Stroke in patients with SARS-CoV-2 infection: case series

Abstract

Background Italy is one of the most affected countries by the coronavirus disease 2019 (COVID-19). The responsible pathogen is named severe acute respiratory syndrome coronavirus (SARS-CoV-2). The clinical spectrum ranges from asymptomatic infection to severe pneumonia, leading to intensive care unit admission. Evidence of cerebrovascular complications associated with SARS-CoV-2 is limited. We herein report six patients who developed acute stroke during COVID-19 infection. Methods A retrospective case series of patients diagnosed with COVID-19 using reverse-transcriptase polymerase chain reaction (RT-PCR) on nasopharyngeal swabs, who developed clinical and neuroimaging evidence of acute stroke during SARS-CoV-2 infection. Results Six patients were identified (5 men); median age was 69 years (range 57-82). Stroke subtypes were ischemic (4, 67%) and hemorrhagic (2, 33%). All patients but one had pre-existing vascular risk factors. One patient developed encephalopathy prior to stroke, characterized by focal seizures and behavioral abnormalities. COVID-19-related pneumonia was severe (i.e., requiring critical care support) in 5/6 cases (83%). Liver enzyme alteration and lactate dehydrogenase (LDH) elevation were registered in all cases. Four patients (67%) manifested acute kidney failure prior to stroke. Four patients (67%) had abnormal coagulation tests. The outcome was poor in the majority of the patients: five died (83%) and the remaining one (17%) remained severely neurologically affected (mRS: 4). Conclusions Both ischemic and hemorrhagic stroke can complicate the course of COVI-19 infection. In our series, stroke developed mostly in patients with severe pneumonia and multiorgan failure, liver enzymes and LDH were markedly increased in all cases, and the outcome was poor.

Exacerbation of neurological symptoms and COVID-19 severity in patients with preexisting neurological disorders and COVID-19: A systematic review

“…The full-text screening of these studies led to the exclusion of 286 that did not meet the inclusion criteria. The remaining 26 studies were identified as eligible to be reviewed [ 6 , 7 , [11] , [12] , [13] , [14] , [15] , [16] , [17] , [18] , [19] , [20] , [21] , [22] , [23] , [24] , [25] , [26] , [27] , [28] , [29] , [30] , [31] , [32] , [33] , [34] ]. Fig.…”

Stroke and Novel Coronavirus Infection in Humans: A Systematic Review and Meta-Analysis

“…A total sample of 8,771 participants was included in the systematic review. These studies were conducted in many countries worldwide including in China ( 13 , 40 , 43 ), France ( 37 , 39 , 48 , 50 ), India ( 42 ), Iran ( 51 ), Italy ( 32 , 33 , 46 ), the Netherlands ( 34 ), Philippines ( 52 ), Spain ( 44 , 53 ), Turkey ( 58 ), UK ( 41 , 55 ), and the USA ( 21 , 35 , 36 , 45 , 47 , 49 , 54 , 56 , 57 ). Out of 27 studies, eight studies were of retrospective cohort study design, 11 were case series, and nine were case reports.…”

Neurological Manifestations in Critically Ill Patients With COVID-19: A Retrospective Study

“…Accumulating evidence suggested that neuroimaging features of hospitalized COVID-19 patients were variable, dominated by acute ischemic infarction and intracranial hemorrhages (19)(20)(21)(22)(23)(24). Besides, leptomeningeal enhancement, hypoxic-ischemic brain injury, cortical signal abnormalities that may be caused by systemic toxemia were also reported (23,34,35).…”

“…Data from Wuhan, China, reported that acute cerebrovascular disease (mainly ischemic stroke) was more common among 88 patients with severe COVID-19 than those with non-severe disease (5.7 vs. 0.8%) (13). In recent case series, ischemic stroke of both large artery-and small vessel-etiology have been reported (19)(20)(21)(22)(23)(24). In the present study, stroke was diagnosed in 7 of 86 critically ill patients with COVID-19 and 6 cases were classified as ischemic stroke.…”

“…Recent data from Wuhan, China, reported neurological complications in 36% of 214 COVID-19 patients (13). The neurological manifestations can vary from mild and unspecific symptoms, such as headache and hyposmia, to catastrophic symptoms, including stroke, acute hemorrhagic necrotizing encephalopathy, encephalitis/meningitis and Guillain-Barré syndrome (13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25). However, neurological features of COVID-19 infection in critically ill patients, have not been fully investigated.…”