Novel coronavirus SARS-CoV-2 has created unprecedented healthcare challenges. Neurologic deficits are often an important presenting symptom. To date, the only reported post-infectious COVID-19 manifestations of neurologic disease include cognitive deficits and dysfunction of the peripheral nervous system. Here we report that seizure can also be a post-COVID-19 or “long-COVID” complication. We present a 71-year-old man with hypertension, diabetes mellitus, and COVID-19 diagnosed by RT-PCR who initially presented with posterior circulation stroke-like symptoms, which completely resolved after emergent thrombolysis. Six days later, the patient returned with seizure activity, supported by radiographic and electroencephalographic studies. Notably, he was negative for SARS-CoV-2, and no other provoking factor was uncovered after a comprehensive work-up. To our knowledge, this is the first report of post-infectious seizures after a case of COVID-19, highlighting the potential importance of monitoring for neurologic symptoms in COVID-19 patients, even after convalescence.
Mucormycosis is a fast-spreading angioinvasive fungal infection with a very high mortality rate. It is associated with immunodeficiency, diabetes mellitus, iron overload, stem cell transplantation and the use of steroids. As cultures and histopathological biopsy may have low yield in invasive fungal infections, new generation sequencing of cfDNA (cell free deoxyribonucleic acid) has become a cornerstone for diagnosis. Over the past 18 months, increasing reports of COVID-19 associated Mucormycosis have emerged, most specifically in India and other nearby developing countries. Awareness and knowledge of this newly discovered association is of high importance and clinical relevance as the global COVID-19 pandemic continues. Herein, we present a case of a patient who was treated with steroids for COVID-19 in the outpatient setting and presented with unilateral periorbital pain and blurry vision. She progressively developed bilateral vision loss, fixed bilateral mydriasis, ophthalmoplegia and coma. Imaging findings included leptomeningeal, vascular, and subcortical enhancement accompanied with multifocal infarction. Subsequent biopsy of the paranasal sinuses revealed broad type fungal elements and cfDNA sequencing identified the pathogen as Rhizopus species. She was treated with intravenous amphotericin B, but succumbed to the infection.
Introduction: Primary care plays an essential role in stroke prevention. Yet still, for many stroke patients, a relationship with a primary care provider (PCP) is not established until after stroke. Our goal was to determine if lack of PCP and the consequential differences in management affects stroke severity. Methods: Data was obtained from our Institutional Review Board approved stroke admission database from 2017 to November 2019 of all stroke subtypes (ischemic stroke, transient ischemic attack, subarachnoid and intracerebral hemorrhages). Non-parametric Mann Whitney t-test and regression analysis was used to identify significant differences in medications, stroke risk factors and stroke severity. Results: A total of 559 patients were included, median age 67 (interquartile range (IQR) 58-76), 49% woman, 32% established care with a PCP, 36% on medications for diabetes mellitus (DM), 42% hyperlipidemia, 66% anti-hypertensives, 39% anti-platelet agents, and 10% anticoagulation. More patients with PCP were taking anti-hypertensive medications (80% versus (vs) 60%, p value < 0.0001), DM medications (56% vs 30%, p value < 0.0001), anti-platelet agents (46% vs 35%, p value = 0.0149), and medications for hyperlipidemia (49% vs 39%, p value = 0.0426). Admission NIHSS was lower in patients with a PCP median 6 (IQR 3-11) vs median 9 (IQR 4 -15), p value= 0.0016, and median hemoglobin A1c was higher in patients with a PCP 8 (IQR 5.7- 9.3) vs patients without a PCP prior to their stroke 6 (IQR 5.4 - 8.5), p value= 0.0002. Admitting systolic blood pressure was similar 155 (137-177) vs 152 (134-171). After correcting for age and gender, regression analysis demonstrated a significant association between whether a patient had PCP and antihypertensive medication use (odds ratio (OR) 2.413, 95% confidence interval 1.511 - 3.914) and hemoglobin A1c (OR 1.122, 95% CI 1.037 - 1.215). Also, patients with a PCP were more likely to have a lower NIHSS on admission (OR 0.9679, 95% CI 0.9423 - 0.9930). Conclusions: These result show that patients not followed by a PCP prior to stroke are less likely to be on medications for primary prevention of stroke, contributing to an increased stroke severity on admission. More research is needed to identify barriers to patients establishing care with PCP.
Introduction: The COVID-19 pandemic has impacted stroke care and highlighted health care disparities. We aimed to determine if stroke alert (SA) volume, stroke alert mimic (SAM) volume, utilization of reperfusion therapies, and socioeconomic and race ethnic determinants of clinical outcome were impacted by the pandemic. Methods: Data was obtained from our Institutional Review Board approved SA database from February 2019-June 2019 and February 2020-June 2020 to capture the impact of the stay at home orders enacted at the end of March 2020 and the increase of COVID-19 cases in Florida in June 2020. Regression analysis was used to identify differences in volumes of SA, reperfusion therapy, SAM, and clinical factors (NIHSS, age, sex, race, ethnicity, insurance status, and rural region). Results: A total of 1171 SA were included, median age 66 (interquartile range 55-76), 50% woman, 23% Black, 68% Non-Hispanic White, 1% Hispanic, 8% unknown; 52% of the SA were SAM. SA volumes, thrombolysis and endovascular therapy use was unchanged. The volume of SAM did not differ between time intervals, but SAM were more likely to be older (odds ratio (OR) 1.03, 95% confidence interval (CI) 1.02 - 1.04), White (OR 1.80, 95% CI 1.09 -2.99), uninsured (OR 2.19, 95% CI 1.35 - 3.46), arrive by EMS (OR 1.77, 95% CI 1.31- 2.40), and have a higher NIHSS (OR 1.02, 95% CI 1.003 - 1.034). SAM secondary to migraine, intoxication, medication toxicity, or psychiatric disease were less likely to occur in April 2020 (OR 0.37, CI 0.15- 0.96) and in patients from rural regions (OR 0.42, CI 0.19 - 0.95). They were more likely to occur in older patients (OR 1.06, CI 1.05-1.07) and men (OR 2.31, CI 1.62 - 3.31). SAM secondary to seizure were more likely to occur in April 2020 (OR 2.46, CI 1.06- 0.96) and Whites (OR 2.22, CI 1.16 -4.26). SAM from medical or non-cerebrovascular or epileptic neurologic disease were unchanged. Conclusions: Significant changes in the frequency of SAM subtypes occurred in close proximity to stay-at-home orders. Our findings suggest that a proportion of Blacks and Hispanics were not accessing healthcare for stroke like symptoms during the stay-at-home orders. Thus, patient education on how to access healthcare in vulnerable populations should be included with implementation of stay at home orders.
Introduction: Evidence is unclear for invention in patients with a mild stroke (low NIHSS) and LVO (large vessel occlusion) as only 15-17 patients with NIHSS < 6 were included in the randomized trials. Cohort studies report good and poor outcomes in low NIHSS LVO cases, with some reporting poor complications secondary to complications and associated with burden of chronic illness. The THRIVE (Total Health Risk in Vascular Events) score was previously associated with poor outcomes in stroke patients. We hypothesized that the THRIVE score may be associated with poor outcomes in low NIHSS LVO patients. Methods: An IRB approved retrospective stroke study from January 2015 to December 2019 was used. Out of 2401 eligible acute ischemic stroke patients, 107 patients with an NIHSS < 6 with an LVO were included in the analysis. Non-parametric t-test, Chi-squared, and logistic regression were used for statistical analysis. Results: Of the 107 patients, the median age was 65 (55-74, interquartile range (IQR), 36% were female, 79% Caucasian, 44% had a discharge modified Rankin Score (mRS) of 0-1, 65% had a THRIVE score < 3, and time from LSN to presentation was 210 minutes (89 – 723 IQR). There was no difference in age, gender, race, time from LSN, or percent of patients with a THRIVE score < 3 (55% with IR vs 65% No IR). However, patients treated with a thrombectomy were significantly less likely to have a good neurologic outcome with discharge mRS of 0-1 if taken for thrombectomy (0% IR group versus 49% No IR, p=<0.0001). Of those taken for IR, 4 were basilar artery occlusions with poor outcomes, 4 MCA occlusions re-occluded post-IR were complicated by re-occlusion or high-grade stenosis. Notably, 54% had TTP lesions with cortex, but only 2 patients had significant cortical infarcts, and there was no symptomatic hemorrhagic conversion. Conclusion: Decision-making on IR for patients with low NHISS should be tailored to the patient, as it is likely that the inherent clinical factors prompting thrombectomy to be considered despite the low NIHSS are the important driving factors increasing the likelihood of worse outcomes. Further research is needed to evaluate the type of neurologic deficits and the eloquence of the tissue involved.
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