key: cord-1003406-s6lh8h3j
authors: Mishra, Ajay Kumar; George, Anu Anna; Sargent, Jennifer
title: Letter to editor regarding “Acute Stroke Management During the Coronavirus Disease 2019 (COVID-19) Pandemic: From Trough of Disillusionment to Slope of Enlightenment”
date: 2020-06-24
journal: World Neurosurg
DOI: 10.1016/j.wneu.2020.06.111
sha: 7f24afdc3192579b040cc206672c6e225a311bf1
doc_id: 1003406
cord_uid: s6lh8h3j

nan

We believe literature on presentation, and management of stroke in patients with COVID-19 continues to be an evolving topic. COVID-19 which is an illness of international concern continues to affect a large number of patients with each passing day. 2 Literature on stroke in patients with COVID-19 has been limited. In this letter we hope to summarize the literature available on the clinical aspect of acute stroke among patients with COVID-19.

Presence of cerebrovascular events have been reported in less than 2% of patients with severe 

Multiple reports have documented new onset cerebrovascular events in patients with COVID-19.

Presence of low sensorium, focal neurological deficit, low Glasgow Coma Scale, in patients with severe COVID-19 has been instrumental in suspecting this diagnosis. 4 Most studies have reported computed tomography imaging of the brain in these patients. Anecdotal reports of magnetic resonance imaging of brain are also available in literature. Patients with severe COVID-19 are more prone to have these events. In a recent review these events have been shown to predict disease severity. 5

Multiple mechanisms of lung, cardiac, neurological, endothelial injury has been postulated in patients with COVID-19. 6 One of the mechanisms which has been targeted for treatment is injury secondary to embolism in the background of prothrombotic state. 7 These have been looked into due to the increased embolic events among patients with severe COVID-19, requiring intensive care unit admission, invasive mechanical ventilation. These have also been shown to predict disease severity, and mortality. There has been a recent surge of administering therapeutic anticoagulation in patients with elevated D-dimer with and without evident embolism, which has its own challenges. A recent study reported 33 patients of COVID-19, with intracranial hemorrhage while receiving therapeutic anticoagulation with unfractionated heparin or enoxaparin. Mortality in this group was 15.2% and was directly related to raised intracranial pressure. Interestingly only 20% of patients in this study were on any antiplatelet agents prior to the diagnosis of COVID-19. 8 In another study authors reported diffuse intraparenchymal hemorrhage in 3 COVID-19 patients who underwent diagnostic intracerebral biopsy. 9 Authors in this study hypothesized that active COVID-19 infection might predispose to increased risk of bleeding. 9 Hydroxychloroquine has also been used extensively during this pandemic. It has been shown to reduce the rates of acute myocardial infarction and cerebrovascular events in prior studies. 10 In conclusion, the interaction between COVID-19 and cerebrovascular events is complex. 11 Notably patients with severe COVID-19 are more prone to have had a prior stroke or a developing a new onset stroke. Figure 1 shows the mechanisms, interactions, and outcome of cerebrovascular events in COVID-19 patients. 12 Treatment related hemorrhage is significant and contributory to outcome. In patients with COVID-19 presenting with large vessel occlusion resulting in stroke, factors including severity of COVID-19, extent of other organ involvement including acute respiratory distress syndrome, acute myocardial injury, and acute kidney injury, level of inflammatory markers, presence of systemic prothrombotic state, and various treatment related factors should be incorporated into the treatment algorithm. 13 

Acute Stroke Management During the Coronavirus Disease 2019 (COVID-19) Pandemic: From Trough of Disillusionment to Slope of Enlightenment

Cardiovascular factors predicting poor outcome in COVID -19 patients

Cerebrovascular disease is associated with an increased disease severity in patients with coronavirus disease 2019 (COVID-19): a pooled analysis of published literature

Mechanisms of neurological injury in COVID -19

Cerebrovascular events in COVID-19 patients

A review of cardiac manifestations and predictors of outcome in patients with COVID -19

Incidence of thrombotic complications in critically ill ICU patients with COVID-19

Hemorrhagic stroke and anticoagulation in COVID-19

Acute hemorrhage after intra-cerebral biopsy in COVID-19 patients: a report of 3 cases

Hydroxychloroquine Use Is Associated With Decreased Incident Cardiovascular Events in Rheumatoid Arthritis Patients

Cardiovascular factors predicting poor outcome in COVID -19 patients

Reporting of all cardiac medications and their outcome in COVID -19

Figure 1: Factors affecting cerebrovascular events in patients with COVID-19