Acute Stroke in Covid-19 Infection: Neurology Intensive Care Experience

Abstract

Objective: Coronavirus disease 2019 (Covid-19) has been related to an increase in thrombotic events such as stroke. The purpose of this study was to search the effect of Covid-19 on clinical, laboratory parameters, and outcomes in stroke patients.
Material-Method: Patients with acute stroke and Covid 19 who were treated in the Neurology Intensive Care Unit between September 1, 2020 and January 30, 2021 were included in the study retrospectively. Patients' demographics, medical comorbidities, neurological symptoms, stroke risk factors, stroke severity, laboratory test results, imagings, as well as hospital outcomes were all investigated.
Results: 287 Covid-19 patients treated in the neurology intensive care unit were reviewed retrospectively, and 20 patients were included in the study. The meanage of the patients was 72.9 ± 16 (31-95) years-old with 11 males (55 %) and 9 females (45 % ). 9 patients had a pre-stroke diagnosis of Covid-19 infection, 11 patients (55%) were diagnosed with Covid-19 infectionby RT-PCR test (Real-time reverse transcription polymerase chain reaction) at admission. 18 patients had ischemic stroke and 2 patients had intracerebral hemorrhage.
Moderate stroke was detected in 13 (65%) patients at admission according to National Institutes of Health Stroke Scale Scores . The most common complaints at presentation were hemiparesis or hemiplegia (85%), speech disorder (60%), and impaired consciousness (60%). Hypertension (75%), diabetes mellitus (35%), coronary artery disease (30%) were the most common comorbid diseases. The patients had high procalcitonin, C-Reaktif protein, erythrocyte sedimentation rate, interleukin-6, d-dimer, fibrinogen, lactate dehydrogenase and low lymphocyte levels. The mortality rate was 30%.
Conclusion: Covid-19 increases the risk of ischemic stroke in the elderly with comorbid disease.

Keywords

• Covid-19
• stroke
• ischemic Stroke
• hemorrhagic stroke
• mortality

Covid-19 Enfeksiyonunda Akut İnme: Nöroloji Yoğun Bakım Deneyimi

Abstract

Amaç: Coronavirus hastalığı 2019 (Covid-19), inme gibi trombotik olaylardaki artışla ilişkilendirilmiştir. Bu çalışmanın amacı, Covid-19'un inme hastalarının klinik, laboratuvar ve prognoz sonuçları üzerine etkisini araştırmaktır.
Materyal-Metot: 1 Eylül 2020-30 Ocak 2021 tarihleri arasında Nöroloji Yoğun Bakım Ünitesinde tedavi gören akut inme ve Covid-19 birlikteliği olan hastalar retrospektif olarak çalışmaya dahil edildi. Hastaların demografik özellikleri, tıbbi komorbiditeleri, nörolojik semptomları, inme risk faktörleri, inme şiddeti, laboratuvar test sonuçları, görüntülemeleri ve hastane sonuçları kaydedildi.
Bulgular: Nöroloji yoğun bakımda tedavi edilen 287 Covid-19 hasta dosyası retrospektif olarak incelendi ve 20 hasta çalışmaya dahil edildi. Hastaların yaş ortalaması 72,9 ± 16 (31-95), cinsiyetleri 11 erkek (%55) ve 9 kadındı (%45). 9 hasta inme geçirmeden önce Covid-19 enfeksiyonu tanısı almıştı, 11 hastada (%55) ise başvuru sırasında RT-PCR test ile (Real-time reverse transcription polymerase chain reaction) Covid-19 enfeksiyonu teşhisi konuldu. 18 hastada iskemik inme, 2 hastada intraserebral kanama vardı. Başvuru sırasında 13 (%65) hastada National Institutes of Health Stroke Scale Scoress koruna göre orta şiddette inme tespit edildi. En sık başvuru şikayetleri, hemiparezi veya hemipleji (%85), konuşma bozukluğu (%60) ve bilinç bozukluğuydu (%60). Hipertansiyon (%75), diyabetes mellitus (%35), koroner arter hastalığı (%30) en sık eşlik eden komorbit hastalıklardı. Hastalarda prokalsitonin, C-reaktif protein, eritrosit sedimentasyon hızı, interlökin-6, D-dimer, fibrinojen, laktatdehidrogenaz, total bilirubin yüksekliği ve düşük lenfosit seviyeleri mevcuttu. Vaka ölüm oranı %30’du.
Sonuç: Covid-19 komorbid hastalığı olan yaşlılarda iskemik inme riskini artırır. 

Keywords

• Covid-19
• inme
• iskemik inme
• hemorajik inme
• mortalite

References

1. [1] Uday Jain.. Effect of COVID-19 on the Organs. Cureus 2020 Aug; 12(8): e9540.
2. [2] Montalvan V, Lee J, Bueso T, De Toledo J, Rivas K. Neurological manifestations of COVID-19 and other coronavirus infections: a systematic review. In.Vol 194. Clinical Neurology and Neurosurgery: Elsevier B.V.; 2020:105921–105921.
3. [3] Mao L, Jin H, Wang M, Hu Y, Chen S, He Q, Chang J, Hong C, Zhou Y, Wang D, et al. Neurologic manifestations of hospitalized patients with Coronavirus disease 2019 in Wuhan, China. JAMA Neurol. 2020;77:683–690. doi:10.1001/jamaneurol.2020.1127
4. [4] Li Y, Li M, Wang M, Zhou Y, Chang J, Xian Y, Wang D, Mao L, Jin H, Hu B. Acute cerebrovascular disease following COVID-19: a single center, retrospective, observational study. Stroke Vasc Neurol. 2020;5:279–284. doi: 10.1136/svn-2020-000431
5. [5] Lodigiani C, Iapichino G, Carenzo L, Cecconi M, Ferrazzi P, Sebastian T, Kucher N, Studt JD, Sacco C, Bertuzzi A, et al; Humanitas COVID-19 Task Force. Venous and arterial thromboembolic complications in COVID-19 patients admitted to an academic hospital in Milan, Italy. Thromb Res. 2020;191:9–14. doi: 10.1016/j.thromres.2020.04.024
6. [6] Klok FA, Kruip MJHA, van der Meer NJM, Arbous MS, Gommers D, Kant KM, Kaptein FHJ, van Paassen J, Stals MAM, Huisman MV, et al. Confirmation of the high cumulative incidence of thrombotic complications in critically ill ICU patients with COVID-19: an updated analysis. Thromb Res. 2020;191:148–150. doi: 10.1016/j.thromres.2020.04.041
7. [7] Helms J, Kremer S, Merdji H, Clere-Jehl R, Schenck M, Kummerlen C, Collange O, Boulay C, Fafi-Kremer S, Ohana M, et al. Neurologic features in severe SARS-CoV-2 infection. N Engl J Med. 2020;382:2268–2270. doi: 10.1056/NEJMc2008597.
8. [8] Li Y,Man Li M, Wang M, Zhou Y, Chang J, Xian Y,et all. Acute cerebrovascular disease following COVID-19: a single center, retrospective, observational study. Stroke & Vascular Neurology 2020;5:e000431. doi:10.1136/svn-2020-000431

9. [9] Benussi A, Pilotto A, Premi E, Libri I, Giunta M, Agosti C, Alberici A, Baldelli E, Benini M, Bonacina S, et al. Clinical characteristics and outcomes of inpatients with neurologic disease and COVID-19 in Brescia, Lombardy, Italy. Neurology. 2020;95:e910–e920. doi: 10.1212/WNL.0000000000009848
10. [10] Beyrouti R, Adams ME, Benjamin L, Cohen H, Farmer SF, Goh YY, Humphries F, Jäger HR, Losseff NA, Perry RJ, et al. Characteristics of ischaemic stroke associated with COVID-19. J Neurol Neurosurg Psychiatry. 2020;91:889–891. doi: 10.1136/jnnp-2020-323586
11. [11] Emsley HC, Hopkins SJ. Acute ischaemic stroke and infection: recent and emerging concepts. Lancet Neurol. 2008;7:341–353. doi: 10.1016/S1474-4422(08)70061-9
12. [12] Shao IY, Elkind MSV, Boehme AK. Risk factors for stroke in patients with sepsis and bloodstream infections. Stroke. 2019;50:1046–1051. doi: 10.1161/ STROKEAHA. 118.023443
13. [13] Esenwa CC, Elkind MS. Inflammatory risk factors, biomarkers and associated therapy in ischaemic stroke. Nat Rev Neurol. 2016;12:594–604. doi: 10.1038/nrneurol. 2016.125
14. [14] Al-Samkari H, Karp Leaf RS, Dzik WH, Carlson JCT, Fogerty AE, Waheed A, et al. COVID-19 and coagulation: bleeding and thrombotic manifestations of SARS-CoV-2 infection. Blood. 2020;136(4):489–500. pmid:32492712
15. [15] Nannoni S, Groot de R, Bell S and Markus S M. Stroke in COVID-19: A systematic review and meta-analysis. International Journal of Stroke 2021, Vol. 16(2) 137–149
16. [16] Ashrafi F, Zali A, Ommi D, et al. COVID-19-related strokes in adults below 55 years of age: a case series. Neurological Sciences volume 4;2020: 1985–1989
17. [17] Oxley TJ, Mocco J, Majidi S, et al. Large-vessel stroke as a presenting feature of Covid-19 in the young. N Engl J Med 2020;382(20). e60e60.
18. [18] Siow I, Lee S. K, Zhang J.Y. J, Saffari E. S, Ng A, and Young B. Stroke as a Neurological Complication of COVID-19: A Systematic Review and Meta-Analysis of Incidence, Outcomes and Predictors. Journal of Stroke and Cerebrovascular Diseases, Vol. 30, No. 3 (March), 2021: 105549
19. [19] Dhamoon S. M, Thaler A, Gururangan K, Kohli A, Sisniega D, Wheelwright D, et all. Acute Cerebrovascular Events With COVID-19 Infection. Stroke. 2021;52:48–56. DOI: 10.1161/STROKEAHA.120.031668
20. [20] You Y, Niu Y, Sun F, Zhang J, Huang S, Ding P, Wang X. Impact of COVID-19 pandemic on haemorrhagic stroke admissions: a systematic review and meta-analysis. BMJ Open 2021;11:e050559. doi:10.1136/bmjopen-2021-050559
21. [21] Syahrul S, Maliga A. H, Ilmawan M, Fahriani M, Mamada S. S, 0002-7813-21645, Fajar K. J, et all. Hemorrhagic and ischemic stroke in patients with coronavirus disease 2019: incidence, risk factors, and pathogenesis - a systematic review and meta-analysis. F1000Res 2021 Jan 19;10:34. doi: 10.12688/f1000research.42308.1. eCollection 2021.
22. [22] Nikolaos Panagiotis Margos P. N, Meintanopoulos S. A, Filioglou D, Ellul J. Intracerebral hemorrhage in COVID-19: A narrative review. Journal of Clinical Neuroscience 89 (2021) 271–278
23. [23] Wang H, Tang X, Fan H, et al. Potential mechanisms of hemorrhagic stroke in elderly COVID-19 patients. Aging. 2020; 12: 10022–10034.
24. [24] Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, Xiang J, Wang Y, Song B, Gu X, et al. Clinical course and risk factors for mortality of adult inpatients with COVID19 in Wuhan, China: a retrospective cohort study. Lancet. 2020;395:1054–1062. doi: 10.1016/S0140-6736(20) 30566-3
25. [25] Aggarwal G, Lippi G, Michael Henry B. Cerebrovascular disease is associated with an increased disease severity in patients with Coronavirus disease 2019 (COVID-19): a pooled analysis of published literature. Int J Stroke.
26. [26] Al-Samkari H, Karp Leaf S. R, Dzik H. W, Carlson C.T. J, Fogerty E. A, Waheed A. Et all. COVID-19 and coagulation: bleeding and thrombotic manifestations of SARS-CoV-2 infection. blood® 2020:136:4;489-500
27. [27] Thachil J, Tang N, Gando S, et al. ISTH interim guidance on recognition and management of coagulopathy in COVID-19. J Thromb Haemost 2020; 18: 1023–26.