Etiologic Subtypes of Ischemic Stroke in SARS-COV-2 Virus patients in a cohort of New York City hospitals

Abstract

Objective:To describe the ischemic stroke subtypes related to COVID-19 in a cohort of NYC hospitals and explore their etiopathogenesis.Background:Extra-pulmonary involvement of COVID-19 has been reported in the hepatic, renal and hematological systems. Most neurological manifestations are non-focal, but few have reported the characteristics of ischemic strokes or investigated its pathophysiology. Methods:Data were collected prospectively from March 15 to April 15, 2020 from four centers in New York City to review possible ischemic stroke types seen in COVID-19 positive patients. Patient presentation, demographics, other related vascular risk factors, associated laboratory and coagulation markers, as well as imaging and outcomes for consecutive stroke patients positive for SARS-COV2 infection over the period studied were collected. Results:In our study, the age range of patients was 25-75 with no significant male preponderance. The median age of LVO patients was 48. Stroke was the presenting and hospitalizing event in 70%.One fifth of patients did not have common risk factors for ischemic stroke and none had atrial fibrillation, coronary or cerebrovascular disease, or were smokers. Half had a poor outcome with All rights reserved. No reuse allowed without permission. : medRxiv preprint 40% ending in mortality (60% in LVO group) and one in a critical condition due ARDS. All had high neutrophil/lymphocyte ratio except one who demonstrated some neurological recovery. Ddimer levels showed mild to severe elevation when collected. None of the LVO cases had known cardiac risk factors but two out of five were found to have cardiac abnormalities during their hospitalization. All LVOs had hypercoagulable lab markers especially elevated D-dimer and/or fibrinogen. The LVO patients were younger and sicker with a median age of 46 and mean NIHSS of 24 as opposed to non-LVOs with a median age of 62 and mean NIHSS of 6 respectively. Conclusion:COVID-19 related ischemic events can be small vessel, branch emboli or large vessel occlusions. The latter is often associated with either a hypercoagulable state or cardio-embolism.Patient outcomes were worse when multi-organ or pulmonary system failure prevailed.

Exacerbation of neurological symptoms and COVID-19 severity in patients with preexisting neurological disorders and COVID-19: A systematic review

“…The full-text screening of these studies led to the exclusion of 286 that did not meet the inclusion criteria. The remaining 26 studies were identified as eligible to be reviewed [ 6 , 7 , [11] , [12] , [13] , [14] , [15] , [16] , [17] , [18] , [19] , [20] , [21] , [22] , [23] , [24] , [25] , [26] , [27] , [28] , [29] , [30] , [31] , [32] , [33] , [34] ]. Fig.…”

“…Tracheostomy 4. Need to remove respiratory secretions 2/4) Severe 5/7 (71) Liao et al [ 24 ] Retro 4 NA NA RT-PCR Cerebrovascular disease 4 Severe 1/4 (25) Bruce et al [ 25 ] Retro 79 NA NA RT-PCR Stroke 79 Severe 19/79 (24) Yin et al [ 26 ] Retro 106 72.7 (±11.8) 60 RT-PCR Cerebral infarction 81, Dementia 20, Acute cerebral infarction 10, Cerebral hemorrhage 5, Intracranial mass lesions 4, Epilepsy 3, Parkinson’s disease 2, and Myelopathy 1 Exacerbation of preexisting neurological symptoms 8/106 (8), Severe 59/106 (56) Ji et al [ 27 ] Retro 967 NA NA RT-PCR Parkinson's disease and movement disorder 209, Dementia and degenerative disease 206, Stroke and Transient cerebral ischemia 349, Epilepsy 97, Systemic atrophy 5, Multiple sclerosis 1 Severe 162/967 (17) Haimovich et al [ 28 ] Retro 356 NA NA PCR Neurologic disorders 356 Severe 36/356 (10) Berekashvili et al [ 29 ] Retro 1 70−80 0 RT-PCR Cerebral vascular accident 1 Severe 1/1 (100) Kim et al [ …”

Vasculopathy and Coagulopathy Associated with SARS-CoV-2 Infection

“…Although three of these patients had pre-existing risk factors for stroke, this incidence of stroke represented a seven-fold increase over previous comparable periods [182]. In a subsequent prospective series over the following month involving a group of New York City Hospitals [183], the age range of ten SARS-CoV-2-infected patients presenting with stroke had broadened to include patients 27 to 75 years old. Although none of these patients had pre-existing cerebrocardiovascular conditions, 8/10 had diabetes with or without hypertension and/or other predisposing comorbidities.…”

Anticipating and managing coagulopathy and thrombotic manifestations of severe COVID-19

“…33 Small vessel in situ stroke, embolic stroke and large vessel in situ occlusions are possible mechanisms for stroke in patients with COVID-19. 34 Cardiac injury (defined as serum high-sensitivity troponin above the 99th percentile of the upper limit of normal) has been shown to be common in patients with COVID-19 and associated with a markedly poorer prognosis. 35,36 Among 416 patients admitted to hospital with COVID-19, about 20% had cardiac injury.…”