Abstract P89: Covid-19 and Ischemic Stroke: A Systematic Review and Meta-Summary of the Literature

Abstract

Background: Acute ischemic stroke (AIS) is a life-threatening complication of coronavirus disease 2019 (COVID-19) infection. Increasing reports suggest an association between COVID-19 and AIS, although the underlying mechanism remains uncertain. Objectives: We performed a systematic review to characterize the clinical characteristics, neuroimaging findings, and outcomes of AIS in COVID-19 patients. Methods: A literature search was performed in PubMed and Embase using a suitable keyword search strategy from 1st December 2019 to 29th May 2020. All studies reporting AIS occurrence in COVID-19 patients were included. Results: A total of 39 studies comprising 135 patients were studied. The pooled incidence of AIS in COVID-19 patients from observational studies was 1.2% (54/4466) with a mean age of 63.4 ± 13.1 years. The mean duration of AIS from COVID-19 symptoms onset was 10 ± 8 days, and the mean NIHSS score was 19 ± 8. Laboratory investigations revealed an elevated mean D-dimer (9.2 ± 14.8 mg/L) and fibrinogen (5.8 ± 2.0 g/L). Antiphospholipid antibodies were detected in a significant number of cases. The majority of AIS neuroimaging patterns observed was large vessel thrombosis, embolism or stenosis (62.1%, 64/103), followed by multiple vascular territory (26.2%, 27/103). A high mortality rate was reported (38.0%, 49/129). Conclusion: We report the pooled incidence of AIS in COVID-19 patients to be 1.2%, with a high mortality rate. Elevated D-dimer, fibrinogen and the presence of antiphospholipid antibodies appear to be prominent in COVID-19 patients with concomitant AIS, but further mechanistic studies are required to elucidate their role in pathogenesis.

The Impact of the Pandemic on Acute Ischaemic Stroke Endovascular Treatment from a Multidisciplinary Perspective: A Nonsystematic Review

“…Despite current data showing reduced rates of stroke admissions during the pandemic, it is important to note that the full extent of stroke incidence in COVID-19 patients is difficult to accurately gauge, as evaluating critically ill, intubated and heavily sedated patients for acute neurological deficiencies is difficult, time-consuming and not routinely performed; incidentally, this group of patients may be at highest risk of developing AIS as a complication of SARS-CoV-2 infection, some of which may ultimately remain undiagnosed due to death from the underlying illness. A systematic review by Tan et al reported incidences of AIS among COVID-19 patients in five hospitals in different countries ranging from 0.9% to 2.7%, with an overall pooled incidence of 1.2%, with greater rates of stroke in patients hospitalised with a severe form of the infection [ 15 ]. A study by Merkler et al conducted in two New York hospitals found that the rate of stroke was higher in patients hospitalised or attending the ED due to COVID-19 infection compared to patients presenting with influenza; the authors did not, however, compare the incidence of AIS in COVID-19 patients to the general population [ 16 ].…”

Global impact of COVID-19 on stroke care

“…Our 1.45% stroke rate in COVID-19 hospitalizations is similar to the pooled incidence of 1.1-1.2% (range, 0.9-2.7%) of hospitalized COVID-19 patients. 28,29 Some variations in the proportions are expected given the different definitions (all strokes vs. ischemic only) and populations involved (all hospitalized vs. severely infected only) across studies. We also provide a new perspective on this relationship by reporting an incidence of 3.9% (784/20,250) for SARS-CoV-2 infection across all stroke admissions among centers with documented COVID-19 hospitalization.…”

Brain perfusion single-photon emission computerized tomography/computerized tomography: Stroke-like manifestations of COVID-19 with transient antiphospholipid elevation

“…Prior case series have shown an increased incidence of stroke [3] and deep venous thromboembolism, including younger patients, [7] suggesting an increased risk for hypercoagulable states such as antiphospholipid syndrome. In the case presented, brain perfusion ECD-SPECT/CT evaluation supported a diagnosis of cerebral ischemia rather than epilepsy in a patient with nonspecific neurologic manifestations and largely negative neurologic work up -in the setting COVID-19 and newly-elevated antiphospholipid markers.…”

“…[1] Neurologic manifestations associated with COVID-19 encompass a wide variety of symptoms with different proposed etiologies. The most common manifestations are headache and anosmia but, less commonly, patients may also present seizures, [2] ischemic stroke, [3] and GuillainBarre syndrome. [4,5] Determining the etiology of serious neurologic manifestations, such as seizures, in patients with COVID-19 can be a challenging undertaking as their pathophysiologic mechanisms are often unclear.…”