COVID-19-associated stroke
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Parul Pahal, M.B.B.S[2]
Synonyms and keywords:
Overview
Historical Perspective
Neurological symptoms in Coronavirus disease 2019 (COVID-19) patients were first reported in February 2020 in a retrospective case series study by Mao L. et al. in hospitalized COVID-19 patients in Wuhan. Ling Mao from Tongji Medical College in Wuhan, and his group reviewed the data retrospectively from January 16, 2020, to February 19, 2020. One third of the 214 hospitalized laboratory- confirmed COVID-19 patients included in this study reported at least one neurologic symptom. The symptoms range from non-specific symptoms like headache, myalgia, fatigue, to more specific symptoms like seizure, coma, and acute cerebrovascular disease. However, incidence of acute cerebrovascular disease or stroke was higher in severe cases of COVID-19.[1]
Classification
There is no specific classification established for 'Stroke in COVID-19 patients. It is same as the general classification of stroke
Stroke can be classified into
- Ischemic stroke: This can be due to
- Thrombosis (Large vessel or Small vessel thrombosis)
- Embolism
- Systemic hypoperfusion
- Hemorrhagic stroke: This can be due to
Pathophysiology
The exact pathogenesis of 'stroke in COVID-19' is not fully understood. However, the following explanation regarding pathogenesis is-
- Sepsis induced coagulopathy in COVID-19 patients is thought to be contributing to microthromobosis.
- The angiotensin-converting enzyme II (ACEII) receptors are also present on the vascular endothelial cells and neural cells in the brain . These receptors expressed in the brain are responsible for sympathoadrenal system regulation, and vascular autoregulation[2]. When the virus binds to these receptors, this vascular autoregulation is hampered and can lead to elevated blood pressure, eventually leading to rupture of the cerebral vessels and intracranial hemorrhage[3]. It does so by altering the balance of renin-angiotensin system which likely triggers endothelium dysfunction, organ damage, which eventually results in stroke[4].
- Viral Neurotropism is another possible pathogenic mechanism for cerebrovascular accidents in COVID-19 patients. The coronaviruses usually cause mild respiratory illness, but the beta coronavirues are known to have a role in nervous system involvement[5]. The Novel coronavirus “severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)” is a beta coronavirus, similar to severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV)[6]. It,therefore, has infection mechanism and potential to invade the nervous system, similar to SARS-Cov and MERS-Cov[7]. The detection of virus in the cells of the brain on autopsy[8] (neural and capillary endothelial cells), and viral presence in the cerebrospinal fluid of the encephalitis patient infected with SARS-Cov-2[9] supports the neuro-invasiveness of the virus. The two possible routes are retrograde axonal transport (via nasal cavity) or hematogenous spread (via blood brain barrier endothelial cells)[8]. Once the virus reaches the brain, it attaches with the ACE II receptors.
Further investigations should be done to better understand the mechanism of Stroke in patients with COVID-19.
Causes
- Coronavirus disease 2019 (COVID-19) associated stroke is caused by SARS-CoV-2.
- click here to read more about SARS-Cov-2 virus
Differentiating COVID-19-associated stroke from other Diseases
[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].
OR
[Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].
Epidemiology and Demographics
The incidence of stroke in hospitalized COVID-19 patients is reported to be 0.9–2%.[10] The incidence of stroke in patients infected with SARS-Cov-2 virus was higher in younger men.[11]
Stroke is one of the neurological manifestations in patients with severe infection (Mao et al., 2020).
Risk Factors
There are no established risk factors for [disease name].
OR
The most potent risk factor in the development of [disease name] is [risk factor 1]. Other risk factors include [risk factor 2], [risk factor 3], and [risk factor 4].
OR
Common risk factors in the development of [disease name] include [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].
OR
Common risk factors in the development of [disease name] may be occupational, environmental, genetic, and viral.
Screening
There is insufficient evidence to recommend routine screening for [disease/malignancy].
OR
According to the [guideline name], screening for [disease name] is not recommended.
OR
According to the [guideline name], screening for [disease name] by [test 1] is recommended every [duration] among patients with [condition 1], [condition 2], and [condition 3].
Natural History, Complications, and Prognosis
If left untreated, [#]% of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
OR
Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
OR
Prognosis is generally excellent/good/poor, and the 1/5/10-year mortality/survival rate of patients with [disease name] is approximately [#]%.
Cerebral hemorrhage or ischemia disrupts cerebral perfusion and can lead to an acute neurologic condition, stroke. It is one of the neurological complications of SARS-Cov-2 infection, and is seen in critically ill COVID-19 patients. 5% of hospitalized COVID-19 patients with severe illness had acute stroke, with majority of patients with Ischemic stroke. The severe and critically ill patients when compared to moderate cases, had increased hypercoagulability and inflammatory markers. These patients are at higher risk for stroke. The better outcomes in critically ill patients who received prophylactic thrombolytic therapy points towards a possibility of hypercoagulability associated with COVID-19.[10]
Diagnosis
Diagnostic Study of Choice
The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1], [criterion 2], [criterion 3], and [criterion 4].
OR
The diagnosis of [disease name] is based on the [criteria name] criteria, which include [criterion 1], [criterion 2], and [criterion 3].
OR
The diagnosis of [disease name] is based on the [definition name] definition, which includes [criterion 1], [criterion 2], and [criterion 3].
OR
There are no established criteria for the diagnosis of [disease name].
History and Symptoms
- The majority of patients with COVID-19-associated stroke present with respiratory symptoms. e.g. cough, shortness of breath etc.
- ....reported till now has specific clinical manifestations:
The majority of patients with [disease name] are asymptomatic.
OR
The hallmark of [disease name] is [finding]. A positive history of [finding 1] and [finding 2] is suggestive of [disease name]. The most common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3]. Common symptoms of [disease] include [symptom 1], [symptom 2], and [symptom 3]. Less common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3].
Physical Examination
Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
OR
Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].
OR
The presence of [finding(s)] on physical examination is diagnostic of [disease name].
OR
The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
Laboratory Findings
An elevated/reduced concentration of serum/blood/urinary/CSF/other [lab test] is diagnostic of [disease name].
OR
Laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].
OR
[Test] is usually normal among patients with [disease name].
OR
Some patients with [disease name] may have elevated/reduced concentration of [test], which is usually suggestive of [progression/complication].
OR
There are no diagnostic laboratory findings associated with [disease name].
Electrocardiogram
There are no ECG findings associated with [disease name].
OR
An ECG may be helpful in the diagnosis of [disease name]. Findings on an ECG suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
X-ray
There are no x-ray findings associated with [disease name].
OR
An x-ray may be helpful in the diagnosis of [disease name]. Findings on an x-ray suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
OR
There are no x-ray findings associated with [disease name]. However, an x-ray may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
Echocardiography or Ultrasound
There are no echocardiography/ultrasound findings associated with [disease name].
OR
Echocardiography/ultrasound may be helpful in the diagnosis of [disease name]. Findings on an echocardiography/ultrasound suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
OR
There are no echocardiography/ultrasound findings associated with [disease name]. However, an echocardiography/ultrasound may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
CT scan
There are no CT scan findings associated with [disease name].
OR
[Location] CT scan may be helpful in the diagnosis of [disease name]. Findings on CT scan suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
OR
There are no CT scan findings associated with [disease name]. However, a CT scan may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
MRI
There are no MRI findings associated with [disease name].
OR
[Location] MRI may be helpful in the diagnosis of [disease name]. Findings on MRI suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
OR
There are no MRI findings associated with [disease name]. However, a MRI may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
Other Imaging Findings
There are no other imaging findings associated with [disease name].
OR
[Imaging modality] may be helpful in the diagnosis of [disease name]. Findings on an [imaging modality] suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
Other Diagnostic Studies
There are no other diagnostic studies associated with [disease name].
OR
[Diagnostic study] may be helpful in the diagnosis of [disease name]. Findings suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
OR
Other diagnostic studies for [disease name] include [diagnostic study 1], which demonstrates [finding 1], [finding 2], and [finding 3], and [diagnostic study 2], which demonstrates [finding 1], [finding 2], and [finding 3].
Treatment
Medical Therapy
There is no treatment for [disease name]; the mainstay of therapy is supportive care.
OR
Supportive therapy for [disease name] includes [therapy 1], [therapy 2], and [therapy 3].
OR
The majority of cases of [disease name] are self-limited and require only supportive care.
OR
[Disease name] is a medical emergency and requires prompt treatment.
OR
The mainstay of treatment for [disease name] is [therapy].
OR
The optimal therapy for [malignancy name] depends on the stage at diagnosis.
OR
[Therapy] is recommended among all patients who develop [disease name].
OR
Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
OR
Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
OR
Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
OR
Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].
Surgery
Surgical intervention is not recommended for the management of [disease name].
OR
Surgery is not the first-line treatment option for patients with [disease name]. Surgery is usually reserved for patients with either [indication 1], [indication 2], and [indication 3]
OR
The mainstay of treatment for [disease name] is medical therapy. Surgery is usually reserved for patients with either [indication 1], [indication 2], and/or [indication 3].
OR
The feasibility of surgery depends on the stage of [malignancy] at diagnosis.
OR
Surgery is the mainstay of treatment for [disease or malignancy].
Primary Prevention
There are no established measures for the primary prevention of [disease name].
OR
There are no available vaccines against [disease name].
OR
Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].
OR
[Vaccine name] vaccine is recommended for [patient population] to prevent [disease name]. Other primary prevention strategies include [strategy 1], [strategy 2], and [strategy 3].
Secondary Prevention
There are no established measures for the secondary prevention of [disease name].
OR
Effective measures for the secondary prevention of [disease name] include [strategy 1], [strategy 2], and [strategy 3].
References
- ↑ Mao, Ling; Wang, Mengdie; Chen, Shanghai; He, Quanwei; Chang, Jiang; Hong, Candong; Zhou, Yifan; Wang, David; Li, Yanan; Jin, Huijuan; Hu, Bo (2020). doi:10.1101/2020.02.22.20026500. Missing or empty
|title=(help) - ↑ Saavedra, Juan M. (2005). "Brain Angiotensin II: New Developments, Unanswered Questions and Therapeutic Opportunities". Cellular and Molecular Neurobiology. 25 (3–4): 485–512. doi:10.1007/s10571-005-4011-5. ISSN 0272-4340.
- ↑ Sharifi-Razavi, A.; Karimi, N.; Rouhani, N. (2020). "COVID-19 and intracerebral haemorrhage: causative or coincidental?". New Microbes and New Infections. 35: 100669. doi:10.1016/j.nmni.2020.100669. ISSN 2052-2975.
- ↑ Hess, David C.; Eldahshan, Wael; Rutkowski, Elizabeth (2020). "COVID-19-Related Stroke". Translational Stroke Research. 11 (3): 322–325. doi:10.1007/s12975-020-00818-9. ISSN 1868-4483.
- ↑ Arbour, Nathalie; Day, Robert; Newcombe, Jia; Talbot, Pierre J. (2000). "Neuroinvasion by Human Respiratory Coronaviruses". Journal of Virology. 74 (19): 8913–8921. doi:10.1128/JVI.74.19.8913-8921.2000. ISSN 1098-5514.
- ↑ Yu, Fei; Du, Lanying; Ojcius, David M.; Pan, Chungen; Jiang, Shibo (2020). "Measures for diagnosing and treating infections by a novel coronavirus responsible for a pneumonia outbreak originating in Wuhan, China". Microbes and Infection. 22 (2): 74–79. doi:10.1016/j.micinf.2020.01.003. ISSN 1286-4579.
- ↑ Li, Yan‐Chao; Bai, Wan‐Zhu; Hashikawa, Tsutomu (2020). "The neuroinvasive potential of SARS‐CoV2 may play a role in the respiratory failure of COVID‐19 patients". Journal of Medical Virology. 92 (6): 552–555. doi:10.1002/jmv.25728. ISSN 0146-6615.
- ↑ Jump up to: 8.0 8.1 Paniz‐Mondolfi, Alberto; Bryce, Clare; Grimes, Zachary; Gordon, Ronald E.; Reidy, Jason; Lednicky, John; Sordillo, Emilia Mia; Fowkes, Mary (2020). "Central nervous system involvement by severe acute respiratory syndrome coronavirus‐2 (SARS‐CoV‐2)". Journal of Medical Virology. 92 (7): 699–702. doi:10.1002/jmv.25915. ISSN 0146-6615.
- ↑ Moriguchi, Takeshi; Harii, Norikazu; Goto, Junko; Harada, Daiki; Sugawara, Hisanori; Takamino, Junichi; Ueno, Masateru; Sakata, Hiroki; Kondo, Kengo; Myose, Natsuhiko; Nakao, Atsuhito; Takeda, Masayuki; Haro, Hirotaka; Inoue, Osamu; Suzuki-Inoue, Katsue; Kubokawa, Kayo; Ogihara, Shinji; Sasaki, Tomoyuki; Kinouchi, Hiroyuki; Kojin, Hiroyuki; Ito, Masami; Onishi, Hiroshi; Shimizu, Tatsuya; Sasaki, Yu; Enomoto, Nobuyuki; Ishihara, Hiroshi; Furuya, Shiomi; Yamamoto, Tomoko; Shimada, Shinji (2020). "A first case of meningitis/encephalitis associated with SARS-Coronavirus-2". International Journal of Infectious Diseases. 94: 55–58. doi:10.1016/j.ijid.2020.03.062. ISSN 1201-9712.
- ↑ Jump up to: 10.0 10.1 Mao, Ling; Jin, Huijuan; Wang, Mengdie; Hu, Yu; Chen, Shengcai; He, Quanwei; Chang, Jiang; Hong, Candong; Zhou, Yifan; Wang, David; Miao, Xiaoping; Li, Yanan; Hu, Bo (2020). "Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China". JAMA Neurology. 77 (6): 683. doi:10.1001/jamaneurol.2020.1127. ISSN 2168-6149.
- ↑ Yaghi, Shadi; Ishida, Koto; Torres, Jose; Mac Grory, Brian; Raz, Eytan; Humbert, Kelley; Henninger, Nils; Trivedi, Tushar; Lillemoe, Kaitlyn; Alam, Shazia; Sanger, Matthew; Kim, Sun; Scher, Erica; Dehkharghani, Seena; Wachs, Michael; Tanweer, Omar; Volpicelli, Frank; Bosworth, Brian; Lord, Aaron; Frontera, Jennifer (2020). "SARS-CoV-2 and Stroke in a New York Healthcare System". Stroke. 51 (7): 2002–2011. doi:10.1161/STROKEAHA.120.030335. ISSN 0039-2499.