Characteristics of Acute Stroke in Patients with Coronavirus Disease 2019 and Challenges in Stroke Management during an Epidemic

Abstract

Coronavirus disease 2019 (COVID-19) is an ongoing pandemic infection associated with high morbidity and mortality. The Korean city of Daegu endured the first large COVID-19 outbreak outside of China. Since the report of the first confirmed case in Daegu on February 18, 2020, a total of 6,880 patients have been reported until May 29, 2020. We experienced five patients with ischemic stroke and COVID-19 during this period in four tertiary hospitals in Daegu. The D-dimer levels were high in all three patients in whom D-dimer blood testing was performed. Multiple embolic infarctions were observed in three patients and suspected in one. The mean time from stroke symptom onset to emergency room arrival was 22 hours. As a result, acute treatment for ischemic stroke was delayed. The present case series report raises the possibility that the coronavirus responsible for COVID-19 causes or worsens stroke, perhaps by inducing inflammation. The control of COVID-19 is very important; however, early and proper management of stroke should not be neglected during the epidemic.

SARS‐CoV‐2 infection, COVID‐19 pathogenesis, and exposure to air pollution: What is the connection?

“…109 Furthermore, increased circulating inflammatory mediators activate coagulation cascades, promoting microcirculatory thrombi formation 110 in addition to promoting acute kidney injury, gastrointestinal inflammation, cardiovascular injury, and cerebrovascular injury. [109][110][111][112][113][114][115] Severe complications observed in COVID-19 patients include respiratory failure, myocardial injury, arrhythmias, stroke, kidney failure, coagulopathy, secondary bacterial infections, and gastrointestinal disease. [111][112][113][114][115] In the early stages of the pandemic, the primary cause of death was thought to be due to ARDS, caused by an excessive and prolonged production of proinflammatory cytokines-a cytokine stormthat caused extensive tissue damage.…”

“…[109][110][111][112][113][114][115] Severe complications observed in COVID-19 patients include respiratory failure, myocardial injury, arrhythmias, stroke, kidney failure, coagulopathy, secondary bacterial infections, and gastrointestinal disease. [111][112][113][114][115] In the early stages of the pandemic, the primary cause of death was thought to be due to ARDS, caused by an excessive and prolonged production of proinflammatory cytokines-a cytokine stormthat caused extensive tissue damage. 6,[116][117][118] However, levels of cytokines, such as IL-1β, IL-1RA, IL-6, IL-8, IL-18, and TNF-α, in patients with severe COVID-19 have been shown to be elevated at levels expected in critically ill patients, including those with severe cases of COVID-19, and to not be different from those observed in patients with ARDS or sepsis.…”

“…[119][120][121][122] More recent studies indicate that the causes of death in COVID-19 patients include respiratory failure, stroke, myocardial injury, arrhythmias, coagulopathy, kidney failure, and secondary bacterial infections. [111][112][113][114][115] In fact, it is now believed that COVID-19-induced mortality and morbidity is due to an "immunological collapse" 111 characterized by a loss of immune cells (B and T cells) in the spleen and secondary lymphoid organs. 111,123 Thus, an inability to control viral replication in the early stages of disease results in severe disease and death as a result of impaired and/or delayed immune responses, which is why the elderly are severely affected by COVID-19.…”

The impact of COVID-19 on patients with stroke: an integrative review

“…3.3.1 Delayed stroke treatment. Fourteen studies reported that the COVID-19 pandemic caused significantly delayed treatment such as alteplase administration, thrombolysis, thrombectomy, or patients' consultation [17][18][19][20][21][22][23][24][25][26][27][28][29][30]. One cohort study asserted that a trend toward more limited alteplase administration was recorded in patients with stroke throughout the COVID-19 pandemic than a year before the outbreak [17].…”

“…3.3.2 Thrombotic, blood and immune system complications. Thrombotic, blood and immune system complications are the most common reported sequelae in patients with stroke diagnosed with COVID-19 [17][18][19][31][32][33][34][35]. One cohort study shows that acute ischemic stroke patients diagnosed with COVID-19 developed a systemic thrombotic complication [17].…”