Background: Growing evidence showed that coronavirus disease 2019 (COVID-19) infection may present with neurological manifestations. This review aimed to determine the neurological manifestations and complications in COVID-19. Methods: We conducted a systematic review and meta-analysis that included cohort and case series/reports involving a population of patients confirmed with COVID-19 infection and their neurologic manifestations. We searched the following electronic databases until April 18, 2020: PubMed, Embase, Scopus, and World Health Organization database (PROSPERO registration number: CRD42020180658). Results: From 403 articles identified, 49 studies involving a total of 6,335 confirmed COVID-19 cases were included. The random-effects modeling analysis for each neurological symptom showed the following proportional point estimates with 95% confidence intervals: “headache” (0.12; 0.10–0.14; I2 = 77%), “dizziness” (0.08; 0.05–0.12; I2 = 82%), “headache and dizziness” (0.09; 0.06–0.13; I2 = 0%), “nausea” (0.07; 0.04–0.11; I2 = 79%), “vomiting” (0.05; 0.03–0.08; I2 = 74%), “nausea and vomiting” (0.06; 0.03–0.11; I2 = 83%), “confusion” (0.05; 0.02–0.14; I2 = 86%), and “myalgia” (0.21; 0.18–0.25; I2 = 85%). The most common neurological complication associated with COVID-19 infection was vascular disorders (n = 23); other associated conditions were encephalopathy (n = 3), encephalitis (n = 1), oculomotor nerve palsy (n = 1), isolated sudden-onset anosmia (n = 1), Guillain–Barré syndrome (n = 1), and Miller–Fisher syndrome (n = 2). Most patients with neurological complications survived (n = 14); a considerable number of patients died (n = 7); and the rest had unclear outcomes (n = 12). Conclusion: This review revealed that neurologic involvement may manifest in COVID-19 infection. What has initially been thought of as a primarily respiratory illness has evolved into a wide-ranging multi-organ disease.

Background: Despite the well-established potent benefit of mechanical thrombectomy (MT) for large vessel occlusion (LVO) stroke, access to MT has not been studied globally. We conducted a worldwide survey of countries on 6 continents to define MT access (MTA), the disparities in MTA, and its determinants on a global scale. Methods: Our survey was conducted in 75 countries through the Mission Thrombectomy 2020+ global network between November 22, 2020, and February 28, 2021. The primary end points were the current annual MTA, MT operator availability, and MT center availability. MTA was defined as the estimated proportion of patients with LVO receiving MT in a given region annually. The availability metrics were defined as ([current MT operators×50/current annual number of estimated thrombectomy-eligible LVOs]×100 = MT operator availability) and ([current MT centers×150/current annual number of estimated thrombectomy-eligible LVOs]×100= MT center availability). The metrics used optimal MT volume per operator as 50 and an optimal MT volume per center as 150. Multivariable-adjusted generalized linear models were used to evaluate factors associated with MTA. Results: We received 887 responses from 67 countries. The median global MTA was 2.79% (interquartile range, 0.70–11.74). MTA was <1.0% for 18 (27%) countries and 0 for 7 (10%) countries. There was a 460-fold disparity between the highest and lowest nonzero MTA regions and low-income countries had 88% lower MTA compared with high-income countries. The global MT operator availability was 16.5% of optimal and the MT center availability was 20.8% of optimal. On multivariable regression, country income level (low or lower–middle versus high: odds ratio, 0.08 [95% CI, 0.04–0.12]), MT operator availability (odds ratio, 3.35 [95% CI, 2.07–5.42]), MT center availability (odds ratio, 2.86 [95% CI, 1.84–4.48]), and presence of prehospital acute stroke bypass protocol (odds ratio, 4.00 [95% CI, 1.70–9.42]) were significantly associated with increased odds of MTA. Conclusions: Access to MT on a global level is extremely low, with enormous disparities between countries by income level. The significant determinants of MT access are the country’s per capita gross national income, prehospital LVO triage policy, and MT operator and center availability.

In the Philippines, the mortality from stroke during the last 10 years remains high. This paper aims to describe the gaps in stroke care and the development of stroke systems of care in the Philippines. Gaps in stroke systems of care include low number of neurologist, inadequate CT scan machines, lack of stroke training among health workers, lack of stroke protocols and pathways, poor community stroke awareness, low government insurance coverage with high out of pocket medical expenses, lack of infrastructure for EMS, inadequate acute stroke ready hospitals, stroke units and rehabilitation facilities. Although there are government programs for primary stroke prevention, the strategies are inadequate to address the stroke pandemic. The Stroke Society of the Philippines has worked with the government for nationwide and regional stroke training of health care workers, community stroke awareness, setting up acute stroke ready hospitals and acute stroke units in different areas of the country and adapting stroke protocols and pathways. Stroke registries are now utilized for quality improvement. Thrombolysis rate has improved from 1.4% in 2014–2016 to 11% in 2021 based on RES-Q database. Because of government subsidy, thrombolysis in the government hospitals is higher at 7.4% (range 4.4–16.9) compared to 4.8% (range 0–10.1) rate in private hospitals. Mechanical thrombectomy rate remained low at 0.4% of all acute ischemic stroke patients because of the cost. With limited resources, infrastructures for emergency medical service is lacking. The innovations done by other LMIC can be done in the Philippines including the use of technology to reach out to geographically isolated areas and use of mobile stroke units. Non neurologist can be trained to help treat stroke patients. Upgrading of the Philhealth insurance to cover for reperfusion therapies, adequate stroke infrastructures and network, and increase in community stroke awareness are areas for improvement in the Philippine stroke systems of care.

Introduction. Stroke can be a complication and/or a presenting sign of COVID-19 infection. Although there is growing evidence on stroke in COVID-19 infection, only a few of these studies were done in Asia and there is very scarce evidence in the local setting.Objective. This study aimed to characterize the clinical profile, management, and functional outcome of patients with acute stroke and COVID-19 infection.Methods. This was a single-center retrospective study from March 30 to October 20, 2020. The demographic characteristics, respiratory symptoms, risk factors, neuroimaging, stroke characteristics, ancillary test results, treatment given, and functional outcome were obtained through a review of medical records. Computation of the mean, standard deviation, median, interquartile range, total count, and percentage was done for data analysis.Results. Out of 2,018 patients with COVID-19 infection, 41 (2%) developed an acute stroke. The mean age of patients was 59.05 ± 14.04 years. Majority were men (n=24, 59%). Ischemic stroke (n=28, 68%) was the most common stroke with the anterior circulation commonly involved (n=21, 72%). The most common risk factors were hypertension (n=31, n=76%), cigarette smoking (n=18, 44%), dyslipidemia (n=16, 39%), and ethanol use (n=16, 39%). Among those with stroke and COVID-19 infection, 42% had mild infection and 29% had critical disease. The inflammatory markers were elevated in these patients. Upon discharge, 83% had a poor functional outcome (mRS 3-6). The overall mortality rate was high (n=24, 59%) with pulmonary cause as the most common cause of death. Conclusion.Ischemic stroke was the most common stroke type in patients infected with COVID-19. The common risk factors were hypertension, dyslipidemia, smoking, ethanol use, and diabetes mellitus. The functional outcome was generally poor and the mortality rate was high. More studies are needed that compare these subsets of patients with a control group, including a longer follow up.

Background: Stroke is the second leading cause of death in the Philippines. There is no Filipino data on stroke recurrence rates. Aim: The present study aimed to determine the risk of recurrence for stroke, myocardial infarction and death among Filipino patients taking varying doses of aspirin with first-ever non-cardioembolic strokes, and identify factors associated with stroke recurrence. Methods: Patients aged 40-79 years with non-cardioembolic ischemic stroke within 30 days from symptom onset who were taking varying doses of aspirin were included, and followed up monthly for the occurrence of recurrent stroke, myocardial infarction and/or death. Demographic and clinical data were collected at baseline and during each follow-up assessment. Results: A total of 262 patients with first-ever, non-cardioembolic stroke were included. The mean age was 56 AE 9 years. The mean follow-up was 263.4 days. The cumulative survival rate for recurrent stroke was 92.1% at 1 year and 87.6% at 2 years. The cumulative survival rate for combined outcome of recurrent stroke, myocardial infarction, and/ or death was 91.1% at 1 year and 82.1% at 2 years. Stroke recurrence was associated with the lack of effort to modify diet. Conclusions: Among Filipino patients taking aspirin for first-ever, non-cardioembolic ischemic stroke, the risk for stroke recurrence was 7.9% in the first year and 12.4% in the second year. The risk for combined stroke, myocardial infarction, and death was 8.9% in the first year and 17.9% in the second year. The lack of effort to modify diet was associated with stroke recurrence.

Background. Various epidemiologic studies reported different stroke incidence and prevalence rates in the Philippines. Thus, there is a need to synthesize existing information on these indicators to depict more accurate evidence on the burden on stroke in the country.Objective. The objective of this systematic review is to provide evidence on the incidence and prevalence of stroke in the Philippines, as well as its associated risk factors.Methods. PubMed and HERDIN were searched for available full-text Philippine epidemiologic studies on stroke incidence and prevalence, whether population or hospital-based, and its associated risk factors. We used three tools for risk of bias assessment, namely, the Newcastle Ottawa Scale for cohort studies, the Quality assessment checklist of Hoy et al. for cross-sectional prevalence studies, and the AXIS tool for general cross-sectional studies.Results. A total of 14 studies were included in this review. Based on these studies, the national stroke incidence rate ranged from 3.95% to 5.61%, while the national stroke prevalence rate ranged from 0.486% to 6.0%. Hypertension remains the commonly reported risk factor of stroke alongside diabetes, smoking, and high cholesterol level. Conclusions.Despite limitations, we were able to perform a complete assessment of the risk of bias in included studies which provide information on the studies with reliable information. Based on this systematic review, there is variability on data and limited studies on the national epidemiology of stroke in the Philippines. It is recommended that the national government consider establishing a system such as a national registry for better data collection and analysis.

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