Characteristics of a Diverse Cohort of Stroke Patients with SARS-CoV-2 and Outcome by Sex

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COVID-19 disease is associated with stroke

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All strokes subtypes are seen in association with COVID-19, with ischemic stroke being most prevalent

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The most common etiology for ischemic stroke in SARS-CoV2 infection is cryptogenic

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Sex plays an important role in stroke outcomes in patients with COVID-19 disease

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Males have higher rates of ICU admission, in-hospital complications and more likely to have worse outcome at hospital discharge compare with females

Background and Purpose

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection is associated with stroke. The role of sex on stroke outcome has not been investigated. To objective of this paper is to describe the characteristics of a diverse cohort of acute stroke patients with COVID-19 disease and determine the role of sex on outcome.

Methods

This is a retrospective study of patients with acute stroke and SARS-CoV-2 infection admitted between March 15 to May 15, 2020 to one of the six participating comprehensive stroke centers. Baseline characteristics, stroke subtype, workup, treatment and outcome are presented as total number and percentage or median and interquartile range. Outcome at discharge was determined by the modified Rankin Scale Score (mRS). Variables and outcomes were compared for males and females using univariate and multivariate analysis.

Results

The study included 83 patients, 47% of which were Black, 28% Hispanics/Latinos, and 16% whites. Median age was 64 years. Approximately 89% had at least one preexisting vascular risk factor (VRF). The most common complications were respiratory failure (59%) and septic shock (34%). Compared with females, a higher proportion of males experienced severe SARS-CoV-2 symptoms requiring ICU hospitalization (73% vs. 49%; p = 0.04). When divided by stroke subtype, there were 77% ischemic, 19% intracerebral hemorrhage and 3% subarachnoid hemorrhage. The most common ischemic stroke etiologies were cryptogenic (39%) and cardioembolic (27%). Compared with females, males had higher mortality (38% vs. 13%; p = 0.02) and were less likely to be discharged home (12% vs. 33%; p = 0.04). After adjustment for age, race/ethnicity, and number of VRFs, mRS was higher in males than in females (OR = 1.47, 95% CI = 1.03–2.09).

Conclusion

In this cohort of SARS-CoV-2 stroke patients, most had clinical evidence of coronavirus infection on admission and preexisting VRFs. Severe in-hospital complications and worse outcomes after ischemic strokes were higher in males, than females.

Increased von Willebrand factor in migraine

The authors determined von Willebrand factor (vWF) in 63 persons with migraine, 11 persons with migraine and prior stroke, and 35 frequency-matched controls. Additional studies were done in a subset with migraine without aura who were headache free for >7 days. Migraineurs with prior stroke had significantly higher vWF antigen (170% versus 106%) and activity (162% versus 108%) than the control group. vWF antigen (126%) and activity (130%) were also significantly higher in migraineurs without stroke. Multimers and protease activity were normal in the interictal subset.

Fluorouracil-induced neurotoxicity

OBJECTIVE

To report a case of acute neurologic adverse effects related to fluorouracil administration and to review the neurotoxicity of this agent.

CASE SUMMARY

A 73-year-old white man with a history of esophageal carcinoma was treated with fluorouracil 1,500 mg iv daily for four days. After completing treatment, he presented with sudden onset of confusion, cognitive disturbances, a cerebellar syndrome, and repeated seizures. A magnetic resonance image of the brain showed no structural abnormalities, and cerebrospinal fluid examination was normal; none of the other laboratory tests provided an explanation for his symptoms. The patient was treated with anticonvulsants, and the cognitive changes resolved in 72 hours. The cerebellar signs, however, did not resolve completely and persisted when the patient was examined two weeks after discharge.

DISCUSSION

Fluorouracil can cause both acute and delayed neurotoxicity. Acute neurotoxicity manifests as encephalopathy or as cerebellar syndrome; seizures, as seen in our patient, have rarely been reported. Acute neurotoxicity due to fluorouracil is dose related and generally self-limiting. Various mechanisms for such toxicity have been postulated, and treatment with thiamine has been recommended. Delayed neurotoxicity has been reported when fluorouracil was given in combination with levamisole; this form of subacute multifocal leukoencephalopathy is immune mediated and responds to treatment with corticosteroids.

CONCLUSIONS

Clinicians should be aware of the adverse neurologic effects of fluorouracil and should include them in the differential diagnosis when patients receiving the drug present with neurologic problems.