes and use of hospital resources from prolonged intensive care and inpatient admission; preliminary data suggest these may differ according to WHO regions and country income levels. The different risk factors for encephalopathy and stroke suggest different disease mechanisms which may be amenable to intervention, especially in those who develop neurological symptoms after hospital admission.

Reperfusion Therapies for Acute Ischemic Stroke in COVID-19 Patients: A Nationwide Multi-Center Study

(1) Background: Acute ischemic stroke (AIS) is a possible complication of the coronavirus disease 2019 (COVID-19). Safety and efficacy data on reperfusion therapies (RT)—intravenous thrombolysis and endovascular treatment (EVT)—in stroke patients with COVID-19 is lacking. (2) Methods: We performed a retrospective nationwide multi-center pair-matched analysis of COVID-19 patients with AIS who underwent RT. We included adult COVID-19 patients with AIS who were treated with RT between 16 March 2020 and 30 June 2021. All subjects were paired with non-infected controls, matched for age, sex, stroke arterial vascular territory, and RT modality. The primary outcome measure was a favorable functional outcome defined by the modified Rankin scale (mRS 0–2). (3) Results: Thirty-one subjects and thirty-one matched controls were included. The median baseline National Institutes of Health Stroke Scale (NIHSS) score was higher in the COVID-19 group (16 vs. 12, p = 0.028). Rates of ischemic changes and symptomatic intracerebral hemorrhages did not differ significantly between the two groups at 24 h after RT. The median NIHSS 24 h after reperfusion remained significantly higher in the COVID-19 group (16 vs. 5, p = 0.003). MRS 0–2 at discharge was significantly less common in COVID-19 patients (22.6% vs. 51.8%, p = 0.018). Three-month mortality was 54.8% in the COVID-19 group versus 12.9% in controls (p = 0.001). (4) Conclusion: Reperfusion therapies on AIS in COVID-19 patients appear to be safe; however, functional outcomes are significantly worse, and 3-month mortality is higher.

Perspective: The Case for Acute Large Vessel Ischemic Stroke in COVID-19 Originating Within Thrombosed Pulmonary Venules

The main burden of SARS-CoV-2 falls on the lungs but neurological manifestations, the most disabling of which are strokes and which correlate with disease severity, are common. We proffer a novel mechanism for acute COVID-19 stroke whereby pulmonary vein clots developing within the characteristic pulmonary intravascular thrombotic lesions can embolize to the brain. Appreciation of this mechanism requires an understanding of the tricompartmental model of lung parenchyma oxygenation (the alveolus, the bronchial artery, and the pulmonary artery), all of which are compromised in COVID-19. Of these 3 sources, the bronchial artery plays a crucial role in COVID-19 stroke because the unique collaterals from bronchial artery to pulmonary vein which exist under normal physiological conditions (and which maintain venous patency when the pulmonary artery is blocked by embolus) are occluded, thus leading to venular thrombosis in the presence of hypercoagulability. Dislodgement of clots from this source translocates the pathology to the brain and is a disease mechanism, formerly rare, which may account for many cases of large vessel occlusion stroke in COVID-19. This mechanism extends the concept of cardioembolic stroke from endocardium retrogradely into the pulmonary circulation with which the left cardiac chambers lie in direct continuity, and which is an accepted stroke mechanism under other circumstances such as lung lobectomy, where surgical ligation of the pulmonary vein creates a blind sac from which thrombi can embolize. The proposed model is supported by postmortem studies which have demonstrated venular thrombosis and by case reports of pulmonary vein thrombosis in COVID-19. This concept provides a more plausible cause for COVID-19 associated large vessel occlusion stroke than other putative mechanisms, such as cerebral endotheliitis, cytokine storm, and hypercoagulopathy, although it is acknowledged that the latter mechanism contributes to the genesis of pulmonary vein clots. Recognizing that extrapulmonary manifestations including stroke arise within thrombosed pulmonary veins is key to understanding of neurological manifestations of SARS-CoV-2 infection.

Impact of COVID-19 pandemic on acute stroke admissions and case-fatality rate in lower-income and middle-income countries: a protocol for systematic review and meta-analysis

INTRODUCTION

The current review primarily aims to ascertain the impact of COVID-19 on stroke admission as well as stroke case fatality in Low-income and Middle-Income Countries (LMICs).

METHODS AND ANALYSIS

Four international databases (PubMed/Medline, Google Scholar, African Journals Online, Latin American and Caribbean Health Sciences Literature) and one preprint database (medRxiv). Studies will be included if they are conducted in LMICs, all stroke types without age and language restriction, from December 2019 to 31 December 2021. Two authors will screen the titles and abstracts against the prespecified eligibility criteria for inclusion in the review, and then repeat the process after retrieving the full text. Joanna Briggs critical appraisal checklist for analytical cross-sectional studies will be used for the quality assessment and risk of bias by two coauthors. The characteristics of the studies will be presented and summarised in a table. We aim to perform meta-analyses on a pooled proportional change in acute stroke admissions and case fatality with 95% CI using a random-effects meta-analysis. Publication bias will be assessed using funnel plot and Egger's regression test if ≥10 studies are involved. A sub group analysis will be performed to determine the sources of heterogeneity. Leave-one-out sensitivity analysis will be performed to examine the impact of a single study on the overall pool estimate.

ETHICS AND DISSEMINATION

Ethical approval is not required as this is secondary research and will use reported data in scientific literature. A full manuscript will be submitted to a reputable peer-review journal for publication and disseminated electronically and in print.

PROSPERO REGISTRATION NUMBER

CRD42021281580.

COVID-19 and the Brain

Entering the third year into the pandemic, overwhelming evidence demonstrates that Coronavirus disease 2019 (COVID-19) infection is a systemic illness, often with involvement of the central nervous system. Multiple mechanisms may underlie the development of neurologic manifestations of illness, including hypoxia, systemic illness, hypercoagulability, endothelial dysfunction, general critical illness, inflammatory response, and neurotropism of the severe acute respiratory syndrome coronavirus 2 (SARS-Co-V2) virus. COVID-19 infection is associated with neurologic involvement in all stages; acute infection, subacute/post-infection, and growing evidence also suggests during a chronic phase, the post-acute sequalae of COVID-19 (PASC). With over 20,000 published articles on COVID and the brain at the time of writing, it is virtually impossible to present an unbiased comprehensive review of how SARS-Co-V2 impacts the nervous system. In this review, we will present an overview of common neurologic manifestations, in particular focusing on the cerebrovascular complications, and proposed pathophysiology.

Emerging Knowledge of the Neurobiology of COVID-19

Many patients with COVID-19 will experience acute or longer-term neuropsychiatric complications. The neurobiological mechanisms behind these are beginning to emerge; however, the neurotropic hypothesis is not strongly supported by clinical data. The inflammatory response to SARS-CoV-2 is likely to be responsible for delirium and other common acute neuropsychiatric manifestations. Vascular abnormalities such as endotheliopathies contribute to stroke and cerebral microbleeds, with their attendant neuropsychiatric sequelae. Longer-term neuropsychiatric syndromes fall into 2 broad categories: neuropsychiatric deficits occurring after severe (hospitalized) COVID-19 and "long COVID," which occurs in many patients with a milder acute COVID-19 illness.

Acute cerebrovascular events in severe and nonsevere COVID-19 patients: a systematic review and meta-analysis

The degree to which COVID-19 severity influences the development of acute cerebrovascular events (ACVE) is unknown. Therefore, we aimed to describe the prevalence and risk of ACVE in patients with severe and nonsevere COVID-19. We systematically reviewed MEDLINE, EMBASE, Web of Science, and Scopus and identified observational and interventional studies of patients with COVID-19 allocated by respiratory severity that reported ACVE development. Case reports/series were excluded. The main outcome assessed was the pooled rate of ACVE in patients with severe and nonsevere COVID-19. To determine the risk of ACVE development by COVID-19 severity, a meta-analysis was performed. PROSPERO registration number: CRD42020178905. About 19 of 5758 identified studies were analyzed. From 11,886 COVID-19 patients analyzed, 421 had at least one ACVE [3.6%, 95% confidence interval (CI) 2.904-4.179]. Severe COVID-19 increased the risk of ACVE (odds ratio 1.96, 95% CI 1.22-3.15; P = 0.005; I ² = 64%), specifically hemorrhagic stroke (4.12, 2.0-8.53; P = 0.001; I ² = 0%). There was no difference in the risk of developing ischemic stroke between patients with severe and nonsevere COVID-19 (1.53, 0.87-2.7; P = 0.14; I ² = 52%). From the patients who developed any ACVE, those with severe COVID-19 had a greater mortality risk than those with nonsevere COVID-19 (3.85, 1.08-13.70; P = 0.04; I ² = 0%). The main limitations of our study were the heterogeneity found in the main meta-analysis studies and in their reported definition for COVID-19 severity. In conclusion, our findings provide evidence that COVID-19 respiratory severity could lead to ACVE development that increases mortality. The effect of COVID-19 management in ACVE needs to be evaluated.

Risk of ischemic stroke in patients with COVID-19 infection: A systematic review and meta-analysis

An ongoing global pandemic, the coronavirus disease 2019 is posing threat to people all over the world. The association between COVID-19 and the risk of ischemic stroke remains unclear. This study systematically reviewed published studies and conducted meta-analysis to evaluate the association between the risk of ischemic stroke and COVID-19. This study was conducted according to guidelines from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The protocol used in this study had been registered in the International Prospective Register of Systematic Reviews. EMBASE, PubMed, Cochrane Library and Web of Science were searched from 1st December 2019–19th February 2021. This systematic review and meta-analysis analysed the combined effect estimations based on odds ratios (OR) with the random-effects model. Four studies were screened from 31,634 participants including 171 COVID-19 positive patients with ischemic stroke were included. The mean age of COVID-19 positive patients with ischemic stroke was 69.45 years (Range: 63–77 years) and the male patients were 56%. Countries covered by these articles were USA, Italy and France. Three of the articles were retrospective cohort studies and one was prospective cohort study. Our analysis revealed that the risk of ischemic stroke (combined OR: 2.41; 95% CI: 1.08–5.38) was significantly increased. Four included studies were significantly heterogeneous (I2 = 75.2%, P = 0.007). Significant association between the risk of ischemic stroke and COVID-19 was observed in the North America group (combined OR: 2.90; 95% CI: 0.45–18.80, I2 = 89.60%, P = 0.002). This study found that the risk for ischemic stroke was increased in COVID-19 patients, especially in patients from North America. Further studies with larger sample sizes that include different ethnic populations are required to confirm our analysis.

Coronavirus infections from 2002-2021: Neuropsychiatric Manifestations

Coronaviruses have been known to infect humans for several decades and there are four endemic subtypes: HCoV (human coronavirus) −229E, -NL63, -OC43 and -HKU1. These mainly cause a mild upper respiratory illness, but occasionally in vulnerable individuals they can result in more severe respiratory disease and, rarely, CNS involvement. Prior exposure to these viruses has also been associated with an increased odds of having a major psychiatric illness. The severe acute respiratory syndrome (SARS), caused by SARS-CoV, started in 2002 and, as well as causing a more severe respiratory phenotype, was also associated with delirium and affective symptoms acutely. Psychosis occurred in about 1% of individuals and was generally thought to be due to corticosteroid administration. The Middle East respiratory syndrome (MERS), caused by MERS-CoV, revealed similar findings. Survivors of both SARS and MERS reported persistent physical and psychological symptoms at least several months after the acute illness. The reported neuropsychiatric symptoms of COVID-19 range from the common symptoms of systemic and upper respiratory infections to severe and disabling conditions. Delirium has been described using varying terminology; as well as being a possible presenting feature of COVID-19, it has also been shown to be a marker of severe disease. Stroke, both ischaemic and haemorrhagic, have been reported to be more common in COVID-19 than in other medical illnesses. Mood and anxiety disorders are likely to be common at follow-up, while psychosis remains rare and controversial. ‘Long Covid’ is likely to represent a highly clinically and aetiologically heterogeneous group.

Immune-mediated neurological syndrome in SARS-CoV-2 infection: a review of literature on autoimmune encephalitis in COVID-19

INTRODUCTION

The novel Coronavirus Disease 2019 (COVID-19) is an infection caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) which has been spreading rapidly amongst humans and causing a global pandemic. The notorious infection has shown to cause a wide spectrum of neurological syndrome, including autoimmune encephalitis.

OBJECTIVE

Here, we systematically review the literature on autoimmune encephalitis that developed in the background of SARS-CoV-2 infections and also the possible pathophysiological mechanisms of auto-immune mediated damage to the nervous system.

METHODOLOGY

An exhaustive search was made in Medline/PubMed, Embase, Scopus and other medical databases, and 28 relevant published articles were selected according to the strict inclusion criteria.

RESULTS

Autoimmune encephalitis can occur via three possible proposed pathophysiological mechanism and can manifest during or after the acute infection period. It is more common in adult but can also occur in the paediatric patients. There were various spectra of autoantibody panels reported including antineuronal antibody, anti-gangliosides antibody and onconeural antibody. Majority of the patients responded well to the immunomodulating therapy and achieved good recovery.

CONCLUSION

In conclusion, SARSCoV-2 infection can induce various spectrum of autoimmune encephalitis. It is a major concern since there is very limited long-term study on the topic. Hence, this review aims to elucidate on the potential long-term complication of SARS-CoV-2 infection and hopefully to improve the management and prognosis of COVID-19.

Prevalence of Atrial Fibrillation and Associated Mortality Among Hospitalized Patients With COVID-19: A Systematic Review and Meta-Analysis

Background: Epidemiological studies have shown that atrial fibrillation (AF) is a potential cardiovascular complication of coronavirus disease 2019 (COVID-19). We aimed to perform a systematic review and meta-analysis to clarify the prevalence and clinical impact of AF and new-onset AF in patients with COVID-19. Methods: PubMed, Embase, the Cochrane Library, and MedRxiv up to February 27, 2021, were searched to identify studies that reported the prevalence and clinical impact of AF and new-onset AF in patients with COVID-19. The study was registered with PROSPERO (CRD42021238423). Results: Nineteen eligible studies were included with a total of 21,653 hospitalized patients. The pooled prevalence of AF was 11% in patients with COVID-19. Older (≥60 years of age) patients with COVID-19 had a nearly 2.5-fold higher prevalence of AF than younger (<60 years of age) patients with COVID-19 (13 vs. 5%). Europeans had the highest prevalence of AF (15%), followed by Americans (11%), Asians (6%), and Africans (2%). The prevalence of AF in patients with severe COVID-19 was 6-fold higher than in patients with non-severe COVID-19 (19 vs. 3%). Furthermore, AF (OR: 2.98, 95% CI: 1.91 to 4.66) and new-onset AF (OR: 2.32, 95% CI: 1.60 to 3.37) were significantly associated with an increased risk of all-cause mortality among patients with COVID-19. Conclusion: AF is quite common among hospitalized patients with COVID-19, particularly among older (≥60 years of age) patients with COVID-19 and patients with severe COVID-19. Moreover, AF and new-onset AF were independently associated with an increased risk of all-cause mortality among hospitalized patients with COVID-19.

Analysis of COVID-19 Infection and Mortality Among Patients With Psychiatric Disorders, 2020

IMPORTANCE

People with major psychiatric disorders are more likely to have comorbidities associated with worse outcomes of COVID-19. This fact alone could determine greater vulnerability of people with major psychiatric disorders to COVID-19.

OBJECTIVE

To assess the odds of testing positive for and mortality from COVID-19 among and between patients with schizophrenia, mood disorders, anxiety disorders and a reference group in a large national database.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used an electronic health record data set aggregated from many national sources in the United States and licensed from Optum with current and historical data on patients tested for COVID-19 in 2020. Three psychiatric cohorts (patients with schizophrenia, mood disorders, or anxiety disorders) were compared with a reference group with no major psychiatric conditions. Statistical analysis was performed from March to April 2021.

EXPOSURE

The exposures observed include lab-confirmed positivity for COVID-19 and mortality.

MAIN OUTCOMES AND MEASURES

The odds of testing positive for COVID-19 in 2020 and the odds of death from COVID-19 were measured.

RESULTS

The population studied included 2 535 098 unique persons, 3350 with schizophrenia, 26 610 with mood disorders, and 18 550 with anxiety disorders. The mean (SD) age was 44 (23) years; 233 519 were non-Hispanic African American, 1 583 440 were non-Hispanic Caucasian; and 1 580 703 (62%) were female. The schizophrenia cohort (positivity rate: 9.86%; adjusted OR, 0.90 [95% CI, 0.84-0.97]) and the mood disorder cohort (positivity rate: 9.86%; adjusted OR, 0.93 [95% CI, 0.87-0.99]) had a significantly lower rate of positivity than the anxiety disorder cohort (positivity rate: 11.17%; adjusted OR, 1.05 [95% CI, 0.98-1.12) which was closer to the reference group (11.91%). After fully adjusting for demographic factors and comorbid conditions, patients with schizophrenia were nearly 4 times more likely to die from the disease than the reference group (OR, 3.74; 95% CI, 2.66-5.24). The mood disorders COVID-19 cohort had a 2.76 times greater odds of mortality than the reference group (OR, 2.76; 95% CI, 2.00-3.81), and the anxiety disorders cohort had a 2.39 times greater odds of mortality than the reference group (OR, 2.39; 95% CI, 1.68-3.27).

CONCLUSIONS AND RELEVANCE

By examining a large database while controlling for multiple confounding factors such as age, race and ethnicity, and comorbid medical conditions, the present study found that patients with schizophrenia had much increased odds of mortality by COVID-19.

Descriptive analysis of Acute Ischemic stroke in COVID-19 patients through the course of the COVID-19 pandemic

Coronavirus disease 2019 (COVID-19) has been associated with Acute Ischemic Stroke (AIS). Here, we characterize our institutional experience with management of COVID-19 and AIS. Baseline demographics, clinical, imaging, and outcomes data were determined in patients with COVID-19 and AIS presenting within March 2020 to October 2020, and November 2020 to August 2021, based on institutional COVID-19 hospitalization volume. Of 2512 COVID-19 patients, 35 (1.39%, mean age 63.3 years, 54% women) had AIS. AIS recognition was frequently delayed after COVID-19 symptoms (median 19.5 days). Four patients (11%) were on therapeutic anticoagulation at AIS recognition. AIS mechanism was undetermined or due to multiple etiologies in most cases (n = 20, 57%). Three patients underwent IV TPA, and three underwent mechanical thrombectomy, of which two suffered re-occlusion. Three patients had incomplete mRNA vaccination course. Fourteen (40%) died, with 26 (74%) having poor outcomes. Critical COVID-19 severity was associated with worsened mortality (p = 0.02). More patients (12/16; 75%) had either worsened or similar 3-month functional outcomes, than those with improvement, indicating the devastating impact of co-existing AIS and COVID-19. Comparative analysis showed that patients in the later cohort had earlier AIS presentation, fewer stroke risk factors, more comprehensive workup, more defined stroke mechanisms, less instance of critical COVID-19 severity, more utilization of IV TPA, and a trend towards worse outcomes for the sub-group of mild-to-moderate COVID-19 severity. AIS incidence, NIHSS, and overall outcomes were similar. Further studies should investigate outcomes beyond 3 months and their predictive factors, impact of completed vaccination course, and access to neurologic care.

Neurological Complications of Pulmonary Embolism: a Literature Review

PURPOSE OF REVIEW

The present review discusses in-depth about neurological complications following acute venous thromboembolism (VTE).

RECENT FINDINGS

Intracranial hemorrhage, acute ischemic cerebrovascular events, and VTE in brain tumors are described as central nervous system (CNS) complications of PE, while peripheral neuropathy and neuropathic pain are reported as peripheral nervous system (PNS) sequelae of PE. Syncope and seizure are illustrated as atypical neurological presentations of PE. Mounting evidence suggests higher risk of venous thromboembolism (VTE) in patients with neurological diseases, but data on reverse, i.e., neurological sequelae following VTE, is underexplored. The present review is an attempt to explore some of the latter issues categorized into CNS, PNS, and atypical complications following VTE.