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Janes F, Sozio E, Gigli GL, Ripoli A, Sbrana F, Kuris F, Nesi L, Semenzin T, Bertolino G, Deana C, Bagatto D, Ciardi C, Fabris M, Merlino G, Bax F, Nilo A, Pez S, Valente M, Tascini C. Ischemic strokes in COVID-19: risk factors, obesity paradox, and distinction between trigger and causal association. Front Neurol 2023; 14:1222009. [PMID: 37592943 PMCID: PMC10428626 DOI: 10.3389/fneur.2023.1222009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 07/17/2023] [Indexed: 08/19/2023] Open
Abstract
Background and purpose Stroke has been described as a COVID-19 complication. However, its occurrence rate, risk factors, and causal relationships are still not well established. Methods We describe the characteristics of confirmed COVID-19-related strokes among all cases of COVID-19 hospitalized in our health network, from November 1, 2020 to April 30, 2021. Risk factor analysis has been conducted for ischemic stroke (IS), which represents 92% of all confirmed cases of Covid-19-related strokes, and a "causal attribution to infection" classification is provided. Results In all, 62/4105 hospitalized COVID-19 patients had an acute stroke (1.51%). Severe COVID-19 (OR 2.27-CI 1.06-4.77; p = 0.032), atrial fibrillation (OR 3.65-CI 1.63-7.98; p = 0.001), and ischemic heart disease (OR 4.590-CI 1.714-12.137; p = 0.002) proved to be independent risk factors for IS, while obesity was a protective factor (OR 0.90-CI 0.82-0.97; p = 0.012). COVID-19 had a causal role in 32.1% of IS cases, was a relevant cofactor in 28.6% of cases of IS, and was a possible trigger in 39.3% of events. Conclusion Our stroke occurrence rate is consistent with other population-based reports (range 0.34-2.7%). Prespecified peculiar clinical and radiological features allow the distinction between "IS caused by COVID-19" and "IS triggered by COVID-19." Clinical history of vascular diseases and risk factors is crucial in determining the risk of IS in patients with COVID-19. However, the protective effect of a BMI > 30 kg/m2 seems to suggest an obesity paradox.
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Affiliation(s)
- Francesco Janes
- Clinic of Neurology, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
- Department of Medical Area (DAME), University of Udine (UNIUD), Udine, Italy
| | - Emanuela Sozio
- Clinic of Infectious Diseases, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
| | - Gian Luigi Gigli
- Department of Medical Area (DAME), University of Udine (UNIUD), Udine, Italy
| | - Andrea Ripoli
- Cardiology OU, Cardiothoracic Department, G. Monasterio Foundation, Pisa, Italy
| | - Francesco Sbrana
- Cardiology OU, Cardiothoracic Department, G. Monasterio Foundation, Pisa, Italy
| | - Fedra Kuris
- Clinic of Neurology, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
- Department of Medical Area (DAME), University of Udine (UNIUD), Udine, Italy
| | - Lorenzo Nesi
- Clinic of Neurology, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
- Department of Medical Area (DAME), University of Udine (UNIUD), Udine, Italy
| | - Tosca Semenzin
- Clinic of Infectious Diseases, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
| | - Giacomo Bertolino
- Clinic of Infectious Diseases, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
| | - Cristian Deana
- Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
| | - Daniele Bagatto
- Institute of Neuroradiology, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
| | - Chiara Ciardi
- Institute of Neuroradiology, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
| | - Martina Fabris
- Institute of Clinical Pathology, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
| | - Giovanni Merlino
- Clinic of Neurology, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
| | - Francesco Bax
- Clinic of Neurology, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
| | - Annacarmen Nilo
- Clinic of Neurology, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
| | - Sara Pez
- Clinic of Neurology, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
- Department of Medical Area (DAME), University of Udine (UNIUD), Udine, Italy
| | - Mariarosaria Valente
- Clinic of Neurology, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
- Department of Medical Area (DAME), University of Udine (UNIUD), Udine, Italy
| | - Carlo Tascini
- Department of Medical Area (DAME), University of Udine (UNIUD), Udine, Italy
- Clinic of Infectious Diseases, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
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2
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Demir G, Hommos R, Al-Sirhan SS, Serhan HA, Haddadin M, Bin Rashid U, Chawa Y. Ischemic stroke in the setting of supratherapeutic International Normalized Ratio following coronavirus disease 2019 infection: a case report. J Med Case Rep 2023; 17:223. [PMID: 37254113 DOI: 10.1186/s13256-023-03936-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 04/17/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND SARS-CoV-19 infection is associated with an increased risk of thrombotic events. We present a case of acute middle cerebral artery ischemic stroke in a patient with SARS-CoV-19 infection despite being on warfarin with supratherapeutic INR (International Normalized Ratio). CASE PRESENTATION A 68-year-old Caucasian female with multiple comorbidities was admitted to the hospital with symptoms of upper respiratory tract infection. A rapid antigen test confirmed the diagnosis of COVID-19 pneumonia, and intravenous remdesivir was initiated. On the fifth day of admission, the patient experienced sudden onset confusion, slurred speech, left-sided hemiplegia, right-sided eye deviation, and left-sided facial droop. Imaging studies revealed an occlusion of the distal anterior M2 segment of the right middle cerebral artery, and an MRI of the brain confirmed an acute right MCA infarction. Notably, the patient was receiving warfarin therapy with a supratherapeutic INR of 3.2. CONCLUSIONS This case report highlights the potential for thromboembolic events, including stroke, in patients with COVID-19 infection, even when receiving therapeutic anticoagulation therapy. Healthcare providers should be vigilant for signs of thrombosis in COVID-19 patients, particularly those with pre-existing risk factors. Further research is necessary to understand the pathophysiology and optimal management of thrombotic complications in COVID-19 patients.
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Affiliation(s)
- Gokhan Demir
- Department of Internal Medicine, Hamad General Hospital, Doha, Qatar.
| | - Rama Hommos
- College of Medicine, Qatar University, Doha, Qatar
| | | | | | - Muhannad Haddadin
- Department of Internal Medicine, Hamad General Hospital, Doha, Qatar
| | - Umar Bin Rashid
- Department of Internal Medicine, Hamad General Hospital, Doha, Qatar
| | - Yamane Chawa
- Department of Internal Medicine, Hamad General Hospital, Doha, Qatar
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3
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Choudhry H, Klingensmith J, Border Dalton L, Myers M, Mercado E. Large Middle Cerebral Artery Ischemic Stroke in a Therapeutically Anticoagulated Patient With Severe SARS-CoV-2 Infection. Neurologist 2022; 27:218-221. [PMID: 34855675 PMCID: PMC9256897 DOI: 10.1097/nrl.0000000000000389] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Coronavirus disease 2019 caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is associated with hypercoagulability which can predispose infected patients to both arterial and venous thromboembolic complications. Despite therapeutic anticoagulation, there remains a risk of ischemic strokes, which may lead to adverse patient outcomes. Only a few cases are described in the literature regarding SARS-CoV-2 positive patients developing thrombotic ischemic strokes despite therapeutic anticoagulation. CASE REPORT The following is a case discussion regarding a 71-year-old female with past medical history of hypertension, diabetes mellitus type 2, hyperlipidemia, and hypothyroidism who was admitted with severe SARS-CoV-2 infection to the intensive care unit and later developed acute left upper extremity weakness on the 5th day of her admission. Initial National Institutes of Health stroke scale (NIHSS) was 15. Subsequent brain imaging was significant for right middle cerebral artery ischemic stroke. The patient was therapeutically anticoagulated with 1.5 mg/kg subcutaneous dose of Enoxaparin since day 1 of her admission. D-dimer upon admission was 1.84 mg/L (<0.59) and fibrinogen 783.1 mg/dL (200 to 450). Other than past medical comorbidities, our patient had no other known stroke risk factors. Unfortunately, despite early transcatheter thrombectomy, the patient remained comatose and eventually expired after withdrawal of ventilatory support and compassionate extubation. CONCLUSION Because of the severity of inflammation and coagulopathic sequelae of coronavirus disease 2019, anticoagulation failure may occur and lead to adverse patient outcomes. Our case report is one of the few discussions in the current literature regarding large vessel thromboembolic ischemic strokes despite therapeutic anticoagulation.
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4
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Janes F, Gigli GL, Kuris F, Morassi M, Costa P, Nesi L, Giacomello R, Mazzacane F, Leuci E, Cavallini A, Valente M. Failure of Therapeutic Anticoagulation in COVID-19 Patients With Acute Ischemic Stroke. A Retrospective Multicenter Study. Front Neurol 2022; 13:834469. [PMID: 35309582 PMCID: PMC8931401 DOI: 10.3389/fneur.2022.834469] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 02/07/2022] [Indexed: 11/14/2022] Open
Abstract
Background Acute ischemic stroke (AIS) is a possible complication of coronavirus disease 2019 (COVID-19) infection. Although peculiar clinical features and underlying specific mechanisms of thrombogenesis have been suggested so far, there is no consensus on the appropriate vascular preventive drug regimen in patients with COVID-19. Aim and Methods From a larger clinical series of consecutive acute ischemic strokes related to COVID-19 admitted to three cerebrovascular units in Northern Italy, herein, we describe the clinical features of a subgroup of patients in whom stroke occurred despite therapeutic anticoagulation. Results A total of seventeen/80 AIS related to COVID-19 (21.2%) occurred in anticoagulated patients. Although no blood level was available for Direct Oral AntiCoagulant, the drug dosage was appropriate according to guidelines. Their National Institute of Health Stroke Scale (NIHSS) at admission was 12.0 (SD = 7.4) and 58.8% of them had evidence of large vessel occlusion. The case fatality rate was as high as 64.7%. Discussion and Conclusions The occurrence of an anticoagulation failure seems to be increased in the setting of COVID-19 infection, with worse clinical outcomes if compared to non-COVID-19 related ischemic strokes. We discuss the diagnostic and therapeutic implications of such evidence, suggesting that some arterial thrombotic complications might be either resistant to or independent of the anticoagulation effect.
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Affiliation(s)
- Francesco Janes
- Clinical Neurology Unit, Santa Maria della Misericordia University Hospital, Udine, Italy
- *Correspondence: Francesco Janes
| | - Gian Luigi Gigli
- Clinical Neurology Unit, Santa Maria della Misericordia University Hospital, Udine, Italy
- Department of Medicine, University of Udine, Udine, Italy
| | - Fedra Kuris
- Department of Medicine, University of Udine, Udine, Italy
| | - Mauro Morassi
- Neuroradiology Unit, Fondazione Poliambulanza, Brescia, Italy
| | - Paolo Costa
- Neurology Unit, Fondazione Poliambulanza, Brescia, Italy
| | - Lorenzo Nesi
- Department of Medicine, University of Udine, Udine, Italy
| | | | - Federico Mazzacane
- Emergency Neurology Unit and Stroke Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Mondino, Pavia, Italy
| | - Eleonora Leuci
- Emergency Neurology Unit and Stroke Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Mondino, Pavia, Italy
| | - Anna Cavallini
- Emergency Neurology Unit and Stroke Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Mondino, Pavia, Italy
| | - Mariarosaria Valente
- Clinical Neurology Unit, Santa Maria della Misericordia University Hospital, Udine, Italy
- Department of Medicine, University of Udine, Udine, Italy
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5
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Del Brutto OH, Mera RM, Del Brutto VJ, Recalde BY, Rumbea DA, Costa AF, Sedler MJ. Risk for Subsequent SARS-CoV-2 Infection and Severe COVID-19 Among Community-Dwellers With Pre-Existing Cervicocephalic Atherosclerosis: A Population-Based Study. J Prim Care Community Health 2022; 13:21501319211070685. [PMID: 35068245 PMCID: PMC8796101 DOI: 10.1177/21501319211070685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND COVID-19 patients may develop atherosclerosis-related complications. Whether a proportion of these patients already had asymptomatic cervicocephalic atherosclerosis before SARS-CoV-2 infection is not known. This study assessed whether pre-existing cervicocephalic atherosclerosis increased the susceptibility to SARS-CoV-2 infection or resulted in more severe or fatal COVID-19. METHODS Individuals enrolled in the Atahualpa Project cohort who received head CT (for assessing carotid siphon calcifications) and B-mode ultrasounds (for measurement of the carotid intima-media thickness) prior to the pandemic were eligible for this study. Among this cohort, those who also received serological tests for detection of SARS-CoV-2 antibodies and clinical evaluations for assessment of COVID-19 severity were enrolled. Multivariate logistic regression and exposure-effect models were fitted to assess the association between pre-existing atherosclerosis biomarkers, and SARS-CoV-2 seropositivity and COVID-19 severity. RESULTS Overall, 154 of 519 study participants (30%) had evidence of cervicocephalic atherosclerosis. A total of 325 (63%) individuals became SARS-CoV-2 positive, and 65 (23.5%) of seropositive individuals had severe or fatal COVID-19. The risk of SARS-CoV-2 seropositive status did not differ across individuals with and without atherosclerosis biomarkers (P = .360). Likewise, seropositive individuals with pre-existing atherosclerosis were not more prone to develop severe or fatal COVID-19 than those without evidence of atherosclerosis (P = .274). Average estimated exposure effects of pre-existing cervicocephalic atherosclerosis versus no atherosclerosis over SARS-CoV-2 seropositivity and COVID-19 severity were not significant. CONCLUSIONS Pre-existing cervicocephalic atherosclerosis does not increase the risk of acquiring SARS-CoV-2 infection nor the severity of COVID-19 among seropositive individuals.
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Affiliation(s)
| | | | | | | | | | - Aldo F Costa
- Hospital Universitario Reina Sofía, Córdoba, Spain
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6
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Deshpande G, Giri P. Acute monocular vision loss as presenting symptom of delayed stroke from internal carotid occlusion in COVID-19. Indian J Ophthalmol 2021; 69:1325-1327. [PMID: 33913892 PMCID: PMC8186595 DOI: 10.4103/ijo.ijo_439_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 03/08/2021] [Accepted: 03/15/2021] [Indexed: 12/01/2022] Open
Abstract
Covid-19 infection has been declared a pandemic by the World Health Organization. We present a unique case of a middle-aged gentleman, who recovered from asymptomatic Covid-19 infection and presented again with delayed stroke. He had vision loss secondary to internal carotid artery occlusion in the absence of neurological symptoms. To the best of our knowledge, this is the first case that describes cerebrovascular stroke due to delayed large vessel occlusion secondary to Covid-19 infection presenting as monocular vision loss.
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Affiliation(s)
| | - Pramod Giri
- Department of Neurosurgery Neuron Hospital, Nagpur, Maharashtra, India
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7
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Rivaroxaban. REACTIONS WEEKLY 2021. [PMCID: PMC7933383 DOI: 10.1007/s40278-021-92226-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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8
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Frisullo G, Scala I, Bellavia S, Broccolini A, Brunetti V, Morosetti R, Della Marca G, Calabresi P. COVID-19 and stroke: from the cases to the causes. Rev Neurosci 2021; 32:659-669. [PMID: 33583167 DOI: 10.1515/revneuro-2020-0136] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 01/19/2021] [Indexed: 12/24/2022]
Abstract
During COVID-19 pandemic, a wide variety of stroke typologies have been described in patients affected by SARS-CoV-2. Investigating the case reports of acute stroke in COVID-19 patients, published since the beginning of the pandemic, we tried to trace the pathogenic mechanisms of stroke during SARS-CoV-2 infection. We conducted a systematic review analyzing demographic data, cerebrovascular risk factors, NIHSS score, vascular territory involvement and laboratory findings of 168 patients described in 89 studies, from a pool of 1243 records. Based on our results, we have identified different stroke profiles: (1) cerebral large vessel disease (CLVD) profile with a low disability, simultaneous onset of COVID-19 and stroke symptoms, good outcome and low serum levels of D-dimer and CRP; (2) intracranial bleeding (IB) profile with high disability, poor outcome and low levels of serum markers of inflammation and coagulopathy; (3) CLVD profile with a short time-lapse between COVID-19 symptoms and stroke onset, high neurological disability and very high systemic inflammatory markers; (4) multiple thrombo-embolic disease (MTED) profile with older patients, many comorbidities, disabling stroke, poor outcome, evident alteration of coagulation tests and high serum levels of both D-dimer and CRP. We therefore summarized these different profiles in a spectrum similar to that of visible light, where the violet-blue band included IB and CSVD with low inflammation and prothrombotic activity, the green-yellow band included CLVD with high inflammation and moderate prothrombotic activity and the orange-red band for MTED with moderate-high levels of inflammation and very high prothrombotic activity.
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Affiliation(s)
- Giovanni Frisullo
- Fondazione Policlinico Universitario A. Gemelli, IRCCS, UOC Neurologia, Dipartimento di Scienze dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Largo A Gemelli, 8, 00168, Rome, Italy
| | - Irene Scala
- Fondazione Policlinico Universitario A. Gemelli, IRCCS, UOC Neurologia, Dipartimento di Scienze dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Largo A Gemelli, 8, 00168, Rome, Italy.,Catholic University of Sacred Heart, Rome, Italy
| | - Simone Bellavia
- Fondazione Policlinico Universitario A. Gemelli, IRCCS, UOC Neurologia, Dipartimento di Scienze dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Largo A Gemelli, 8, 00168, Rome, Italy.,Catholic University of Sacred Heart, Rome, Italy
| | - Aldobrando Broccolini
- Fondazione Policlinico Universitario A. Gemelli, IRCCS, UOC Neurologia, Dipartimento di Scienze dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Largo A Gemelli, 8, 00168, Rome, Italy.,Catholic University of Sacred Heart, Rome, Italy
| | - Valerio Brunetti
- Fondazione Policlinico Universitario A. Gemelli, IRCCS, UOC Neurologia, Dipartimento di Scienze dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Largo A Gemelli, 8, 00168, Rome, Italy
| | - Roberta Morosetti
- Fondazione Policlinico Universitario A. Gemelli, IRCCS, UOC Neurologia, Dipartimento di Scienze dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Largo A Gemelli, 8, 00168, Rome, Italy
| | - Giacomo Della Marca
- Fondazione Policlinico Universitario A. Gemelli, IRCCS, UOC Neurologia, Dipartimento di Scienze dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Largo A Gemelli, 8, 00168, Rome, Italy.,Catholic University of Sacred Heart, Rome, Italy
| | - Paolo Calabresi
- Fondazione Policlinico Universitario A. Gemelli, IRCCS, UOC Neurologia, Dipartimento di Scienze dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Largo A Gemelli, 8, 00168, Rome, Italy.,Catholic University of Sacred Heart, Rome, Italy
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