Ischemic stroke associated with novel coronavirus 2019: a report of three cases

Neurological manifestations of COVID-19: a systematic review and detailed comprehension

The current pandemic caused by severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) is accompanied with a rapid increase of reports and papers detailing its neurological effects and symptoms. The virus infection causes respiratory illness named by the world health organization as corona virus 19 (COVID-19).This systematic review aims to study and summarize the different neurological manifestations of this virus. All articles published and indexed via Pubmed, Medline and Google Scholar databases between January 1st 2020 and February 28th 2021 that reported neurological symptoms of SARS-CoV-2 are reviewed following the Preferred Reporting Items for Systemic review and Meta-Analysis (PRISMA) guidelines.We included data from 113 articles: eight prospective studies, 25 retrospective studies and the rest were case reports/series. COVID-19 can present with central nervous system manifestations, such as headache, encephalitis and encephalopathy, peripheral nervous system manifestations, such as anosmia, ageusia and Guillian Barre syndrome, and skeletal muscle manifestations, such as myalgia and myasthenia gravis. Our systematic review showed that COVID-19 can be manifested by a wide spectrum of neurological symptoms reported either in the early stage or within the course of the disease. However, a detailed comprehension of these manifestations is required and more studies are needed in order to improve our scientific knowledge and to develop preventive and therapeutic measures to control this pandemic.

Potential risk of liver injury in epileptic patients during COVID-19 pandemic

Most of the antiseizure medications (ASMs) are metabolized in liver and many of them particularly first-generation ASMs have the potential to increase liver enzymes or induce liver injury. Hence, treatment of new onset seizures or epilepsy by ASMs during the course of coronavirus disease 2019 (COVID-19), which could potentially be complicated by hepatic dysfunction, is a challenging clinical issue. Intravenous form of levetiracetam which has no significant hepatic metabolism or drug-drug interaction is often a favorable option to control seizures in acute phase of COVID-19. Administration of enzyme inducer ASMs and valproate with the well-known hepatotoxicity and common drug interactions is not generally recommended. In patients with epilepsy who are under control with potentially hepatotoxic ASMs, close observation and cautious dose reduction or drug switch should be considered if any evidence of hepatic impairment exists. However, risks of possible breakthrough seizures should be weighed against benefits of lowering the hazard of liver injury. In patients with epilepsy who receive polytherapy with ASMs, transient dose modification with the tendency to increase the dose of ASMs with more favorable safety profile and less drug interaction and decrease the dose of drugs with main hepatic metabolism, high protein binding, potential to cause liver injury and known drug-drug reaction should be considered. Finally, decision making should be individualized based on patients' conditions and course of illness.

Neurological Manifestations of Hospitalized COVID-19-Infected Patients: A Single-Center Cohort Study

Background: Although COVID-19 preferentially affects the respiratory system, it has been demonstrated that coronaviruses frequently invade the nervous system. Objectives: We aimed to report the frequency and type of neurological manifestations in hospitalized patients with COVID-19. Methods: This is a retrospective, prospective observational cohort study. Data were collected from April to July 2020 at Bu-Ali Sina University Hospital, Sari, Iran. Demographic data and clinical symptoms were recorded at the onset of the disease. Neurological manifestations were recorded into 5 categories: nonspecific central nervous system (CNS) manifestations, acute cerebrovascular disease (CVD), meningitis/encephalitis, peripheral nervous system manifestations, and inflammatory disorders (myelitis and acute disseminated encephalomyelitis). Results: A total of 420 patients were admitted to the hospital with confirmed SARS-CoV-2 infection. Of the 420 patients hospitalized with COVID-19, 282 (67%) showed some form of neurological symptoms, of whom 48.33% had nonspecific neurological symptoms. Further, 35 (8.3%) patients had acute CVD, 2 patients had encephalitis (the RNA of SARS-CoV-2 was detected in cerebrospinal fluid (CSF), 1 patient had myelitis, and 83 (19.76%) patients had peripheral nervous system manifestations. Conclusions: Neurologic symptoms (from mild symptoms to life-threatening CNS disorders) are common in admitted patients with COVID-19. As a result of coagulation disorder in patients with COVID-19, some conditions (such as stroke) can be seen, even during recovery.

Foreign accent syndrome and other neuropsychological sequelae of a parieto-occipital lesion following COVID-19 associated posterior reversible encephalopathy syndrome

OBJECTIVE

We describe a previously fit and well 54-year-old female who acquired a range of severe and persisting neuropsychological impairments following a posterior reversible encephalopathy syndrome (PRES) complication of COVID-19. The initial presentation included aphasia, a neurogenic foreign accent syndrome (FAS) and a persisting complete cortical blindness from the underpinning parieto-occipital brain injury.

METHOD

Neuropsychological single clinical case report.

RESULTS

The patient retained insight and made good early progress with their adjustment to the numerous losses caused by the COVID-19 associated acquired brain injury. Comprehensive neuropsychological investigation characterised an acalculia, along with deficits in focused, sustained and divided attention impacting on verbal memory, working memory and executive functioning, amongst numerous relative strengths.

CONCLUSION

Similar to PRES from other aetiologies, COVID-19 associated PRES can in some cases cause irreversible acquired brain injury. The diverse neuropsychological effects need to be comprehensively investigated and managed. This case adds to the neuropsychological literature on PRES, FAS and acquired brain injury as a rare complication of SARS-CoV-2.

Cerebral microvascular complications associated with SARS-CoV-2 infection: How did it occur and how should it be treated?

Cerebral microvascular disease has been reported as a central feature of the neurological disorders in patients with SARS-CoV-2 infection that may be associated with an increased risk of ischemic stroke. The main pathomechanism in the development of cerebrovascular injury due to SARS-CoV-2 infection can be a consequence of endothelial cell dysfunction as a structural part of the blood-brain barrier (BBB), which may be accompanied by increased inflammatory response and thrombocytopenia along with blood coagulation disorders. In this review, we described the properties of the BBB, the neurotropism behavior of SARS-CoV-2, and the possible mechanisms of damage to the CNS microvascular upon SARS-CoV-2 infection.

Systemic inflammation in COVID‐19 patients may induce various types of venous and arterial thrombosis: A systematic review

COVID‐19 is a global pandemic with a daily increasing number of affected individuals. Thrombosis is a severe complication of COVID‐19 that leads to a worse clinical course with higher rates of mortality. Multiple lines of evidence suggest that hyperinflammation plays a crucial role in disease progression. This review compiles clinical data of COVID‐19 patients who developed thrombotic complications to investigate the possible role of hyperinflammation in inducing hypercoagulation. A systematic literature search was performed using PubMed, Embase, Medline and Scopus to identify relevant clinical studies that investigated thrombotic manifestations and reported inflammatory and coagulation biomarkers in COVID‐19 patients. Only 54 studies met our inclusion criteria, the majority of which demonstrated significantly elevated inflammatory markers. In the cohort studies with control, D‐dimer was significantly higher in COVID‐19 patients with thrombosis as compared to the control. Pulmonary embolism, deep vein thrombosis and strokes were frequently reported which could be attributed to the hyperinflammatory response associated with COVID‐19 and/or to the direct viral activation of platelets and endothelial cells, two mechanisms that are discussed in this review. It is recommended that all admitted COVID‐19 patients should be assessed for hypercoagulation. Furthermore, several studies have suggested that anticoagulation may be beneficial, especially in hospitalized non‐ICU patients. Although vaccines against SARS‐CoV‐2 have been approved and distributed in several countries, research should continue in the field of prevention and treatment of COVID‐19 and its severe complications including thrombosis due to the emergence of new variants against which the efficacy of the vaccines is not yet clear.

Neurological manifestations and neuroimaging findings in patients with SARS-CoV2-a systematic review

BACKGROUND

The COVID-19 pandemic has drastically affected everyone in a hit or miss manner. Since it began, evidence of the neuro-invasive potential of the virus has been intensifying significantly. Several pathways have been hypothesized to elucidate the neurotropic nature of SARS-CoV2. It is the need of the hour to collect vital information.

OBJECTIVE

To evaluate and correlate the neuro-radiological and neurological manifestations in patients diagnosed with SARS-CoV2.To identify neuro-invasive pathways of COVID infection.

METHODS

Relevant studies were identified through four databases-the Cochrane Library, PubMed, Science Direct, and Web of Science. These were searched using relevant keywords-"COVID-19," "SARS-CoV2," "neurological manifestations," "neuroimaging," "CT," and "MRI." Relevant articles were screened according to a pre-defined inclusion and exclusion criteria from December 2019 to August 2020.

RESULTS

Our review included a total of 63 full text publications with 584 patients, composed mainly of observational studies, case reports, and case series. The most common neurological manifestations associated with COVID-19 were altered mental status, stroke, and paralysis. About 17.85% patients who underwent neuroimaging were found to be having ischemic changes suggestive of a stroke. This was followed by hemorrhagic changes as the second most common finding. The most commonly involved vessel was the Middle Cerebral Artery. Besides stroke, we found that SARS-CoV2 could be the cause for new-onset seizures, Guillain-Barre Syndrome, encephalitis, and many other severe neurological diseases.

CONCLUSION

The information that we have obtained so far will prove dynamic to healthcare providers working against the COVID-19 pandemic. It is necessary to be aware of these atypical neurological findings for the early diagnosis and treatment of COVID-19 infected patients. However, to completely understand the connection between SARS-CoV2 and the nervous system, further research is necessary.

Neurological manifestations of COVID-19: with emphasis on Iranian patients

The novel coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has instigated a global pandemic as a formidable and highly contagious infectious disease. Although the respiratory system remains the most frequently affected organ, several case reports have revealed that the complications are not merely limited to the respiratory system, and neurotropic and neuroinvasive properties have also been observed, leading to neurological diseases. In the present paper, it was intended to review the possible neuroinvasive routes of SARS-CoV-2 and its mechanisms that may cause neurological damage. Additionally, the neurological manifestations of COVID-19 across the globe were discussed with emphasis on Iran, while highlighting the impact of SARS-CoV-2 on the central and peripheral nervous systems.

COVID-19 and stroke: from the cases to the causes

During COVID-19 pandemic, a wide variety of stroke typologies have been described in patients affected by SARS-CoV-2. Investigating the case reports of acute stroke in COVID-19 patients, published since the beginning of the pandemic, we tried to trace the pathogenic mechanisms of stroke during SARS-CoV-2 infection. We conducted a systematic review analyzing demographic data, cerebrovascular risk factors, NIHSS score, vascular territory involvement and laboratory findings of 168 patients described in 89 studies, from a pool of 1243 records. Based on our results, we have identified different stroke profiles: (1) cerebral large vessel disease (CLVD) profile with a low disability, simultaneous onset of COVID-19 and stroke symptoms, good outcome and low serum levels of D-dimer and CRP; (2) intracranial bleeding (IB) profile with high disability, poor outcome and low levels of serum markers of inflammation and coagulopathy; (3) CLVD profile with a short time-lapse between COVID-19 symptoms and stroke onset, high neurological disability and very high systemic inflammatory markers; (4) multiple thrombo-embolic disease (MTED) profile with older patients, many comorbidities, disabling stroke, poor outcome, evident alteration of coagulation tests and high serum levels of both D-dimer and CRP. We therefore summarized these different profiles in a spectrum similar to that of visible light, where the violet-blue band included IB and CSVD with low inflammation and prothrombotic activity, the green-yellow band included CLVD with high inflammation and moderate prothrombotic activity and the orange-red band for MTED with moderate-high levels of inflammation and very high prothrombotic activity.

[COVID-19 and stroke]

Due to the pandemic of corona virus disease 2019 (COVID-19), the stroke medical care system is unavoidably undergoing major changes such as a decrease in the number of stroke patients receiving consultation, delay in consultation, and a decrease in the number of intravenous thrombolysis and mechanical thrombectomy procedures. Stroke incidence in COVID-19 patients is approximately 1.1%. The features of stroke with COVID-19 have been elucidated: higher incidence in ischemic stroke than hemorrhagic stroke, increasing number of young patients, high D-dimer levels, and higher risk in elderly patients with cardiovascular risk factors such as hypertension and diabetes. In patients with COVID-19, venous thromboembolism is more common than arterial thromboembolism, and stroke is more common than acute coronary syndrome. Protected code stroke (PCS) has been proposed which provides safe, effective and prompt treatment under complete infection control.

Neurological manifestations of COVID-19: a systematic review and meta-analysis of proportions

BACKGROUND

Coronaviruses mainly affect the respiratory system; however, there are reports of SARS-CoV and MERS-CoV causing neurological manifestations. We aimed at discussing the various neurological manifestations of SARS-CoV-2 infection and to estimate the prevalence of each of them.

METHODS

We searched the following electronic databases; PubMed, MEDLINE, Scopus, EMBASE, Google Scholar, EBSCO, Web of Science, Cochrane Library, WHO database, and ClinicalTrials.gov . Relevant MeSH terms for COVID-19 and neurological manifestations were used. Randomized controlled trials, non-randomized controlled trials, case-control studies, cohort studies, cross-sectional studies, case series, and case reports were included in the study. To estimate the overall proportion of each neurological manifestations, the study employed meta-analysis of proportions using a random-effects model.

RESULTS

Pooled prevalence of each neurological manifestations are, smell disturbances (35.8%; 95% CI 21.4-50.2), taste disturbances (38.5%; 95%CI 24.0-53.0), myalgia (19.3%; 95% CI 15.1-23.6), headache (14.7%; 95% CI 10.4-18.9), dizziness (6.1%; 95% CI 3.1-9.2), and syncope (1.8%; 95% CI 0.9-4.6). Pooled prevalence of acute cerebrovascular disease was (2.3%; 95%CI 1.0-3.6), of which majority were ischaemic stroke (2.1%; 95% CI 0.9-3.3), followed by haemorrhagic stroke (0.4%; 95% CI 0.2-0.6), and cerebral venous thrombosis (0.3%; 95% CI 0.1-0.6).

CONCLUSIONS

Neurological symptoms are common in SARS-CoV-2 infection, and from the large number of cases reported from all over the world daily, the prevalence of neurological features might increase again. Identifying some neurological manifestations like smell and taste disturbances can be used to screen patients with COVID-19 so that early identification and isolation is possible.

Clinical Characteristics of Stroke with COVID-19: A Systematic Review and Meta-Analysis

BACKGROUND

The coronavirus disease 2019 (COVID-19) potentially increases the risk of thromboembolism and stroke. Numerous case reports and retrospective cohort studies have been published with mixed characteristics of COVID-19 patients with stroke regarding age, comorbidities, treatment, and outcome. We aimed to depict the frequency and clinical characteristics of COVID-19 patients with stroke.

METHODS

PubMed and EMBASE were searched on June 10, 2020, to investigate COVID-19 and stroke through retrospective cross-sectional studies, case series/reports according to PRISMA guidelines. Study-specific estimates were combined using one-group meta-analysis in a random-effects model.

RESULTS

10 retrospective cohort studies and 16 case series/reports were identified including 183 patients with COVID-19 and stroke. The frequency of detected stroke in hospitalized COVID-19 patients was 1.1% ([95% confidential interval (CI)]: [0.6-1.6], I2 = 62.9%). Mean age was 66.6 ([58.4-74.9], I2 = 95.1%), 65.6% was male (61/93 patients). Mean days from symptom onset of COVID-19 to stroke was 8.0 ([4.1-11.9], p< 0.001, I2 = 93.1%). D-dimer was 3.3 μg/mL ([1.7-4.9], I2 = 86.3%), and cryptogenic stroke was most common as etiology at 50.7% ([31.0-70.4] I2 = 64.1%, 39/71patients). Case fatality rate was 44.2% ([27.9-60.5], I2 = 66.7%, 40/100 patients).

CONCLUSIONS

This systematic review assessed the frequency and clinical characteristics of stroke in COVID-19 patients. The frequency of detected stroke in hospitalized COVID-19 patients was 1.1% and associated with older age and stroke risk factors. Frequent cryptogenic stroke and elevated d-dimer level support increased risk of thromboembolism in COVID-19 associated with high mortality. Further study is needed to elucidate the pathophysiology and prognosis of stroke in COVID-19 to achieve most effective care for this population.

COVID-19 and Cerebrovascular Diseases: A Systematic Review and Perspectives for Stroke Management

Importance: Reported cerebrovascular events in patients with COVID-19 are mainly ischemic, but hemorrhagic strokes and cerebral venous sinus thrombosis (CSVT), especially in critically ill patients, have also been described. To date, it is still not clear whether cerebrovascular manifestations are caused by direct viral action or indirect action mediated by inflammatory hyperactivation, and in some cases, the association may be casual rather than causal. Objective: To conduct a systematic review on the cerebrovascular events in COVID-19 infection. Evidence review: A comprehensive literature search on PubMed was performed including articles published from January 1, 2020, to July 23, 2020, using a suitable keyword strategy. Additional sources were added by the authors by reviewing related references. The systematic review was conducted in accordance with the PRISMA guidelines. Only articles reporting individual data on stroke mechanism and etiology, sex, age, past cardiovascular risk factors, COVID symptoms, admission NIHSS, D-dimer levels, and acute stroke treatment were selected for the review. Articles that did not report the clinical description of the cases were excluded. A descriptive statistical analysis of the data collected was performed. Finding: From a total of 1,210 articles published from January 1, 2020, to July 23, 2020, 80 articles (275 patients), which satisfied the abovementioned criteria, were included in this review. A total of 226 cases of ischemic stroke (IS), 35 cases of intracranial bleeding, and 14 cases of CVST were found. Among patients with IS, the mean age was 64.16 ±14.73 years (range 27-92 years) and 53.5% were male. The mean NIHSS score reported at the onset of stroke was 15.23 ±9.72 (range 0-40). Primary endovascular thrombectomy (EVT) was performed in 24/168 patients (14.29%), intravenous thrombolysis (IVT) was performed in 17/168 patients (10.12%), and combined IVT+EVT was performed in 11/168 patients (6.55%). According to the reported presence of large vessel occlusion (LVO) (105 patients), 31 patients (29.52%) underwent primary EVT or bridging. Acute intracranial bleeding was reported in 35 patients: 24 patients (68.57%) had intracerebral hemorrhage (ICH), 4 patients (11.43%) had non-traumatic subarachnoid hemorrhage (SAH), and the remaining 7 patients (20%) had the simultaneous presence of SAH and ICH. Fourteen cases of CVST were reported in the literature (50% males), mean age 42.8 years ±15.47 (range 23-72). Treatment was reported only in nine patients; seven were treated with anticoagulant therapy; one with acetazolamide, and one underwent venous mechanical thrombectomy. Conclusion: Cerebrovascular events are relatively common findings in COVID-19 infection, and they could have a multifactorial etiology. More accurate and prospective data are needed to better understand the impact of cerebrovascular events in COVID-19 infection.

Neurological complications of coronavirus infection; a comparative review and lessons learned during the COVID-19 pandemic

INTRODUCTION

Coronavirus disease-19 (COVID-19) pandemic continues to grow all over the world. Several studies have been performed, focusing on understanding the acute respiratory syndrome and treatment strategies. However, there is growing evidence indicating neurological manifestations occur in patients with COVID-19. Similarly, the other coronaviruses (CoV) epidemics; severe acute respiratory syndrome (SARS-CoV-1) and Middle East respiratory syndrome (MERS-CoV) have been associated with neurological complications.

METHODS

This systematic review serves to summarize available information regarding the potential effects of different types of CoV on the nervous system and describes the range of clinical neurological complications that have been reported thus far in COVID-19.

RESULTS

Two hundred and twenty-five studies on CoV infections associated neurological manifestations in human were reviewed. Of those, 208 articles were pertinent to COVID-19. The most common neurological complaints in COVID-19 were anosmia, ageusia, and headache, but more serious complications, such as stroke, impairment of consciousness, seizures, and encephalopathy, have also been reported.

CONCLUSION

There are several similarities between neurological complications after SARS-CoV-1, MERS-CoV and COVID-19, however, the scope of the epidemics and number of patients are very different. Reports on the neurological complications after and during COVID-19 are growing on a daily basis. Accordingly, comprehensive knowledge of these complications will help health care providers to be attentive to these complications and diagnose and treat them timely.

COVID-19 Accompanied with Intracerebral Hemorrhage: A Case Series

Introduction: The new coronavirus, also known as COVID-19, can potentially involve in the central nervous system. The most important neurological manifestations include dizziness, headache, hypogeusia, hyposmia, ataxia, seizure, ischemic stroke, cerebral hemorrhage, encephalopathy, encephalitis, meningitis, seizure, cerebral vein thrombosis, and Guillain-Barre syndrome. Case Presentation: In this case series, we reported five patients with consciousness alteration and focal neurological deficit and neuroimaging that is consistent with intracerebral hemorrhage. In all patients, there was an association with COVID-19 infection. Conclusions: While the neurological manifestation of COVID-19 has not been appropriately defined, it is possible that a number of patients, particularly those who suffer from a severe illness, had central nervous system involvement. Thus, the neurologists should be aware of the likelihood of any neurological symptoms of COVID-19 infection.

Innovative diagnostic approach and investigation trends in COVID19-A systematic review

A highly contagious viral infection emerged in Wuhan city; China had increased mortality with uncertain pathogenesis spreads throughout the world to become a pandemic. It is reported to be caused by a member of β coronaviruses and named it as COVID-19 by the World Health Organization (WHO). The disease is caused by a mutant strain of coronavirus SARS-COV-2 that affects the respiratory tract causing mild to severe respiratory tract illness. The clinical manifestation ranges from mild, moderate, severe and very severe signs and symptoms result in death due to severe hypoxia or multi-organ dysfunction. Also, the affected persons were capable of infecting others through various modes of transmission through respiratory droplets (aerosol spread). A definite investigation protocol has followed to diagnose COVID 19 disease but mainly confirmed with reverse transcription polymerase chain reaction. Computerized tomography scan plays a significant role in the diagnosis and prognosis of affected individuals. The major problem with COVID-19 is due to its novelty and lack of vaccination or treatment. This review focuses on the mutation, pathogenesis, various diagnostic tests adopted and autopsy findings in patients affected with COVID-19.

COVID-19 and kidney transplant recipients

Background

The novel coronavirus has become a global threat and healthcare concern. The manifestations of COVID‐19 pneumonia in transplant patients are not well understood and may have more severe symptoms, longer duration, and a worse prognosis than in immunocompetent populations.

Aims

This study proposed to evaluate the clinical characteristics of COVID‐19 pneumonia in kidney transplant recipients.

Patients/Methods

Clinical records, laboratory results, radiological characteristics, and clinical outcome of 24 kidney transplant patients with COVID‐19 pneumonia were evaluated from March 20, 2020, to May 20, 2020.

Results

The most common symptom was shortness of breath (70.8%), followed by fever (62.5%) and cough (45.8%). Five patients had leukopenia, and only one patient had leukocytosis, while 75% of the patients had a white blood cell (WBC) count in the normal range, and 79% of recipients developed lymphopenia. All of the patients had an elevated concentration of C‐reactive protein and an increase in blood urea levels. Chest CT images of 23 patients (95.8%) showed typical findings of patchy ground‐glass shadows in the lungs. Of the 24 patients, 12 were admitted to ICU (invasive care unit), and ten of 24 patients (41.6%) died, and 14 patients were discharged after complete recovery.

Conclusion

It seems that COVID‐19 is more severe in transplant patients and has poorer outcomes. Multiple underlying diseases, low O₂ saturation, and multilobar view in chest CT scan may be of prognostic value. However, many SARS‐CoV‐2 demonstrations are similar to those of the general population.