Outcomes and Spectrum of Major Neurovascular Events Among COVID-19 Patients: A 3-Center Experience

Cerebral small vessel disease pathology in COVID-19 patients: A systematic review

Cerebral small vessel disease (CSVD) is the leading cause of vascular cognitive impairment and is associated with COVID-19. However, contributing factors that often accompany CSVD pathology in COVID-19 patients may influence the incidence of cerebrovascular complications. Thus, a mechanism linking COVID-19 and CSVD has yet to be uncovered and differentiated from age-related comorbidities (i.e., hypertension), and medical interventions during acute infection. We aimed to evaluate CSVD in acute and recovered COVID-19 patients and to differentiate COVID-19-related cerebrovascular pathology from the above-mentioned contributing factors by assessing the localization of microbleeds and ischemic lesions/infarctions in the cerebrum, cerebellum, and brainstem. A systematic search was performed in December 2022 on PubMed, Web of Science, and Embase using a pre-established search criterion related to history of, or active COVID-19 with CSVD pathology in adults. From a pool of 161 studies, 59 met eligibility criteria and were included. Microbleeds and ischemic lesions had a strong predilection for the corpus callosum and subcortical/deep white matter in COVID-19 patients, suggesting a distinct CSVD pathology. These findings have important implications for clinical practice and biomedical research as COVID-19 may independently, and through exacerbation of age-related mechanisms, contribute to increased incidence of CSVD.

Stringent public health measures during COVID-19 across ischemic stroke care systems: the potential impact of patient perceptions on health care-seeking behaviors

Decreases in acute stroke presentations have been reported during the coronavirus disease 2019 (COVID-19) pandemic surges. A recent study by Bojti et al. (GeroScience. 2021;43:2231–2248) sought to understand the relationship of public health mandates in Hungary as they were implemented with acute ischemic stroke admissions and interventions during two separate COVID-19 waves. We sought to perform a similar analysis of changes in ischemic stroke care at two distinct medical institutions in the USA. Two separate institutions and systems of ischemic stroke care were evaluated through a regional comprehensive stroke center telestroke service and a Veterans Affairs (VA) inpatient stroke and neurorehabilitation service. Telestroke consultations in a single system in Chicago, IL, were significantly decreased during the first COVID-19 wave during severely restricted public health mandates (z-score <  − 2), and were less depressed during a subsequent wave with less severe restrictions (z-score approaching − 1), which resembles findings in Hungary as reported by Bojti et al. In contrast, inpatient admissions during the first and second COVID-19 waves to a VA stroke and neurorehabilitation service in Oklahoma City remained unchanged. The Chicago and Hungary patterns of stroke presentations suggest that public perceptions, as informed by regional health mandates, might influence healthcare-seeking behavior. However, the VA experience suggests that specific patient populations may react differently to given public health mandates. These observations highlight that changes in stroke presentation during the COVID-19 pandemic may vary regionally and by patient population as well as by the severity of public health mandates implemented. Further study of COVID-19-related public health policies on acute stroke populations is needed to capture the long-term impact of such policies. Learning from the real-time impact of pandemic surges and public health policy on presentation of acute medical conditions, such as ischemic stroke, may prove valuable for designing effective policies in the future.

COVID-19 Associated Wake-Up Stroke Treated With DWI/FLAIR Mismatch Guided Intravenous Alteplase: A Case Report

INTRODUCTION

Wake-up strokes are challenging to manage due to unknown time of onset. Recently, the wake-up trial demonstrated that recombinant tissue plasminogen activator (rtPA) could be administered based on the magnetic resonance imaging (MRI)- diffusion weighted imaging/fluid attenuated inversion recovery mismatch. Many still doubt the safety results due to the higher rate of hemorrhagic conversion reported. Although it was statistically insignificant, the study was terminated early. Furthermore, Corona virus disease-19 is associated with coagulopathy and a higher risk of hemorrhagic conversion.

CASE REPORT

A 46-year-old fully functioning male presented with a wake-up right hemiparesis, right facial droop, and expressive aphasia. His National Institute of Health Stroke Scale was 4 upon arrival. Last known well state was >4.5 hours. He tested positive for SARS-CoV-2 viral infection. He had left distal-M2 occlusion. He was deemed not a candidate for rtPA. Hyperacute-MRI protocol showed diffusion weighted imaging/fluid attenuated inversion recovery mismatch. The patient received rtPA at 6.5 hours from the last knwn well state. Follow-up MRI-susceptibility weighted imaging revealed fragmented clot. The stroke burden was less than that shown on the initial computed tomography-perfusion scans implying saved penumbra. There was no hemorrhagic conversion despite low fibrinogen levels.

CONCLUSION

The hyperacute-MRI protocol for wake-up COVID-19 associated strokes might be a safe option.

Comprehensive Review on Neuro-COVID-19 Pathophysiology and Clinical Consequences

Aside from the respiratory distress as the predominant clinical presentation of SARS-CoV-2 infection, various neurological complications have been reported with the infection during the ongoing pandemic, some of which cause serious morbidity and mortality. Herein, we gather the latest anatomical evidence of the virus's presence within the central nervous system. We then delve into the possible SARS-CoV-2 entry routes into the neurological tissues, with the hematogenous and the neuronal routes as the two utmost passage routes into the nervous system. We then give a comprehensive review of the neurological manifestations of the SARS-CoV-2 invasion in both the central and peripheral nervous system and its underlying pathophysiology via investigating large studies in the field and case reports in cases of study scarcity.

Ischaemic stroke as the presenting feature of COVID-19: a series of three cases from Qatar

Most cases of stroke associated with coronavirus disease 2019 (COVID-19) occur during the course of a characteristic COVID-19 respiratory illness. We report three patients where the presenting feature of COVID-19 was stroke. Two patients had no respiratory symptoms throughout their clinical course. In each case, COVID-19 was confirmed by a reverse transcription polymerase chain reaction (RT-PCR) test and the diagnosis of ischaemic stroke by brain imaging. The patients were relatively young (40, 45 and 50 years). None had a prior history of cerebrovascular events. Stroke risk factors were absent in one, limited to overweight and smoking in another but more prominent in the third patient. Two patients had large vessel occlusion and elevated D-dimer levels. Multiple infarcts were seen in two patients. Clinicians should consider the possibility of COVID-19 in patients presenting with stroke and conversely consider investigating for stroke if a patient with COVID-19, even if mildly ill, develops acute neurological symptoms.

Internal carotid artery thrombosis in COVID 19

CASE DESCRIPTION

37-year-old female with PCR-RT swab for COVID-19 positive, with neurological manifestation as a result of internal carotid artery occlusion.

CLINICAL FINDINGS

Nasal congestion and sneezing of 5 days duration; pulsatile headache in the left hemicranium 3 days prior to admission, with intensity 6/10 according to the visual analogue scale, accompanied by phosphenes, photophobia and diplopia; with subsequent developing right hemiparesis over a 26-hour period.

TREATMENT AND RESULT

She was given medical management with oral antiplatelet agents and anticoagulants (subcutaneous and oral) during his hospitalization, it was not possible to perform thrombolysis and thrombectomy due to the high risk of complications. He was discharged at 14 days, without functional limitation, symmetrical strength in upper and lower limbs, bilateral visual acuity 20/20, denying headache.

CLINICAL RELEVANCE

The case presented here describes a pattern in how data supporting an association between COVID-19 and stroke in young populations with or without typical vascular risk factors, sometimes with only mild respiratory symptoms, is increasing. Prospective studies are required to further evaluate this association, as well as anticoagulation studies to prevent these potentially life-threatening events.