Coronavirus disease 2019 and stroke in Iran: a case series and effects on stroke admissions

Abstract

Objective The coronavirus disease 2019 pandemic has affected healthcare systems around the globe and massively impacted patients with various non-infectious, life-threatening conditions. Stroke is a major neurological disease contributing to death and disability worldwide, and is still an ongoing issue during the pandemic. Here we investigate the impact of the coronavirus disease 2019 outbreak on stroke manifestations, treatment courses, the outcome of stroke patients, and the hospitalization rate in a referral center for stroke management in Tehran, Iran. Methods We extracted data regarding 31 stroke patients (10 patients with laboratory-confirmed coronavirus disease 2019) and compared the demographic and pathological characteristics of the patients with or without coronavirus disease 2019 infection. The association of demographic/pathological characteristics of stroke patients during the coronavirus disease 2019 pandemic and a corresponding period during the previous year (49 patients) and an earlier period during the same year as the pandemic (50 patients) was also evaluated. Results The absolute number of admissions decreased about 40% during the coronavirus disease 2019 pandemic. Except for the stroke severity (P = 0.002), there were no significant changes in the demographic and pathological characteristics of the stroke patients during the three studied periods. A significantly higher mean of age (75.60 ± 9.54 versus 60.86 ± 18.45; P = 0.007), a significant difference in the type of stroke (P = 0.046), and significantly higher stroke severity (P = 0.024) were observed in stroke patients with coronavirus disease 2019 compared with those of stroke patients without coronavirus disease 2019. Treatment approaches, duration of hospitalization, and mortality rates did not differ significantly. Conclusions This report shows that the pandemic caused the number of acute stroke admissions to plummet compared to other periods. Although the pandemic did not affect the treatment plans and care of the patients, stroke cases with coronavirus disease 2019 had higher age, more large vessel ischemic stroke, and more severe stroke. Further studies are urgently needed to realize the probable interaction of the coronavirus disease 2019 pandemic and the neurologic disease.

Characteristics and Comparison of 32 COVID-19 and Non-COVID-19 Ischemic Strokes and Historical Stroke Patients

“…To our knowledge, this is the first study that compares COVID-19 patients to non-COVID-19 patients within a prospectively collected stroke database. Similar to previous case reports and case-controlled studies, from USA ( 10 ), Iran ( 26 ), Dubai ( 27 ), France ( 28 ) and China ( 8 ), a third of our COVID-19 positive patients had severe disease, required ICU admissions, stayed longer in hospital and had fewer subjects with good outcome. These patients likely represent a subset of stroke patients in whom the viral infection likely contributed to a prothrombotic state resulting in vascular occlusions and large strokes.…”

SARS-CoV-2 and Stroke Characteristics: A Report from the Multinational COVID-19 Stroke Study Group

“…Comparing these patients with our stroke registry of 8,929 AIS patients (GNSIS, Geisinger NeuroScience Ischemic Stroke database) indicated a higher prevalence of patients with no known risk factor (22.0% in this study versus 11.5% in GNSIS, p<0.001). We also observed that the patients in this study were younger (60.0±18.0 years versus 62.9±17.6 years, p=0.004) and had more severe strokes (NIHSS of 8 [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22] Among the AIS patients, 13.6% of patients received intravenous thrombolysis, while 7.4% underwent mechanical thrombectomy. These rates are similar to the multinational study on 174 AIS SARS-CoV-2 infected patients (12.7% thrombolysis, 6.9% thrombolysis, and thrombectomy, and 5.2% mechanical thrombectomy).…”

“…[5,78,79,83] In addition, less severe stroke symptoms, mostly in critically ill patients or overwhelmed health centers, were more likely to be under-diagnosed. We observed a lower median NIHSS score in countries with middle to high-health expenditure-8 [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17] versus 11 [5][6][7][8][9][10][11][12][13][14][15][16][17] in countries with lower health expenditure. The regional difference in the severity of stroke in our study-NIHSS of 12 [6][7][8][9][10][11][12][13][14][15][16][17] in the Middle East, versus 7[0-16] in America and 8 [4][5][6][7]…”

“…versus 4[2][3][4][5][6][7], p<0.001). Further investigation is needed to present the etiology and possible risk factors among these patients as well as to define the underlying predispositions and pathogenic pathways occurring in SARS-CoV-2 infected individuals.…”

COVID‐19 as a Blood Clotting Disorder Masquerading as a Respiratory Illness: A Cerebrovascular Perspective and Therapeutic Implications for Stroke Thrombectomy

“…This reduction in stroke admissions is reiterated in a nationwide analysis of data ( n = 231,753 patients), on patients who underwent neuroimaging studies for stroke in 856 hospitals in the United States, which showed a 39% reduction in the number of patients who received evaluations for acute stroke in a 2‐week period between March 26, 2020 and April 8, 2020 (during the initial surge phase) compared to the prepandemic era 30 . Similar reductions in stroke admissions due to a possible “bystander effect” have been reported in Michigan and Northwest Ohio (17.8% reduction in March 2020 compared to February 2020), 31 and in Tehran, Iran (40% reduction between February 15, 2020 and April 15, 2020 compared to the period between September 15, 2019 and February 15, 2020) 32 …”