Acute Stroke in COVID-19 Patients

Mohsen Alshamam^1, , Merjona Saliaj¹, Nso Nso¹, Priyanka Moondra² and Umair Ali¹

¹Internal Medicine, NYC H+H-Queens, NYC, 11432, U.S

²Neurology, Northwell Health, New Hyde Park, NY, 11042, U.S

Cite this paper:
Mohsen Alshamam, Merjona Saliaj, Nso Nso, Priyanka Moondra and Umair Ali. Acute Stroke in COVID-19 Patients. International Journal of Clinical and Experimental Neurology. 2020; 8(1):14-23. doi: 10.12691/ijcen-8-1-4

Abstract

The novel Coronavirus-19 (COVID-19) outbreak has brought unprecedented implications globally for the medical community and continues to present challenges when delivering neurological care and intervention. Here we describe six patients with acute cerebrovascular symptoms and concurrent COVID-19 infection who presented to our hospital. This is a retrospective case series study of six patients presenting with neurological, either with or without respiratory symptoms. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was suspected in the patients. Testing was conducted by BioReference Lab with the reverse-transcriptase polymerase chain reaction (RT-PCR) assay for most patients. Brain imaging revealed evidence of acute cerebral infarction. Ethical approval and informed consent waivers when appropriate were granted by the Mount Sinai Institutional Review Board. The study was conducted at NYC Health + Hospitals-Queens in Jamaica, New York. All patients were men, ages 39 to 69 years, four of whom were found to have associated risk factors for stroke. Inflammatory markers were elevated in most patients and brain imaging revealed ischemic infarcts. With the exception of one patient who expired, five patients made a significant recovery. Ischemic stroke was one of many newfound complications related to the COVID-19 infection. In our case reports, many patients did not present with respiratory symptoms, however, all tested positive for COVID-19. Neurological sequelae related to COVID-19 apart from cerebrovascular disease continue to be discovered. With growing evidence that the central nervous system is vulnerable to the devastating effects of COVID-19, testing should be expedited in all patients presenting with neurological symptoms during the COVID-19 pandemic.

Keywords:
CVA/Acute stroke COVID-19 coronavirus neurology hypercoagulability

This work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/

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References:

[1]	Markus HS, Brainin M. COVID-19 and stroke-A global World Stroke Organization perspective. Int J Stroke. 2020; 15(4): 361-4.
[2]	World Health Organization. Coronavirus disease (COVID-19) Situation Report - 201 2020 [Available from: https://www.who.int/docs/default-source/coronaviruse/situation- reports/20200808-covid-19-sitrep-201.pdf?sfvrsn=121bb855_2.
[3]	Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020; 395(10223): 497-506.
[4]	Inciardi RM, Lupi L, Zaccone G, Italia L, Raffo M, Tomasoni D, et al. Cardiac Involvement in a Patient With Coronavirus Disease 2019 (COVID-19). JAMA Cardiol. 2020.
[5]	Fan H, Tang X, Song Y, Liu P, Chen Y. Influence of COVID-19 on Cerebrovascular Disease and its Possible Mechanism. Neuropsychiatr Dis Treat. 2020; 16: 1359-67.
[6]	Mao L, Jin H, Wang M, Hu Y, Chen S, He Q, et al. Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China. JAMA Neurology. 2020; 77(6): 683-90.
[7]	Rothstein A, Oldridge O, Schwennesen H, Do D, Cucchiara BL. Acute Cerebrovascular Events in Hospitalized COVID-19 Patients. Stroke. 2020: STROKEAHA120030995.
[8]	Merkler AE, Parikh NS, Mir S, Gupta A, Kamel H, Lin E, et al. Risk of Ischemic Stroke in Patients With Coronavirus Disease 2019 (COVID-19) vs Patients With Influenza. JAMA Neurol. 2020.
[9]	Tang Y, Liu J, Zhang D, Xu Z, Ji J, Wen C. Cytokine Storm in COVID-19: The Current Evidence and Treatment Strategies. Front Immunol. 2020; 11: 1708. Published 2020 Jul 10.
[10]	Zhang, Y. et al. Coagulopathy and antiphospholipid antibodies in patients with Covid-19. N. Engl. J. Med. 382, e38 (2020).
[11]	Merrill, J.T., Erkan, D., Winakur, J. et al. Emerging evidence of a COVID-19 thrombotic syndrome has treatment implications. Nat Rev Rheumatol (2020).
[12]	Yaghi S, Ishida K, Torres J, Grory BM, Raz E, Humbert K, et al. SARS2-CoV-2 and Stroke in a New York Healthcare System. Stroke. 2020; 51(7): 2002-11.
[13]	Moshayedi P, Ryan TE, Mejia LLP, Nour M, Liebeskind DS. Triage of Acute Ischemic Stroke in Confirmed COVID-19: Large Vessel Occlusion Associated With Coronavirus Infection. Front Neurol. 2020; 11: 353.
[14]	Diaz-Segarra N, Edmond A, Kunac A, Yonclas P. COVID-19 Ischemic Strokes as an Emerging Rehabilitation Population: A Case Series. Am J Phys Med Rehabil. 2020.
[15]	Sharifi-Razavi A, Karimi N, Zarvani A, Cheraghmakani H, Baghbanian SM. Ischemic stroke associated with novel coronavirus 2019: a report of three cases. Int J Neurosci. 2020: 1-5.
[16]	Rudilosso S, Esteller D, Urra X, Chamorro A. Thalamic perforating artery stroke on computed tomography perfusion in a patient with coronavirus disease 2019. J Stroke Cerebrovasc Dis. 2020; 29(8): 104974.
[17]	Reddy ST, Garg T, Shah C, Nascimento FA, Imran R, Kan P, et al. Cerebrovascular Disease in Patients with COVID-19: A Review of the Literature and Case Series. Case Rep Neurol. 2020; 12(2): 199-209.
[18]	Meyer D, Meyer BC, Rapp KS, Modir R, Agrawal K, Hailey L, et al. A Stroke Care Model at an Academic, Comprehensive Stroke Center During the 2020 COVID-19 Pandemic. J Stroke Cerebrovasc Dis. 2020; 29(8):104927.
[19]	Bersano A, Kraemer M, Touze E, Weber R, Alamowitch S, Sibon I, et al. Stroke care during the COVID-19 pandemic: experience from three large European countries. Eur J Neurol. 2020.
[20]	Baracchini C, Pieroni A, Viaro F, Cianci V, Cattelan AM, Tiberio I, et al. Acute stroke management pathway during Coronavirus-19 pandemic. Neurol Sci. 2020; 41(5): 1003-5.
[21]	Rinkel LA, Prick JCM, Slot RER, Sombroek NMA, Burggraaff J, Groot AE, et al. Impact of the COVID-19 outbreak on acute stroke care. J Neurol. 2020.
[22]	Morelli N, Rota E, Terracciano C, Immovilli P, Spallazzi M, Colombi D, et al. The Baffling Case of Ischemic Stroke Disappearance from the Casualty Department in the COVID-19 Era. Eur Neurol. 2020; 83(2): 213-5.
[23]	Thornton J. Stroke: "striking reductions" are seen in number of people with symptoms seeking help. BMJ. 2020; 369: m1406.
[24]	Bres Bullrich M, Fridman S, Mandzia JL, Mai LM, Khaw A, Vargas Gonzalez JC, et al. COVID-19: Stroke Admissions, Emergency Department Visits, and Prevention Clinic Referrals. Can J Neurol Sci. 2020: 1-4.
[25]	Mehta P, McAuley DF, Brown M, Sanchez E, Tattersall RS, Manson JJ, et al. COVID-19: consider cytokine storm syndromes and immunosuppression. Lancet. 2020; 395(10229): 1033-4.
[26]	Chen G, Wu D, Guo W, Cao Y, Huang D, Wang H, et al. Clinical and immunological features of severe and moderate coronavirus disease 2019. J Clin Invest. 2020; 130(5): 2620-9.
[27]	Akhmerov A, Marban E. COVID-19 and the Heart. Circ Res. 2020; 126(10): 1443-55.
[28]	Ackermann M, Verleden SE, Kuehnel M, Haverich A, Welte T, Laenger F, et al. Pulmonary Vascular Endothelialitis, Thrombosis, and Angiogenesis in Covid-19. N Engl J Med. 2020; 383(2): 120-8.
[29]	Bikdeli B, Madhavan MV, Jimenez D, Chuich T, Dreyfus I, Driggin E, et al. COVID-19 and Thrombotic or Thromboembolic Disease: Implications for Prevention, Antithrombotic Therapy, and Follow-Up: JACC State-of-the-Art Review. J Am Coll Cardiol. 2020; 75(23): 2950-73.
[30]	Belani P, Schefflein J, Kihira S, Rigney B, Delman BN, Mahmoudi K, et al. COVID-19 Is an Independent Risk Factor for Acute Ischemic Stroke. AJNR Am J Neuroradiol. 2020.
[31]	Li B, Yang J, Zhao F, Zhi L, Wang X, Liu L, et al. Prevalence and impact of cardiovascular metabolic diseases on COVID-19 in China. Clin Res Cardiol. 2020; 109(5): 531-8.
[32]	Arany PR, Cho A, Hunt TD, Sidhu G, Shin K, Hahm E, et al. Photoactivation of endogenous latent transforming growth factor-beta1 directs dental stem cell differentiation for regeneration. Sci Transl Med. 2014; 6(238): 238ra69.
[33]	Wu C, Chen X, Cai Y, Xia J, Zhou X, Xu S, et al. Risk Factors Associated With Acute Respiratory Distress Syndrome and Death in Patients With Coronavirus Disease 2019 Pneumonia in Wuhan, China. JAMA Intern Med. 2020.
[34]	Lippi G, Plebani M. Procalcitonin in patients with severe coronavirus disease 2019 (COVID-19): A meta-analysis. Clin Chim Acta. 2020; 505: 190-1.
[35]	Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020; 395(10229): 1054-62.
[36]	Wu Y, Xu X, Chen Z, Duan J, Hashimoto K, Yang L, et al. Nervous system involvement after infection with COVID-19 and other coronaviruses. Brain Behav Immun. 2020; 87: 18-22.
[37]	Zhao J, Li H, Kung D, Fisher M, Shen Y, Liu R. Impact of the COVID-19 Epidemic on Stroke Care and Potential Solutions. Stroke. 2020; 51(7): 1996-2001.
[38]	Fifi JT, Mocco J. COVID-19 related stroke in young individuals. Lancet Neurol. 2020; 19(9): 713-715.