Stroke as a Potential Complication of COVID-19-Associated Coagulopathy: A Narrative and Systematic Review of the Literature

Stroke and COVID-19: An Umbrella Review

Introduction

Acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH) are among the acute cerebrovascular diseases (CVDs) that have been reported as a result of COVID-19. It will be a significant step forward if our research helps improve the compilation and analysis of existing data from other studies.

Methods

The study is registered on PROSPERO with an ID of CRD42023464058. It encompasses articles published until December 2023 and involves searching databases such as PubMed, Scopus, Web of Knowledge, Embase, and Cochrane. Additionally, we conducted manual searches in respected publications within this discipline, utilized the Google Scholar search engine, and conducted reference checks, citation checks, and study of gray literature. The publications' reporting quality was assessed using the "Assessment of Multiple Systematic Reviews" (AMSTAR) checklist. The meta-analysis was conducted using Stata software (StataCorp, version 16).

Results

We analyzed the findings of 23 meta-analyses, which included 795 articles and encompassed 5,937 patients who had previously experienced a stroke. The average age of these patients was 62.3 years, and 68.3% were male. The findings indicated that the collective incidence of stroke among individuals with COVID-19 is roughly 1.75% [95% confidence interval (CI): 0.4%-3.03], with 1.59% for ischemic strokes and 0.3% for hemorrhagic strokes. 32.3% (95% CI: 27.8%-36.9%) of COVID-19 patients with stroke passed away, approximately 27% were discharged from the hospital with very mild or no complications, and around 28.1% (95% CI: 14.1%-42.1%) were referred for rehabilitation.

Conclusions

The overall rate of stroke in COVID-19 patients was approximately 1.75%, with a higher incidence in males and those with an average age of 62.3 years. Almost 80% of the strokes were ischemic, and the mortality rate was approximately 32%. Finally, 27% of the patients were discharged without complications, and 28% required rehabilitation.

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.

Correlation between Hepatocyte Growth Factor (HGF) with D-Dimer and Interleukin-6 as Prognostic Markers of Coagulation and Inflammation in Long COVID-19 Survivors

In general, an individual who experiences the symptoms of Severe Acute Respiratory Syndrome Coronavirus 2 or SARS-CoV-2 infection is declared as recovered after 2 weeks. However, approximately 10-20% of these survivors have been reported to encounter long-term health problems, defined as 'long COVID-19', e.g., blood coagulation which leads to stroke with an estimated incidence of 3%, and pulmonary embolism with 5% incidence. At the time of infection, the immune response produces pro-inflammatory cytokines that stimulate stromal cells to produce pro-hepatocyte growth factor (pro-HGF) and eventually is activated into hepatocyte growth factor (HGF), which helps the coagulation process in endothelial and epithelial cells. HGF is a marker that appears as an inflammatory response that leads to coagulation. Currently, there is no information on the effect of SARS-CoV-2 infection on serum HGF concentrations as a marker of the prognosis of coagulation in long COVID-19 survivors. This review discusses the pathophysiology between COVID-19 and HGF, IL-6, and D-dimer.

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.

Clinical Application of Thromboelastography in Acute Ischemic Stroke

Acute ischemic stroke (AIS), characterized by high morbidity and mortality, has imposed a considerable burden on society. Despite rapid development in the treatment of AIS, there is still a high risk of recurrence. Furthermore, there is a time delay in waiting for the results of conventional coagulation tests in candidate patients for intravenous thrombolysis therapy. Heterogeneous responses to antiplatelet, intravascular thrombolysis, and endovascular therapies also worsen the situation. Thromboelastography (TEG), as a global and portable detection method for hemostasis, facilitates clinicians in disease monitoring, treatment evaluation, and prognosis prediction in AIS. In this narrative review, we provided a comprehensive summary of the clinical application of TEG in ischemic stroke and gave insights to further studies.

Pharmacotherapy consideration of thrombolytic medications in COVID-19-associated ARDS

BACKGROUND

In late 2019, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which is responsible for coronavirus disease (COVID-19), was identified as the new pathogen to lead pneumonia in Wuhan, China, which has spread all over the world and developed into a pandemic. Despite the over 1 year of pandemic, due to the lack of an effective treatment plan, the morbidity and mortality of COVID-19 remains high. Efforts are underway to find the optimal management for this viral disease.

MAIN BODY

SARS-CoV-2 could simultaneously affect multiple organs with variable degrees of severity, from mild to critical disease. Overproduction of pro-inflammatory mediators, exacerbated cellular and humoral immune responses, and coagulopathy such as Pulmonary Intravascular Coagulopathy (PIC) contributes to cell injuries. Considering the pathophysiology of the disease and multiple microthrombi developments in COVID-19, thrombolytic medications seem to play a role in the management of the disease. Beyond the anticoagulation, the exact role of thrombolytic medications in the management of patients with COVID-19-associated acute respiratory distress syndrome (ARDS) is not explicit. This review focuses on current progress in underlying mechanisms of COVID-19-associated pulmonary intravascular coagulopathy, the historical use of thrombolytic drugs in the management of ARDS, and pharmacotherapy considerations of thrombolytic therapy, their possible benefits, and pitfalls in COVID-19-associated ARDS.

CONCLUSIONS

Inhaled or intravenous administration of thrombolytics appears to be a salvage therapy for severe ARDS associated with COVID-19 by prompt attenuation of lung injury. Considering the pathogenesis of COVID-19-related ARDS and mechanism of action of thrombolytic agents, thrombolytics appear attractive options in stable patients without contraindications.

Stroke in the COVID-19 pandemic era

Purpose

The aim of this article is to outline the impact of COVID-19 on the frequency of occurrence, course of stroke treatment, and to highlight the cause-effect relationship between SARS-CoV-2 infection and stroke on the basis of a literature overview.

Views

Since the end of 2019, the whole world has been struggling with the effects of the pandemic caused by the coronavirus SARS-CoV-2. The virus induces a wide spectrum of symptoms, ranging from mild or serious ones, which may lead to a severe multiorgan failure. Acute ischaemic stroke (AIS) might be associated with COVID-19 as a potentially fatal complication, while hemorrhagic stroke is less frequent. In most cases, stroke is caused by large artery occlusion. One of its reasons is hypercoagulation with a complex mechanism, which has not been fully explained. Research has shown that during COVID-19 pandemic, the number of patients admitted to hospitals due to AIS decreased. During the first pandemic wave there was no change regarding the proportion of patients with cerebral vessel obstruction who received endovascular treatment.

Conclusions

In the COVID-19 pandemic era, rapid intravenous administration of tissue plasminogen activator remains the main treatment for acute ischaemic stroke. Patients often fail to report to hospital for the fear of SARS-CoV-2 infection. It is of the utmost importance to raise society's awareness of the necessity to report to hospital when experiencing serious symptoms, including stroke.

Distinct etiologies of high-sensitivity troponin T elevation predict different mortality risks for patients hospitalized with COVID-19

Background

Cardiovascular events in the context of COVID-19 infection increase the risk of negative patient outcomes, but large cohort studies describing this association are limited. The purpose of the current study was to investigate the potential associations between cardiovascular events and mortality in patients hospitalized due to COVID-19.

Methods

A retrospective chart review was performed in 2450 patients hospitalized for confirmed COVID-19 infection within a single hospital network between March 15 and June 15, 2020. Logistic regression analysis was used to identify predictors of mortality.

Results

In the study population, 57% of patients had elevated high sensitivity troponin (hs-TnT) levels. Acute heart failure occurred in 23% of patients and arrhythmias were observed in 8% of patients. Of the 1401 patients with elevated hs-TnT levels, a primary cardiac etiology (e.g., myocardial infarction) was identified in 653 (47%) patients. In the remaining 748 (53%) patients, there was evidence of a primary non-cardiac etiology for hs-TnT elevation such as renal failure (n = 304) and critical illness (n = 286). Elevated hs-TnT was associated with increased risk of mortality. A significantly higher mortality rate was observed for hs-TnT elevation associated with a primary cardiac etiology (OR 4.6, 95% CI: 2.7–7.6; P < 0.001) than a primary non-cardiac etiology (OR 2.7, 95% CI: 1.6–4.5; P < 0.001).

Conclusions

Elevated hs-TnT in the context of COVID-19 infection is associated with a significantly increased mortality risk. Hs-TnT elevation in the context of a primary cardiac etiology confers a nearly 2-fold higher mortality risk than hs-TnT elevation due to a primary non-cardiac etiology.

Ischemic Stroke following COVID-19 in a Patient without Comorbidities

Background

Stroke is a rare complication of COVID-19. Post-COVID-19 stroke occurs mainly in older patients who have preexisting vascular risk factors. Most strokes are possibly related to hypercoagulability associated with COVID-19 where elevated D-dimer levels were the most common finding. In this case, post-COVID-19 ischemic stroke occurred in a relatively young patient without preexisting cerebrovascular risk factors which were rarely reported before. Case Presentation. A 40-year-old male presented lack of concentration, sluggish mind, and forgetfulness. The patient has a positive COVID-19 history 5 weeks ago. The noncontrast MSCT scan confirmed multifocal lacunar cerebral infarction on the left lateral ventricle. Laboratory tests showed an increase in D-dimer of 1.22 g/ml.

Conclusion

In COVID-19 patients without comorbidities, ischemic stroke should be considered.

Multifocal and Microvascular Involvement in Ischemic Stroke During COVID-19: A Cohort Study With Comparison With Non-COVID-19 Stroke

Introduction: Thromboembolic events, including ischemic stroke, are major complications of coronavirus disease 2019 (COVID-19). The clinical characteristics of COVID-19-related stroke are not clearly defined, and few controlled studies assessed the underlying mechanisms of cerebrovascular complications of COVID-19. This single-center retrospective observational study compared stroke characteristics between patients with and without COVID-19. Methods: This study included all patients hospitalized between March 1, 2020, and April 30, 2020, in Colmar Hospital for ischemic stroke as confirmed by imaging. The characteristics of patients with laboratory-confirmed severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection by real-time reverse transcriptase polymerase chain reaction or serology were compared with those without SARS-CoV-2 infection. Result: Among 772 patients, nine COVID-19 patients were compared with 50 patients without COVID-19. The following inflammatory and procoagulant marker levels were significantly higher in the COVID-19 group than those in the control group: C-reactive protein, 57.3 ± 43.4 vs. 15.0 ± 30.6 mg/L, p < 0.001; fibrinogen, 5.89 ± 1.75 vs. 4.03 ± 1.26 g/L, p < 0.001; and D-dimer, 4,833.9 ± 6,549.4 vs. 1,028.6 ± 942.6 ng/ml, p < 0.001. The rates of multifocal cerebral territory involvement (4 vs. 7, p = 0.05), microvascular involvement (4 vs. 6, p = 0.04), and thrombophilia (4 vs. 4, p = 0.014) were significantly higher in the COVID-19 group than in the control group, whereas no significant intergroup differences were found in the stroke mechanisms, i.e., cardio-embolic, atherosclerotic, small vessel disease, and cryptogenic. Conclusion: COVID-19-related stroke is characterized by hypercoagulability and hyperinflammation that may favor strokes via microvascular circulation abnormalities, microthrombus formation, and multifocal lesions.

Prior Stroke and Age Predict Acute Ischemic Stroke Among Hospitalized COVID-19 Patients: A Derivation and Validation Study

Objectives: Our objective was to identify characteristics associated with having an acute ischemic stroke (AIS) among hospitalized COVID-19 patients and the subset of these patients with a neurologic symptom.

Materials and Methods: Our derivation cohort consisted of COVID-19 patients admitted to Yale-New Haven Health between January 3, 2020 and August 28, 2020 with and without AIS. We also studied a sub-cohort of hospitalized COVID-19 patients demonstrating a neurologic symptom with and without an AIS. Demographic, clinical, and laboratory results were compared between AIS and non-AIS patients in the full COVID-19 cohort and in the sub-cohort of COVID-19 patients with a neurologic symptom. Multivariable logistic regression models were built to predict ischemic stroke risk in these two COVID-19 cohorts. These 2 models were externally validated in COVID-19 patients hospitalized at a major health system in New York. We then compared the distribution of the resulting predictors in a non-COVID ischemic stroke control cohort.

Results: A total of 1,827 patients were included in the derivation cohort (AIS N = 44; no AIS N = 1,783). Among all hospitalized COVID-19 patients, history of prior stroke and platelet count ≥ 200 × 1,000/μL at hospital presentation were independent predictors of AIS (derivation AUC 0.89, validation AUC 0.82), irrespective of COVID-19 severity. Among hospitalized COVID-19 patients with a neurologic symptom (N = 827), the risk of AIS was significantly higher among patients with a history of prior stroke and age <60 (derivation AUC 0.83, validation AUC 0.81). Notably, in a non-COVID ischemic stroke control cohort (N = 168), AIS patients were significantly older and less likely to have had a prior stroke, demonstrating the uniqueness of AIS patients with COVID-19.

Conclusions: Hospitalized COVID-19 patients who demonstrate a neurologic symptom and have either a history of prior stroke or are of younger age are at higher risk of ischemic stroke.

Acute Ischemic Stroke Due to Basilar Artery Occlusion with Coronavirus Disease 2019: A Case Report

Although it is increasingly recognized that coronavirus disease 2019 (COVID-19) can cause multi-organ disease, including acute ischemic stroke, the incidence of coagulation disorder is reported to be lower in Asian countries. We report a case of a 47-year-old Asian man with mild COVID-19 respiratory symptoms who had acute basilar artery occlusion. Despite successful recanalization with mechanical thrombectomy, the patient developed extensive cerebral infarction in the posterior circulation, necessitating decompressive craniotomy. Our findings suggest that severe large vessel occlusion (LVO) can occur even in young Asian patients with mild COVID-19 respiratory symptoms and that its outcome can be extremely severe despite successful recanalization. The management of COVID-19-related LVO can be very challenging, as both the prevention of possible nosocomial infection and early recanalization are required simultaneously.

Neurological manifestations of COVID-19 infection: an umbrella review

BACKGROUND

Neurological involvements of COVID-19 are one of the most reported manifestations of this infection. This study aims to systematically review the previous systematic reviews which addressed the neurological manifestations of the COVID-19 infection.

METHODS

Following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines, a comprehensive search was conducted in PubMed, Embase, Scopus, Web of Science databases and Google Scholar from December 2019 to December 2020. Articles were critically screened by two independent reviewers and if met the inclusion criteria, entered the study. Assessment of methodological quality was conducted by Assessment of Multiple Systematic Reviews-2 (AMSTAR-2) tool. Statistical analysis was not applicable. From a total of 1302 studies, 308 studies were removed due to their irrelevant title and abstract. After screening the full texts, a total of 66 found to be eligible. Twenty-one studies reported general manifestations of the COVID-19, 13 studies reported cerebrovascular events, 19 olfactory and oral dysfunctions, 5 systematic reviews on Guillen-Barré syndrome (GBS) and 8 articles on the sporadic manifestations like ocular signs and symptoms. The majority of the studies were classified as critically low or low in terms of quality.

CONCLUSION

Despite great heterogeneity in the current literature, neurological involvements are an important extra-pulmonary aspect of the COVID-19; most commonly in the form of general manifestations like headache and olfactory disturbances. Long-term effects of this virus on the nervous system must be a research priority for future references.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1186/s41983-021-00366-5.

Ischemic Stroke: An Underestimated Complication of COVID-19

The coronavirus disease 2019 (COVID-19) has spread rapidly as a pandemic around the world. In addition to severe acute respiratory syndrome, more and more studies have focused on the complication of COVID-19, especially ischemic stroke. Here, we propose several pathophysiological processes and possible mechanisms underlying ischemic stroke after COVID-19 for early prevention and better treatment of COVID-19-related stroke.

Generation and validation of in-hospital mortality prediction score in COVID-19 patients: Alba-score

BACKGROUND

COVID-19 has a wide range of symptoms reported, which may vary from very mild cases (even asymptomatic) to deadly infections. Identifying high mortality risk individuals infected with the SARS-CoV-2 virus through a prediction instrument that uses simple clinical and analytical parameters at admission can help clinicians to focus on treatment efforts in this group of patients.

METHODS

Data was obtained retrospectively from the electronic medical record of all COVID-19 patients hospitalized in the Albacete University Hospital Complex until July 2020. Patients were split into two: a generating and a validating cohort. Clinical, demographical and laboratory variables were included. A multivariate logistic regression model was used to select variables associated with in-hospital mortality in the generating cohort. A numerical and subsequently a categorical score according to mortality were constructed (A: mortality from 0% to 5%; B: from 5% to 15%; C: from 15% to 30%; D: from 30% to 50%; E: greater than 50%). These scores were validated with the validation cohort.

RESULTS

Variables independently related to mortality during hospitalization were age, diabetes mellitus, confusion, SaFiO2, heart rate and lactate dehydrogenase (LDH) at admission. The numerical score defined ranges from 0 to 13 points. Scores included are: age ≥71 years (3 points), diabetes mellitus (1 point), confusion (2 points), onco-hematologic disease (1 point), SaFiO2 ≤ 419 (3 points), heart rate ≥ 100 bpm (1 point) and LDH ≥ 390 IU/L (2 points). The area under the curve (AUC) for the numerical and categorical scores from the generating cohort were 0.8625 and 0.848, respectively. In the validating cohort, AUCs were 0.8505 for the numerical score and 0.8313 for the categorical score.

CONCLUSIONS

Data analysis found a correlation between clinical admission parameters and in-hospital mortality for COVID-19 patients. This correlation is used to develop a model to assist physicians in the emergency department in the COVID-19 treatment decision-making process.

The Pathobiological Basis for Thrombotic Complications in COVID-19: a Review of the Literature

Purpose of Review

COVID-19 has rapidly evolved into a global pandemic infecting over two hundred and forty-four million individuals to date. In addition to the respiratory sequelae and systemic infection that ensues, an alarming number of micro and macrovascular thrombotic complications have been observed. This review examines the current understanding of COVID-19-associated thrombotic complications, potential mechanisms, and pathobiological basis for thromboses development.

Recent Findings

The endothelium plays a major role in the process due to direct and indirect injury. The immune system also contributes to a pro-thrombotic environment with immune cell dysregulation leading to excessive formation of cytokines, also called cytokine storm, and an eventual promotion of a hypercoagulable environment, known as immunothrombosis. Additionally, neutrophils play an important role by forming neutrophil extracellular traps, which are shown to be pro-thrombotic and further enhanced in COVID-19 patients. A disruption of the fibrinolysis system has also been observed.

Summary

Multiple pathways likely contribute synergistically to form a pro-thrombotic milieu. A better understanding of these factors and the complex interplay between them will lead to the improvement of diagnostic and therapeutic interventions.