Background: Coronavirus disease 2019 (COVID-19) has placed a tremendous strain on healthcare services. This study, prepared by a large international panel of stroke experts, assesses the rapidly growing research and personal experience with COVID-19 stroke and offers recommendations for stroke management in this challenging new setting: modifications needed for prehospital emergency rescue and hyperacute care; inpatient intensive or stroke units; posthospitalization rehabilitation; follow-up including at-risk family and community; and multispecialty departmental developments in the allied professions. Summary: The severe acute respiratory syndrome coronavirus 2 uses spike proteins binding to tissue angiotensin-converting enzyme (ACE)-2 receptors, most often through the respiratory system by virus inhalation and thence to other susceptible organ systems, leading to COVID-19. Clinicians facing the many etiologies for stroke have been sobered by the unusual incidence of combined etiologies and presentations, prominent among them are vasculitis, cardiomyopathy, hypercoagulable state, and endothelial dysfunction. International standards of acute stroke management remain in force, but COVID-19 adds the burdens of personal protections for the patient, rescue, and hospital staff and for some even into the postdischarge phase. For pending COVID-19 determination and also for those shown to be COVID-19 affected, strict infection control is needed at all times to reduce spread of infection and to protect healthcare staff, using the wealth of well-described methods. For COVID-19 patients with stroke, thrombolysis and thrombectomy should be continued, and the usual early management of hypertension applies, save that recent work suggests continuing ACE inhibitors and ARBs. Prothrombotic states, some acute and severe, encourage prophylactic LMWH unless bleeding risk is high. COVID-19-related cardiomyopathy adds risk of cardioembolic stroke, where heparin or warfarin may be preferable, with experience accumulating with DOACs. As ever, arteritis can prove a difficult diagnosis, especially if not obvious on the acute angiogram done for clot extraction. This field is under rapid development and may generate management recommendations which are as yet unsettled, even undiscovered. Beyond the acute management phase, COVID-19-related stroke also forces rehabilitation services to use protective precautions. As with all stroke patients, health workers should be aware of symptoms of depression, anxiety, insomnia, and/or distress developing in their patients and caregivers. Postdischarge outpatient care currently includes continued secondary prevention measures. Although hoping a COVID-19 stroke patient can be considered cured of the virus, those concerned for contact safety can take comfort in the increasing use of telemedicine, which is itself a growing source of patient-physician contacts. Many online resources are available to patients and physicians. Like prior challenges, stroke care teams will also overcome this one. Key Messages: Evidence-based stroke management should continue to be provided throughout the patient care journey, while strict infection control measures are enforced.

Introduction. The processes of cognitive decline, which are typical for elderly and senile people, as well as for patients with chronic cerebral circulation insufficiency, involve pro-inflammatory cytokines, such as tumor necrosis factor (TNF-), interleukin-6, etc. The aim of this work was to study the association of TNF- with brain network structure and cognitive functions in patients with chronic cerebral ischemia (CCI). Materials and methods. We examined 101 patients with CCI (5085 years old, men and women) who were assessed for the saliva levels of TNF- during cognitive testing. The status of resting-state networks was analyzed in 55 patients using functional magnetic resonance therapy. Results. After cognitive tasks, the saliva level of TNF- increased by 17.6 6.2 pg/mL. Half of the CCI patients older than 60 years showed a significant increase in the level of TNF-. This cytokine correlated with delayed word recall and the ratio of delayed recall to their performance on the Luria Memory Words Test. The change in TNF- saliva levels correlated with the status of the resting-state network, mainly with the salience network. An increase in TNF- levels was associated with a higher frequency of negative correlations than at lower values of TNF- (less than 80 pg/mL). TNF--sensitive connectivities correlated with cognitive tasks, not only memory tests, but also with the Montreal Cognitive Assessment Scale, verbal fluency test scores, etc. Discussion. The study revealed two significant facts: an increase in the TNF- saliva level during cognitive performance and a lower success rate of cognitive performance associated with an increase in the levels of this cytokine. The central mechanism for the implementation of this relationship includes the restructuring of the salience network, namely the additional increase of negative correlations within the connective structure of the salience neural network of the right hemisphere. Conclusions. A change in the saliva level of TNF- affects the connectivity of resting-state networks, mainly the salience network

Background: Type 2 diabetes mellitus (T2DM) is a significant independent risk factor for ischaemic stroke. Carotid revascularisation procedures are an effective method of primary and secondary stroke prevention. However, patients developed postoperative acute ischaemic lesions (AILs), which were identified via magnetic resonance imaging (MRI) of the brains. Most of the patients with these AILs lack clinically overt symptoms. Aims: To assess the risk of ischaemic brain damage in patients with T2DM in the setting of carotid angioplasty with stenting (CAS) or carotid endarterectomy (CAE). Materials and methods: This open prospective study comprised of 164 patients with carotid atherosclerosis, who have undergone either CAS or CAE. Patients with T2DM were included in Group 1: 38 patients and 28 patients with CAE. Group 2 included patients without T2DM: 62 patients with CAS and 36 patients with CAE. All patients underwent a thorough neurological examination and diffusion-weighted brain MRI. In patients with T2DM, plasma glucose levels and glycated haemoglobin (HbA1c) were determined and their relationships to brain damage were evaluated. Results: In CAS, there were no statistically significant differences in the AIL frequency in patients with and without T2DM. AILs were found in 15 patients with T2DM (39.8%) and 29 patients without T2DM (46.8%, р = 0.24); three patients without T2DM were diagnosed with stroke. Of the 28 patients with T2DM who underwent CAE, 13 had AIL (46.4%); three had stroke (10.7%). In patients without T2DM, AILs were less prevalent in seven cases (19.4%, р = 0.012) and appeared asymptomatic. Following CAS, the baseline HbA1c levels were higher in patients with T2DM who developed AILs compared to those who did not develop AIL, 7.8% 1.4% vs 7.1 1.1% (р = 0.0469). Negative impact of hyperglycaemia on the risk of cerebral ischaemia was observed in patients who underwent CAE, the baseline fasting plasma glucose level was 8.5 1.9 mmol/l vs 7.0 1.5 mmol/l in patients without AIL (р = 0.014). The baseline HbA1c levels in patients with and without AILs were 8.0% 1.7% and 6.9% 0.9% respectively (р = 0.023). Conclusions: Carotid revascularisation procedure for patients with carotid atherosclerosis may be associated with risk of stroke and asymptomatic acute cerebral ischaemic lesions, which are more prevalent in patients with T2DM. Also, increased HbA1c levels is a risk factor for AIL.

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One of the methods of assessment of cognitive functions in patients with chronic ischemic cerebrovascular disease — CICD (dyscirculatory encephalopathy) implies studying connectivity of neural networks through the analysis of rest functional magnetic resonance imaging (rest fMRI) data. The main objective of this study was to assess the relationship between working memory (WM) characteristics and connectivity of various parts of the brain in patients diagnosed with CICD. The study involved 22 female CICD patients; they were divided into two groups, one with satisfactory level of WM and the other with compromised WM. We assessed intra-brain connectivity with the help of rest fMRI, using the SPM-12 and CONN18b software applications in Matlab platform. The other aspects evaluated were the gray to white matter ratio and the association of this indicator with WM. Significant differences in the intra-brain connectivity were registered in both the satisfactory WM group and the compromised WM group. The brain parts where those differences were found are left parahippocampal area and right supramarginal gyrus; right cerebellar hemisphere and left parietal, as well as left frontal areas; right cingular and left lingual gyri. In addition, we detected significant differences in the ratio in the gray and white matter volumes in both groups (p = 0.007). The results obtained indicate that memory deterioration in CICD patients is concomitant with deteriorating connectivity between the cortical areas, as well as between cerebellum and cortex, which may be associated with a more significant loss of the white matter.