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Renedo D, Leasure AC, Young R, Rivier CA, Alhanti B, Mac Grory B, Messe SR, Reeves MJ, Hassan AE, Schwamm L, de Havenon A, Matouk CC, Sheth KN, Falcone GJ. COVID-19 Infection Is Associated With Poor Outcomes in Patients With Intracerebral Hemorrhage. J Am Heart Assoc 2024; 13:e030999. [PMID: 38293940 PMCID: PMC11056169 DOI: 10.1161/jaha.123.030999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 01/08/2024] [Indexed: 02/01/2024]
Abstract
BACKGROUND Patients with ischemic stroke and concomitant COVID-19 infection have worse outcomes than those without this infection, but the impact of COVID-19 on hemorrhagic stroke remains unclear. We aimed to assess if COVID-19 worsens outcomes in intracerebral hemorrhage (ICH). METHODS AND RESULTS We conducted an observational study of ICH outcomes using Get With The Guidelines Stroke data. We compared patients with ICH who were COVID-19 positive and negative during the pandemic (March 2020-February 2021) and prepandemic (March 2019-February 2020). Main outcomes were poor functional outcome (defined as a modified Rankin scale score of 4 to 6 at discharge), mortality, and discharge to a skilled nursing facility or hospice. The first stage included 60 091 patients with ICH who were COVID-19 negative and 1326 COVID-19 positive. In multivariable analyses, patients with ICH with versus without COVID-19 infection had 68% higher odds of poor outcome (odds ratio [OR], 1.68 [95% CI, 1.41-2.01]), 51% higher odds of mortality (OR, 1.51 [95% CI, 1.33-1.71]), and 66% higher odds of being discharged to a skilled nursing facility/hospice (OR, 1.66 [95% CI, 1.43-1.93]). The second stage included 62 743 prepandemic and 64 681 intrapandemic cases with ICH. In multivariable analyses, patients with ICH admitted during versus before the COVID-19 pandemic had 10% higher odds of poor outcomes (OR, 1.10 [95% CI, 1.07-1.14]), 5% higher mortality (OR, 1.05 [95% CI, 1.02-1.08]), and no significant difference in the risk of being discharged to a skilled nursing facility/hospice (OR, 0.93 [95% CI, 0.90-0.95]). CONCLUSIONS The pathophysiology of the COVID-19 infection and changes in health care delivery during the pandemic played a role in worsening outcomes in the patient population with ICH.
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Affiliation(s)
- Daniela Renedo
- Department of NeurologyYale School of MedicineNew HavenCT
- Department of NeurosurgeryYale School of MedicineNew HavenCT
| | | | | | | | | | - Brian Mac Grory
- Duke Clinical Research InstituteDurhamNC
- Department of NeurologyDuke University School of MedicineDurhamNC
| | - Steven R. Messe
- Department of NeurologyHospital of the University of PennsylvaniaPhiladelphiaPA
| | - Mathew J. Reeves
- Department of Epidemiology and BiostatisticsMichigan State UniversityEast LansingMI
| | - Ameer E. Hassan
- University of Texas Rio Grande Valley, Valley Baptist Medical CenterHarlingenTX
| | - Lee Schwamm
- Department of NeurologyYale School of MedicineNew HavenCT
| | | | | | - Kevin N. Sheth
- Department of NeurologyYale School of MedicineNew HavenCT
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2
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Gofir A, Satriotomo I, Syamsah YCBN, Rochmah MA, Setyawan TR, Mianoki A, Silalahi RANA, Nugroho DB. Degree of COVID-19 severity and mortality in stroke: correlation of clinical and laboratory parameters. BMC Neurosci 2024; 25:4. [PMID: 38216918 PMCID: PMC10790265 DOI: 10.1186/s12868-023-00837-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 12/07/2023] [Indexed: 01/14/2024] Open
Abstract
BACKGROUND Stroke is one of the neurological manifestations of COVID-19, leading to a significant risk of morbidity and mortality. Clinical manifestations and laboratory parameters were investigated to determine mortality predictors in this case. METHOD The case control study was conducted at Dr. Sardjito General Hospital,Yogyakarta, Indonesia, with data collected between July 2020 and August 2021. All recorded clinical and laboratory data from acute stroke patients with confirmed COVID-19 were collected. Baseline characteristics, bivariate, and multivariate analyses were assessed to determine significant predictors for mortality. RESULT This study involved 72 subjects with COVID-19 and stroke. The majority experienced ischemic stroke, with hypertension as the most prevalent comorbidity. Notably, 45.8% of subjects (p < 0.05) loss of consciousness and 72.2% of exhibited motor deficits (p < 0.05). Severe degree of COVID-19 was observed in 52.8% of patients, with respiratory distress and death rates of 56.9% and 58.3%. Comparison of surviving and deceased groups highlighted significant differences in various clinical and laboratory characteristics differences. Hazard ratio (HR) analysis identified loss of consciousness (HR = 2.68; p = 0.01), motor deficit (HR = 2.34; p = 0.03), respiratory distress (HR = 81.51; p < 0.001), and monocyte count (HR:1.002; p = 0.04) as significant predictors of mortality. CONCLUSION Mortality in COVID-19 patients with stroke was significantly associated with loss of consciousness, motor deficit, respiratory distress, and raised monocyte count. The risk of mortality is heightened when multiple factors coexist.
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Affiliation(s)
- Abdul Gofir
- Department of Neurology, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada/ Dr. Sardjito General Hospital, Jalan Farmako Sekip Utara, Sleman, Mlati, Yogyakarta, 55281, Indonesia.
| | | | - Yossy Catarina Budi Nur Syamsah
- Department of Neurology, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada/ Dr. Sardjito General Hospital, Jalan Farmako Sekip Utara, Sleman, Mlati, Yogyakarta, 55281, Indonesia
| | - Mawaddah Ar Rochmah
- Department of Neurology, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada/ Dr. Sardjito General Hospital, Jalan Farmako Sekip Utara, Sleman, Mlati, Yogyakarta, 55281, Indonesia
| | - Tommy Rachmat Setyawan
- Department of Neurology, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada/ Dr. Sardjito General Hospital, Jalan Farmako Sekip Utara, Sleman, Mlati, Yogyakarta, 55281, Indonesia
| | - Adika Mianoki
- Department of Neurology, Dr. Soeradji Tirtonegoro General Hospital, Klaten, Central Java, Indonesia
| | - Raymond Aris Nimrod Alvonsius Silalahi
- Department of Neurology, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada/ Dr. Sardjito General Hospital, Jalan Farmako Sekip Utara, Sleman, Mlati, Yogyakarta, 55281, Indonesia
| | - Dhite Bayu Nugroho
- Department of Internal Medicine, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
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Bako AT, Potter T, Pan AP, Borei KA, Prince T, Britz GW, Vahidy FS. Poor haemorrhagic stroke outcomes during the COVID-19 pandemic are driven by socioeconomic disparities: analysis of nationally representative data. BMJ Neurol Open 2024; 6:e000511. [PMID: 38268748 PMCID: PMC10806835 DOI: 10.1136/bmjno-2023-000511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 12/22/2023] [Indexed: 01/26/2024] Open
Abstract
Background Nationally representative studies evaluating the impact of the COVID-19 pandemic on haemorrhagic stroke outcomes are lacking. Methods In this pooled cross-sectional analysis, we identified adults (≥18 years) with primary intracerebral haemorrhage (ICH) or subarachnoid haemorrhage (SAH) from the National Inpatient Sample (2016-2020). We evaluated differences in rates of in-hospital outcomes between the prepandemic (January 2016-February 2020) and pandemic (March-December 2020) periods using segmented logistic regression models. We used multivariable logistic regression to evaluate differences in mortality between patients admitted from April to December 2020, with and without COVID-19, and those admitted from April to December 2019. Stratified analyses were conducted among patients residing in low-income and high-income zip codes, as well as among patients with extreme loss of function (E-LoF) and those with minor to major loss of function (MM-LoF). Results Overall, 309 965 patients with ICH (47% female, 56% low income) and 112 210 patients with SAH (62% female, 55% low income) were analysed. Prepandemic, ICH mortality decreased by ~1% per month (adjusted OR, 95% CI: 0.99 (0.99 to 1.00); p<0.001). However, during the pandemic, the overall ICH mortality rate increased, relative to prepandemic, by ~2% per month (1.02 (1.00 to 1.04), p<0.05) and ~4% per month (1.04 (1.01 to 1.07), p<0.001) among low-income patients. There was no significant change in trend among high-income patients with ICH (1.00 (0.97 to 1.03)). Patients with comorbid COVID-19 in 2020 had higher odds of mortality (versus 2019 cohort) only among patients with MM-LoF (ICH, 2.15 (1.12 to 4.16), and SAH, 5.77 (1.57 to 21.17)), but not among patients with E-LoF. Conclusion Sustained efforts are needed to address socioeconomic disparities in healthcare access, quality and outcomes during public health emergencies.
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Affiliation(s)
- Abdulaziz T Bako
- Department of Neurosurgery, Houston Methodist, Houston, Texas, USA
| | - Thomas Potter
- Department of Neurosurgery, Houston Methodist, Houston, Texas, USA
| | - Alan P Pan
- Center for Health Data Science and Analytics, Houston Methodist Research Institute, Houston, Texas, USA
| | - Karim A Borei
- Department of Neurosurgery, Houston Methodist, Houston, Texas, USA
| | - Taya Prince
- Department of Neurosurgery, Houston Methodist, Houston, Texas, USA
| | - Gavin W Britz
- Department of Neurosurgery, Houston Methodist, Houston, Texas, USA
| | - Farhaan S Vahidy
- Department of Neurosurgery, Houston Methodist, Houston, Texas, USA
- TIRR Memorial Hermann, Houston, Texas, USA
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4
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Rezvani M, Sabouri M, Aminmansour B, Falahpour S, Sourani A, Sharafi M, Baradaran Mahdavi S, Foroughi M, Nik Khah R, Sourani A, Veisi S. Spontaneous spinal epidural haematoma following COVID-19 vaccination: a case report. Ann Med Surg (Lond) 2024; 86:612-619. [PMID: 38222759 PMCID: PMC10783308 DOI: 10.1097/ms9.0000000000001604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 11/29/2023] [Indexed: 01/16/2024] Open
Abstract
Introduction COVID-19 vaccination side effects are rare but important medical situations. Spine-affecting side effects are amongst the rarest, but exceedingly important. Haemorrhagic spinal manifestations of COVID-19 and its vaccines are less reported with little knowledge about them. Case presentation An 80-year-old male who received his first shot of the COVID-19 vaccine had developed COVID-19 pneumonia, weakness, and sensory problems in his legs followed by sphincter incontinence within 5 days period. MRI showed a spontaneous epidural spinal epidural haematoma (SSEDH) in T10-L1. He underwent laminectomy and haematoma evacuation. One month follow-up showed no clinical improvement. Discussion To our knowledge, this was the first post-vaccination SSEDH and second in haemorrhagic spinal complications following COVID-19 vaccination. Considering the neuropathogenesis pathway of COVID-19 and its vaccines, there are common mechanisms of action that could potentially justify post-vaccination SSEDH such as seen in COVID-19 infection, itself. Early Neurosurgical intervention and better preoperative neurological status could be a beneficial modifier for favourable clinical outcomes. Conclusion SSEDH and COVID-19 vaccine coincidence is a rare clinical event, still no solid association could be scientifically explained. Further studies are required for a reliable pathophysiologic association. Early diagnosis, interdisciplinary medical approach, and faster intervention are the cornerstone of the treatment paradigm.
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Affiliation(s)
| | | | | | | | - Arman Sourani
- Department of Neurosurgery, School of Medicine
- Environment Research Center
| | | | - Sadegh Baradaran Mahdavi
- Department of Physical Medicine and Rehabilitation, School of Medicine, Student Research Committee, Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-Communicable Disease
| | - Mina Foroughi
- Isfahan Medical Students’ Research Committee (IMSRC), Isfahan University of Medical Sciences, Isfahan, Iran
| | - Roham Nik Khah
- Isfahan Medical Students’ Research Committee (IMSRC), Isfahan University of Medical Sciences, Isfahan, Iran
| | - Armin Sourani
- Isfahan Medical Students’ Research Committee (IMSRC), Isfahan University of Medical Sciences, Isfahan, Iran
| | - Shaahin Veisi
- Isfahan Medical Students’ Research Committee (IMSRC), Isfahan University of Medical Sciences, Isfahan, Iran
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Sourani A, Vahdat N, Son C, Hariri OR, Rezvani M, Foroughi M, Mirza R, Sourani A, Baradaran Mahdavi S. SARS-CoV-2 infection and spontaneous spinal hemorrhage: a systematic review. Neurosurg Rev 2023; 46:300. [PMID: 37966587 DOI: 10.1007/s10143-023-02211-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 10/02/2023] [Accepted: 11/05/2023] [Indexed: 11/16/2023]
Abstract
The neurological manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, including spontaneous spinal hemorrhage (SSH), are diverse. SSH is a detrimental neurosurgical event requiring immediate medical attention. We aimed to investigate the association between SARS-CoV-2 and SSH and delineate a rational clinical approach. The authors searched PubMed, Scopus, Web of Science, and Google Scholar for studies published up to January 25, 2023, on SSH and SARS-CoV-2 infection. For each dataset, the authors performed pooled estimates examining three outcomes of interest: (1) early post-intervention neurological status, (2) mortality, and (3) post-intervention neurological rehabilitation outcomes. After reviewing 1341 results, seven datasets were identified for the final analysis. Fifty-seven percent of patients were females. Twenty-eight percent of the patients experienced severe systemic infection. The mean interval between the SARS-CoV-2 infection and neurological presentation was 18 days. Pain and sensorimotor deficits were the most common (57%). Spinal epidural hematoma (EDH) was the most common presentation (71.4%). Three patients were treated conservatively, while 4 received neurosurgical intervention. Pain and sensorimotor deficits had the best treatment response (100%), while the sphincter had the worst response (0%). Long-term follow-up showed that 71% of patients had good recovery. SARS-CoV-2-associated SSH is a rare complication of infection, with an often insidious presentation that requires high clinical suspicion. Patients with SARS-CoV-2 infection and new neurological symptoms or disproportionate neck or back pain require a neuroaxis evaluation. Neurosurgical intervention and conservative management are both viable options to treat SSH following COVID-19. Still, a homogenous approach to the treatment paradigm of SSH cannot be obtained, but lesions with space-occupying effects are suitable for neurosurgical evacuation-decompression while more indolent lesions could be treated conservatively. These options should be tailored individually until larger studies provide a consensus.
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Affiliation(s)
- Arman Sourani
- Department of Neurosurgery, Isfahan University of Medical Sciences, Isfahan, Iran.
- Environment Research Center, Research Institute for Primordial Prevention of Non-Communicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Noushin Vahdat
- Department of Radiology University of California, San Diego Health, San Diego, CA, USA
- Department of Radiology Veteran Administration Healthcare System, San Diego, CA, USA
| | - Colin Son
- Neurosurgical Associates of San Antonio, San Antonio, TX, USA
- School of Osteopathic Medicine, University of the Incarnate Word, San Antonio, TX, USA
| | - Omid R Hariri
- Department of Neurological Surgery, Kaiser Permanente Orange County, Anaheim, CA, USA
| | - Majid Rezvani
- Department of Neurosurgery, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mina Foroughi
- Student Research Committee, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ryan Mirza
- Department of Radiology University of California, San Diego Health, San Diego, CA, USA
| | - Armin Sourani
- Student Research Committee, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Sadegh Baradaran Mahdavi
- Department of Physical Medicine and Rehabilitation, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
- Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-communicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran.
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6
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Lannon M, Duda T, Greer A, Hewitt M, Sharma A, Martyniuk A, Owen J, Amin F, Sharma S. Intracranial hemorrhage in patients treated for SARS-CoV-2 with extracorporeal membrane oxygenation: A systematic review and meta-analysis. J Crit Care 2023; 77:154319. [PMID: 37178492 PMCID: PMC10173703 DOI: 10.1016/j.jcrc.2023.154319] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 12/21/2022] [Accepted: 04/24/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is routinely used in patients with severe respiratory failure and has been increasingly needed during the COVID-19 pandemic. In patients treated with ECMO, significant intracranial hemorrhage (ICH) risk exists due to circuit characteristics, anticoagulation, and disease characteristics. ICH risk may be substantially higher in COVID-19 patients than patients treated with ECMO for other indications. METHODS We systematically reviewed current literature regarding ICH during ECMO treatment of COVID-19. We utilized Embase, MEDLINE, and Cochrane Library databases. Meta-analysis was performed for included comparative studies. Quality assessment was performed using MINORS criteria. RESULTS A total of 54 studies with 4000 ECMO patients were included, all retrospective. Risk of bias was increased via MINORS score primarily due to retrospective designs. ICH was more likely in COVID-19 patients (RR 1.72, 95% CI 1.23, 2.42). Mortality among COVID patients on ECMO with ICH was 64.0%, compared with 41% in patients without ICH (RR1.9, 95% 1.44, 2.51). CONCLUSION This study suggests increased hemorrhage rates in COVID-19 patients on ECMO compared to similar controls. Hemorrhage reduction strategies may include atypical anticoagulants, conservative anticoagulation strategies, or biotechnology advances in circuit design and surface coatings.
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Affiliation(s)
- Melissa Lannon
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada.
| | - Taylor Duda
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada.
| | - Alisha Greer
- Division of Emergency Medicine, Department of Medicine, Division of Critical Care, McMaster University, Hamilton, Ontario, Canada.
| | - Mark Hewitt
- Division of Emergency Medicine, Department of Medicine, Division of Critical Care, McMaster University, Hamilton, Ontario, Canada.
| | - Arjun Sharma
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, Ontario, Canada.
| | - Amanda Martyniuk
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada.
| | - Julian Owen
- Division of Emergency Medicine, Department of Medicine, Division of Critical Care, McMaster University, Hamilton, Ontario, Canada.
| | - Faizan Amin
- Department of Medicine, Divisions of Critical Care and Cardiology, McMaster University, Hamilton, Ontario, Canada.
| | - Sunjay Sharma
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada.
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7
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Catherine C, Veitinger J, Chou SHY. COVID-19 and Cerebrovascular Disease. Semin Neurol 2023. [PMID: 37216977 DOI: 10.1055/s-0043-1768475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
COVID-19 has been associated with numerous neurological complications, with acute cerebrovascular disease being one of the most devastating complications. Ischemic stroke is the most common cerebrovascular complication of COVID-19, affecting between 1 and 6% of all patients. Underlying mechanisms for COVID-related ischemic strokes are thought to be due to vasculopathy, endotheliopathy, direct invasion of the arterial wall, and platelet activation. Other COVID-19-associated cerebrovascular complications include hemorrhagic stroke, cerebral microbleeds, posterior reversible encephalopathy syndrome, reversible cerebral vasoconstriction syndrome, cerebral venous sinus thrombosis, and subarachnoid hemorrhage. This article discusses the incidence of these cerebrovascular complications, risk factors, management strategies, prognosis and future research directions, as well as considerations in pregnancy-related cerebrovascular events in the setting of COVID-19.
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Affiliation(s)
- Christina Catherine
- Department of Neurology, UPMC Altoona Regional Hospital, Altoona, Pennsylvania
| | - Julia Veitinger
- Division of Neurocritical Care, The Ken and Ruth Davee Department of Neurology, Northwestern Feinberg School of Medicine, Chicago, Illinois
| | - Sherry H-Y Chou
- Division of Neurocritical Care, The Ken and Ruth Davee Department of Neurology, Northwestern Feinberg School of Medicine, Chicago, Illinois
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8
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Abstract
Differences exist between genders in intracerebral hemorrhage cause, epidemiology, and outcomes. These gender differences are in part attributable to physiologic differences; however, demographic, social/behavioral risk factors, along with health care system variation and potential family and/or clinician bias play a role as well. These factors vary from region to region and interact, making comprehensive and definitive conclusions regarding sex differences a challenging task. Differences between the genders in intracerebral hemorrhage epidemiology and extensive differences in underlying pathophysiology, intervention, risk factors, and outcome are all discussed.
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Affiliation(s)
- Nicholas Dykman Osteraas
- Department of Neurological Sciences, Division of Cerebrovascular Diseases, Rush University Medical Center, 1725 West Harrison Street Suite 118, Chicago, IL 60612, USA.
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9
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Narrett JA, Mallawaarachchi I, Aldridge CM, Assefa ED, Patel A, Loomba JJ, Ratcliffe S, Sadan O, Monteith T, Worrall BB, Brown DE, Johnston KC, Southerland AM. Increased stroke severity and mortality in patients with SARS-CoV-2 infection: An analysis from the N3C database. J Stroke Cerebrovasc Dis 2023; 32:106987. [PMID: 36641948 PMCID: PMC9832053 DOI: 10.1016/j.jstrokecerebrovasdis.2023.106987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 01/06/2023] [Accepted: 01/09/2023] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Studies from early in the COVID-19 pandemic showed that patients with ischemic stroke and concurrent SARS-CoV-2 infection had increased stroke severity. We aimed to test the hypothesis that this association persisted throughout the first year of the pandemic and that a similar increase in stroke severity was present in patients with hemorrhagic stroke. METHODS Using the National Institute of Health National COVID Cohort Collaborative (N3C) database, we identified a cohort of patients with stroke hospitalized in the United States between March 1, 2020 and February 28, 2021. We propensity score matched patients with concurrent stroke and SARS-COV-2 infection and available NIH Stroke Scale (NIHSS) scores to all other patients with stroke in a 1:3 ratio. Nearest neighbor matching with a caliper of 0.25 was used for most factors and exact matching was used for race/ethnicity and site. We modeled stroke severity as measured by admission NIHSS and the outcomes of death and length of stay. We also explored the temporal relationship between time of SARS-COV-2 diagnosis and incidence of stroke. RESULTS Our query identified 43,295 patients hospitalized with ischemic stroke (5765 with SARS-COV-2, 37,530 without) and 18,107 patients hospitalized with hemorrhagic stroke (2114 with SARS-COV-2, 15,993 without). Analysis of our propensity matched cohort revealed that stroke patients with concurrent SARS-COV-2 had increased NIHSS (Ischemic stroke: IRR=1.43, 95% CI:1.33-1.52, p<0.001; hemorrhagic stroke: IRR=1.20, 95% CI:1.08-1.33, p<0.001), length of stay (Ischemic stroke: estimate = 1.48, 95% CI: 1.37, 1.61, p<0.001; hemorrhagic stroke: estimate = 1.25, 95% CI: 1.06, 1.47, p=0.007) and higher odds of death (Ischemic stroke: OR 2.19, 95% CI: 1.79-2.68, p<0.001; hemorrhagic stroke: OR 2.19, 95% CI: 1.79-2.68, p<0.001). We observed the highest incidence of stroke diagnosis on the same day as SARS-COV-2 diagnosis with a logarithmic decline in counts. CONCLUSION This retrospective observational analysis suggests that stroke severity in patients with concurrent SARS-COV-2 was increased throughout the first year of the pandemic.
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Affiliation(s)
- Jackson A Narrett
- Department of Neurology, University of Virginia, Charlottesville, VA, USA
| | | | - Chad M. Aldridge
- Department of Neurology, University of Virginia, Charlottesville, VA, USA
| | - Ethan D Assefa
- Data Science Institute, University of Virginia, Charlottesville, VA, USA
| | - Arti Patel
- Data Science Institute, University of Virginia, Charlottesville, VA, USA
| | - Johanna J Loomba
- Data Science Institute, University of Virginia, Charlottesville, VA, USA
| | - Sarah Ratcliffe
- Data Science Institute, University of Virginia, Charlottesville, VA, USA
| | - Ofer Sadan
- Departments of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, Atlanta, GA, USA
| | - Teshamae Monteith
- Division of Headache, Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Bradford B Worrall
- Department of Neurology, University of Virginia, Charlottesville, VA, USA,Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Donald E Brown
- Data Science Institute, University of Virginia, Charlottesville, VA, USA
| | - Karen C Johnston
- Department of Neurology, University of Virginia, Charlottesville, VA, USA,Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Andrew M Southerland
- Department of Neurology, University of Virginia, Charlottesville, VA, USA; Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA.
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10
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Stefanou Ε, Karvelas N, Bennett S, Kole C. Cerebrovascular Manifestations of SARS-CoV-2: A Comprehensive Review. Curr Treat Options Neurol 2023; 25:71-92. [PMID: 36950279 PMCID: PMC9984763 DOI: 10.1007/s11940-023-00747-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2023] [Indexed: 03/06/2023]
Abstract
Purpose of review The risks of cerebrovascular manifestations due to SARS-CoV-2 infection are significantly increased within the first 6 months of the infection. Our work aims to give an update on current clinical aspects of diagnosis and treatment of cerebrovascular manifestations during acute and long-term SARS-CoV-2 infection. Recent findings The incidence of acute ischemic stroke and haemorrhagic stroke during acute SARS-CoV-2 patients is estimated at 0.9 to 4.6% and 0.5-0.9%, respectively, and were associated with increased mortality. The majority presented with hemiparesis, dysarthria, sensory deficits, and a NIHSS score within 5-15. In addition, beyond the first 30 days of infection people with COVID-19 exhibited increased risk of stroke. During acute phase, age, hypertension, diabetes, and medical history of vascular disease were increased in patients with COVID-19 with new onset of cerebrovascular manifestations, while during long-COVID-19, the risk of cerebrovascular manifestations were found increased regardless of these factors. The management of patients with large-vessel ischemic stroke fulfilling the intravenous thrombolysis criteria are successfully treated according to the guidelines, while hyperosmolar therapy is typically administered in 4- to 6-h intervals. In addition, prophylaxis of anticoagulation therapy is associated with a better prognosis and low mortality during acute and post hospital discharge of patients with COVID-19. Summary In this work, we provide a comprehensive review of the current literature on acute and post-acute COVID-19 cerebrovascular sequelae, symptomatology, and its pathophysiology mechanisms. Moreover, we discuss therapeutic strategies for these patients during acute and long-term care and point populations at risk. Our findings suggest that older patients with risk factors such as hypertension, diabetes, and medical history of vascular disease are more likely to develop cerebrovascular complications.
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Affiliation(s)
- Εleni Stefanou
- Artificial Kidney Unit, General Hospital of Messinia, Kalamata, Greece
| | - Nikolaos Karvelas
- grid.5216.00000 0001 2155 0800Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Samuel Bennett
- grid.189967.80000 0001 0941 6502Emory University School of Medicine, Atlanta, GA USA
| | - Christo Kole
- grid.5216.00000 0001 2155 0800Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- grid.416018.a0000 0004 0623 0819Cardiology Department, Sismanoglio General Hospital of Attica, Athens, Greece
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11
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Suprewicz Ł, Tran KA, Piktel E, Fiedoruk K, Janmey PA, Galie PA, Bucki R. Recombinant human plasma gelsolin reverses increased permeability of the blood-brain barrier induced by the spike protein of the SARS-CoV-2 virus. J Neuroinflammation 2022; 19:282. [PMID: 36434734 PMCID: PMC9694610 DOI: 10.1186/s12974-022-02642-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 11/11/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Plasma gelsolin (pGSN) is an important part of the blood actin buffer that prevents negative consequences of possible F-actin deposition in the microcirculation and has various functions during host immune response. Recent reports reveal that severe COVID-19 correlates with reduced levels of pGSN. Therefore, using an in vitro system, we investigated whether pGSN could attenuate increased permeability of the blood-brain barrier (BBB) during its exposure to the portion of the SARS-CoV-2 spike protein containing the receptor binding domain (S1 subunit). MATERIALS AND METHODS Two- and three-dimensional models of the human BBB were constructed using the human cerebral microvascular endothelial cell line hCMEC/D3 and exposed to physiologically relevant shear stress to mimic perfusion in the central nervous system (CNS). Trans-endothelial electrical resistance (TEER) as well as immunostaining and Western blotting of tight junction (TJ) proteins assessed barrier integrity in the presence of the SARS-CoV-2 spike protein and pGSN. The IncuCyte Live Imaging system evaluated the motility of the endothelial cells. Magnetic bead-based ELISA was used to determine cytokine secretion. Additionally, quantitative real-time PCR (qRT-PCR) revealed gene expression of proteins from signaling pathways that are associated with the immune response. RESULTS pGSN reversed S1-induced BBB permeability in both 2D and 3D BBB models in the presence of shear stress. BBB models exposed to pGSN also exhibited attenuated pro-inflammatory signaling pathways (PI3K, AKT, MAPK, NF-κB), reduced cytokine secretion (IL-6, IL-8, TNF-α), and increased expression of proteins that form intercellular TJ (ZO-1, occludin, claudin-5). CONCLUSION Due to its anti-inflammatory and protective effects on the brain endothelium, pGSN has the potential to be an alternative therapeutic target for patients with severe SARS-CoV-2 infection, especially those suffering neurological complications of COVID-19.
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Affiliation(s)
- Łukasz Suprewicz
- grid.48324.390000000122482838Department of Medical Microbiology and Nanobiomedical Engineering, Medical University of Białystok, Mickiewicza 2C, 15-222 Białystok, Poland
| | - Kiet A. Tran
- grid.262671.60000 0000 8828 4546Department of Biomedical Engineering, Rowan University, Glassboro, NJ 08028 USA
| | - Ewelina Piktel
- grid.48324.390000000122482838Department of Medical Microbiology and Nanobiomedical Engineering, Medical University of Białystok, Mickiewicza 2C, 15-222 Białystok, Poland
| | - Krzysztof Fiedoruk
- grid.48324.390000000122482838Department of Medical Microbiology and Nanobiomedical Engineering, Medical University of Białystok, Mickiewicza 2C, 15-222 Białystok, Poland
| | - Paul A. Janmey
- grid.25879.310000 0004 1936 8972Department of Physiology and Institute for Medicine and Engineering, University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Peter A. Galie
- grid.262671.60000 0000 8828 4546Department of Biomedical Engineering, Rowan University, Glassboro, NJ 08028 USA
| | - Robert Bucki
- grid.48324.390000000122482838Department of Medical Microbiology and Nanobiomedical Engineering, Medical University of Białystok, Mickiewicza 2C, 15-222 Białystok, Poland
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12
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Ippolito A, Urban H, Ghoroghi K, Rosbach N, Lingwal N, Adam EH, Friedrichson B, Steinbicker AU, Hattingen E, Wenger KJ. Prevalence of acute neurological complications and pathological neuroimaging findings in critically ill COVID-19 patients with and without VV-ECMO treatment. Sci Rep 2022; 12:17423. [PMID: 36261436 PMCID: PMC9579632 DOI: 10.1038/s41598-022-21475-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 09/27/2022] [Indexed: 01/12/2023] Open
Abstract
Acute brain injuries such as intracerebral hemorrhage (ICH) and ischemic stroke have been reported in critically ill COVID-19 patients as well as in patients treated with veno-venous (VV)-ECMO independently of their COVID-19 status. The purpose of this study was to compare critically ill COVID-19 patients with and without VV-ECMO treatment with regard to acute neurological symptoms, pathological neuroimaging findings (PNIF) and long-term deficits. The single center study was conducted in critically ill COVID-19 patients between February 1, 2020 and June 30, 2021. Demographic, clinical and laboratory parameters were extracted from the hospital's databases. Retrospective imaging modalities included head computed tomography (CT) and magnetic resonance imaging (MRI). Follow-up MRI and neurological examinations were performed on survivors > 6 months after the primary occurrence. Of the 440 patients, 67 patients received VV-ECMO treatment (15%). Sixty-four patients (24 with VV-ECMO) developed acute neurological symptoms (pathological levels of arousal/brain stem function/motor responses) during their ICU stay and underwent neuroimaging with brain CT as the primary modality. Critically ill COVID-19 patients who received VV-ECMO treatment had a significantly lower survival during their hospital stay compared to those without (p < 0.001). Among patients treated with VV-ECMO, 10% showed acute PNIF in one of the imaging modalities during their ICU stay (vs. 4% of patients in the overall COVID-19 ICU cohort). Furthermore, 9% showed primary or secondary ICH of any severity (vs. 3% overall), 6% exhibited severe ICH (vs. 1% overall) and 1.5% were found to have non-hemorrhagic cerebral infarctions (vs. < 1% overall). There was a weak, positive correlation between patients treated with VV-ECMO and the development of acute neurological symptoms. However, the association between the VV-ECMO treatment and acute PNIF was negligible. Two survivors (one with VV-ECMO-treatment/one without) showed innumerable microhemorrhages, predominantly involving the juxtacortical white matter. None of the survivors exhibited diffuse leukoencephalopathy. Every seventh COVID-19 patient developed acute neurological symptoms during their ICU stay, but only every twenty-fifth patient had PNIF which were mostly ICH. VV-ECMO was found to be a weak risk factor for neurological complications (resulting in a higher imaging rate), but not for PNIF. Although logistically complex, repeated neuroimaging should, thus, be considered in all critically ill COVID-19 patients since ICH may have an impact on the treatment decisions and outcomes.
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Affiliation(s)
- Angelo Ippolito
- Institute of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Hans Urban
- Institute of Neurology, University Hospital Frankfurt, Frankfurt, Germany
| | - Kimia Ghoroghi
- Institute of Neuroradiology, University Hospital Frankfurt, Goethe University, Schleusenweg 2-16, 60528, Frankfurt, Germany
| | - Nicolas Rosbach
- Institute of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt, Germany
| | - Neelam Lingwal
- Institute of Biostatistics and Mathematical Modeling, Goethe University, Frankfurt, Germany
| | - Elisabeth H Adam
- Institute of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Benjamin Friedrichson
- Institute of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Andrea U Steinbicker
- Institute of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Elke Hattingen
- Institute of Neuroradiology, University Hospital Frankfurt, Goethe University, Schleusenweg 2-16, 60528, Frankfurt, Germany
| | - Katharina J Wenger
- Institute of Neuroradiology, University Hospital Frankfurt, Goethe University, Schleusenweg 2-16, 60528, Frankfurt, Germany.
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13
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Tyrkalska SD, Martínez-López A, Arroyo AB, Martínez-Morcillo FJ, Candel S, García-Moreno D, Mesa-del-Castillo P, Cayuela ML, Mulero V. Differential proinflammatory activities of Spike proteins of SARS-CoV-2 variants of concern. SCIENCE ADVANCES 2022; 8:eabo0732. [PMID: 36112681 PMCID: PMC9481140 DOI: 10.1126/sciadv.abo0732] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic turned the whole world upside down in a short time. One of the main challenges faced has been to understand COVID-19-associated life-threatening hyperinflammation, the so-called cytokine storm syndrome (CSS). We report here the proinflammatory role of Spike (S) proteins from different severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants of concern in zebrafish. We found that wild-type/Wuhan variant S1 (S1WT) promoted neutrophil and macrophage recruitment, local and systemic hyperinflammation, emergency myelopoiesis, and hemorrhages. In addition, S1γ was more proinflammatory S1δ was less proinflammatory than S1WT, and, notably, S1β promoted delayed and long-lasting inflammation. Pharmacological inhibition of the canonical inflammasome alleviated S1-induced inflammation and emergency myelopoiesis. In contrast, genetic inhibition of angiotensin-converting enzyme 2 strengthened the proinflammatory activity of S1, and angiotensin (1-7) fully rescued S1-induced hyperinflammation and hemorrhages. These results shed light into the mechanisms orchestrating the COVID-19-associated CSS and the host immune response to different SARS-CoV-2 S protein variants.
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Affiliation(s)
- Sylwia D. Tyrkalska
- Departmento de Biología Celular e Histología, Facultad de Biología, Universidad de Murcia, 30100 Murcia, Spain
- Instituto Murciano de Investigación Biosanitaria (IMIB)-Arrixaca, 30120 Murcia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Corresponding author. (S.D.T.); (M.L.C); (V.M.)
| | - Alicia Martínez-López
- Instituto Murciano de Investigación Biosanitaria (IMIB)-Arrixaca, 30120 Murcia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Ana B. Arroyo
- Departmento de Biología Celular e Histología, Facultad de Biología, Universidad de Murcia, 30100 Murcia, Spain
- Instituto Murciano de Investigación Biosanitaria (IMIB)-Arrixaca, 30120 Murcia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Francisco J. Martínez-Morcillo
- Departmento de Biología Celular e Histología, Facultad de Biología, Universidad de Murcia, 30100 Murcia, Spain
- Instituto Murciano de Investigación Biosanitaria (IMIB)-Arrixaca, 30120 Murcia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Sergio Candel
- Departmento de Biología Celular e Histología, Facultad de Biología, Universidad de Murcia, 30100 Murcia, Spain
- Instituto Murciano de Investigación Biosanitaria (IMIB)-Arrixaca, 30120 Murcia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Diana García-Moreno
- Instituto Murciano de Investigación Biosanitaria (IMIB)-Arrixaca, 30120 Murcia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Pablo Mesa-del-Castillo
- Instituto Murciano de Investigación Biosanitaria (IMIB)-Arrixaca, 30120 Murcia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Hospital Clínico Universitario Virgen de la Arrixaca, 30120 Murcia, Spain
| | - María L. Cayuela
- Instituto Murciano de Investigación Biosanitaria (IMIB)-Arrixaca, 30120 Murcia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Hospital Clínico Universitario Virgen de la Arrixaca, 30120 Murcia, Spain
- Corresponding author. (S.D.T.); (M.L.C); (V.M.)
| | - Victoriano Mulero
- Departmento de Biología Celular e Histología, Facultad de Biología, Universidad de Murcia, 30100 Murcia, Spain
- Instituto Murciano de Investigación Biosanitaria (IMIB)-Arrixaca, 30120 Murcia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Corresponding author. (S.D.T.); (M.L.C); (V.M.)
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14
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Graham EL, Koralnik IJ, Liotta EM. Therapeutic Approaches to the Neurologic Manifestations of COVID-19. Neurotherapeutics 2022; 19:1435-1466. [PMID: 35861926 PMCID: PMC9302225 DOI: 10.1007/s13311-022-01267-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2022] [Indexed: 02/07/2023] Open
Abstract
As of May 2022, there have been more than 527 million infections with severe acute respiratory disease coronavirus type 2 (SARS-CoV-2) and over 6.2 million deaths from Coronavirus Disease 2019 (COVID-19) worldwide. COVID-19 is a multisystem illness with important neurologic consequences that impact long-term morbidity and mortality. In the acutely ill, the neurologic manifestations of COVID-19 can include distressing but relatively benign symptoms such as headache, myalgias, and anosmia; however, entities such as encephalopathy, stroke, seizures, encephalitis, and Guillain-Barre Syndrome can cause neurologic injury and resulting disability that persists long after the acute pulmonary illness. Furthermore, as many as one-third of patients may experience persistent neurologic symptoms as part of a Post-Acute Sequelae of SARS-CoV-2 infection (Neuro-PASC) syndrome. This Neuro-PASC syndrome can affect patients who required hospitalization for COVID-19 or patients who did not require hospitalization and who may have had minor or no pulmonary symptoms. Given the large number of individuals affected and the ability of neurologic complications to impair quality of life and productivity, the neurologic manifestations of COVID-19 are likely to have major and long-lasting personal, public health, and economic consequences. While knowledge of disease mechanisms and therapies acquired prior to the pandemic can inform us on how to manage patients with the neurologic manifestations of COVID-19, there is a critical need for improved understanding of specific COVID-19 disease mechanisms and development of therapies that target the neurologic morbidities of COVID-19. This current perspective reviews evidence for proposed disease mechanisms as they inform the neurologic management of COVID-19 in adult patients while also identifying areas in need of further research.
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Affiliation(s)
- Edith L Graham
- The Ken and Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, 625 N. Michigan Ave Suite 1150, Chicago, IL, 60611, USA
| | - Igor J Koralnik
- The Ken and Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, 625 N. Michigan Ave Suite 1150, Chicago, IL, 60611, USA
| | - Eric M Liotta
- The Ken and Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, 625 N. Michigan Ave Suite 1150, Chicago, IL, 60611, USA.
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15
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Brain-Lung Crosstalk: Management of Concomitant Severe Acute Brain Injury and Acute Respiratory Distress Syndrome. Curr Treat Options Neurol 2022; 24:383-408. [PMID: 35965956 PMCID: PMC9363869 DOI: 10.1007/s11940-022-00726-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2022] [Indexed: 12/15/2022]
Abstract
Purpose of Review To summarize pathophysiology, key conflicts, and therapeutic approaches in managing concomitant severe acute brain injury (SABI) and acute respiratory distress syndrome (ARDS). Recent Findings ARDS is common in SABI and independently associated with worse outcomes in all SABI subtypes. Most landmark ARDS trials excluded patients with SABI, and evidence to guide decisions is limited in this population. Potential areas of conflict in the management of patients with both SABI and ARDS are (1) risk of intracranial pressure (ICP) elevation with high levels of positive end-expiratory pressure (PEEP), permissive hypercapnia due to lung protective ventilation (LPV), or prone ventilation; (2) balancing a conservative fluid management strategy with ensuring adequate cerebral perfusion, particularly in patients with symptomatic vasospasm or impaired cerebrovascular blood flow; and (3) uncertainty about the benefit and harm of corticosteroids in this population, with a mortality benefit in ARDS, increased mortality shown in TBI, and conflicting data in other SABI subtypes. Also, the widely adapted partial pressure of oxygen (PaO2) target of > 55 mmHg for ARDS may exacerbate secondary brain injury, and recent guidelines recommend higher goals of 80–120 mmHg in SABI. Distinct pathophysiology and trajectories among different SABI subtypes need to be considered. Summary The management of SABI with ARDS is highly complex, and conventional ARDS management strategies may result in increased ICP and decreased cerebral perfusion. A crucial aspect of concurrent management is to recognize the risk of secondary brain injury in the individual patient, monitor with vigilance, and adjust management during critical time windows. The care of these patients requires meticulous attention to oxygenation and ventilation, hemodynamics, temperature management, and the neurological exam. LPV and prone ventilation should be utilized, and supplemented with invasive ICP monitoring if there is concern for cerebral edema and increased ICP. PEEP titration should be deliberate, involving measures of hemodynamic, pulmonary, and brain physiology. Serial volume status assessments should be performed in SABI and ARDS, and fluid management should be individualized based on measures of brain perfusion, the neurological exam, and cardiopulmonary status. More research is needed to define risks and benefits in corticosteroids in this population.
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16
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Mekheal E, Mekheal M, Roman S, Mikhael D, Mekheal N, Manickam R. A Case Report of Autoimmune Encephalitis: Could Post-COVID-19 Autoimmunity Become a Lethal Health Issue? Cureus 2022; 14:e25910. [PMID: 35844322 PMCID: PMC9278984 DOI: 10.7759/cureus.25910] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2022] [Indexed: 02/01/2023] Open
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17
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Bauer L, Laksono BM, de Vrij FMS, Kushner SA, Harschnitz O, van Riel D. The neuroinvasiveness, neurotropism, and neurovirulence of SARS-CoV-2. Trends Neurosci 2022; 45:358-368. [PMID: 35279295 PMCID: PMC8890977 DOI: 10.1016/j.tins.2022.02.006] [Citation(s) in RCA: 91] [Impact Index Per Article: 45.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 02/14/2022] [Accepted: 02/28/2022] [Indexed: 11/26/2022]
Abstract
Severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) infection is associated with a diverse spectrum of neurological complications during the acute and postacute stages. The pathogenesis of these complications is complex and dependent on many factors. For accurate and consistent interpretation of experimental data in this fast-growing field of research, it is essential to use terminology consistently. In this article, we outline the distinctions between neuroinvasiveness, neurotropism, and neurovirulence. Additionally, we discuss current knowledge of these distinct features underlying the pathogenesis of SARS-CoV-2-associated neurological complications. Lastly, we briefly discuss the advantages and limitations of different experimental models, and how these approaches can further be leveraged to advance the field.
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Affiliation(s)
- Lisa Bauer
- Department of Viroscience, Erasmus MC, Rotterdam, The Netherlands
| | | | | | - Steven A Kushner
- Department of Psychiatry, Erasmus MC, Rotterdam, The Netherlands
| | | | - Debby van Riel
- Department of Viroscience, Erasmus MC, Rotterdam, The Netherlands.
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18
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De Michele M, Kahan J, Berto I, Schiavo OG, Iacobucci M, Toni D, Merkler AE. Cerebrovascular Complications of COVID-19 and COVID-19 Vaccination. Circ Res 2022; 130:1187-1203. [PMID: 35420916 PMCID: PMC9005103 DOI: 10.1161/circresaha.122.319954] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The risk of stroke and cerebrovascular disease complicating infection with SARS-CoV-2 has been extensively reported since the onset of the pandemic. The striking efforts of many scientists in cooperation with regulators and governments worldwide have rapidly brought the development of a large landscape of vaccines against SARS-CoV-2. The novel DNA and mRNA vaccines have offered great flexibility in terms of antigen production and led to an unprecedented rapidity in effective and safe vaccine production. However, as mass vaccination has progressed, rare but catastrophic cases of thrombosis have occurred in association with thrombocytopenia and antibodies against PF4 (platelet factor 4). This catastrophic syndrome has been named vaccine-induced immune thrombotic thrombocytopenia. Rarely, ischemic stroke can be the symptom onset of vaccine-induced immune thrombotic thrombocytopenia or can complicate the course of the disease. In this review, we provide an overview of stroke and cerebrovascular disease as a complication of the SARS-CoV-2 infection and outline the main clinical and radiological characteristics of cerebrovascular complications of vaccinations, with a focus on vaccine-induced immune thrombotic thrombocytopenia. Based on the available data from the literature and from our experience, we propose a therapeutic protocol to manage this challenging condition. Finally, we highlight the overlapping pathophysiologic mechanisms of SARS-CoV-2 infection and vaccination leading to thrombosis.
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Affiliation(s)
- Manuela De Michele
- Stroke Unit, Emergency Department (M.D.M., I.B., O.G.S., D.T.), Sapienza University of Rome, Italy
| | - Joshua Kahan
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY (J.K., A.E.M.)
| | - Irene Berto
- Stroke Unit, Emergency Department (M.D.M., I.B., O.G.S., D.T.), Sapienza University of Rome, Italy
| | - Oscar G Schiavo
- Stroke Unit, Emergency Department (M.D.M., I.B., O.G.S., D.T.), Sapienza University of Rome, Italy
| | - Marta Iacobucci
- Neuroradiology Unit, Department of Human Neurosciences (M.I.), Sapienza University of Rome, Italy
| | - Danilo Toni
- Stroke Unit, Emergency Department (M.D.M., I.B., O.G.S., D.T.), Sapienza University of Rome, Italy
| | - Alexander E Merkler
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY (J.K., A.E.M.)
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19
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Magid-Bernstein J, Girard R, Polster S, Srinath A, Romanos S, Awad IA, Sansing LH. Cerebral Hemorrhage: Pathophysiology, Treatment, and Future Directions. Circ Res 2022; 130:1204-1229. [PMID: 35420918 PMCID: PMC10032582 DOI: 10.1161/circresaha.121.319949] [Citation(s) in RCA: 114] [Impact Index Per Article: 57.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Intracerebral hemorrhage (ICH) is a devastating form of stroke with high morbidity and mortality. This review article focuses on the epidemiology, cause, mechanisms of injury, current treatment strategies, and future research directions of ICH. Incidence of hemorrhagic stroke has increased worldwide over the past 40 years, with shifts in the cause over time as hypertension management has improved and anticoagulant use has increased. Preclinical and clinical trials have elucidated the underlying ICH cause and mechanisms of injury from ICH including the complex interaction between edema, inflammation, iron-induced injury, and oxidative stress. Several trials have investigated optimal medical and surgical management of ICH without clear improvement in survival and functional outcomes. Ongoing research into novel approaches for ICH management provide hope for reducing the devastating effect of this disease in the future. Areas of promise in ICH therapy include prognostic biomarkers and primary prevention based on disease pathobiology, ultra-early hemostatic therapy, minimally invasive surgery, and perihematomal protection against inflammatory brain injury.
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Affiliation(s)
| | - Romuald Girard
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Sean Polster
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Abhinav Srinath
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Sharbel Romanos
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Issam A. Awad
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Lauren H. Sansing
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
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20
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Sarubbo F, El Haji K, Vidal-Balle A, Bargay Lleonart J. Neurological consequences of COVID-19 and brain related pathogenic mechanisms: A new challenge for neuroscience. Brain Behav Immun Health 2022; 19:100399. [PMID: 34870247 PMCID: PMC8629776 DOI: 10.1016/j.bbih.2021.100399] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 11/26/2021] [Accepted: 11/26/2021] [Indexed: 12/15/2022] Open
Abstract
Due to the infection by the SARS-CoV-2 virus (COVID-19) there were also reported neurological symptoms, being the most frequent and best cited those that affect the cerebrovascular, sensorial, cognitive and motor functions, together with the neurological diffuse symptoms as for examples headache or dizziness. Besides, some of them behave high risk of mortality. Consequently, it is crucial to elucidate the mechanisms of action in brain of SARS-CoV-2 virus in order to create new therapeutic targets to fight against this new disease. Since now the mechanisms of arrival to the brain seems to be related with the following processes: blood brain barrier (BBB) disruption together with nervous or axonal transport of the virus by the trigeminal nerve, the vagus nerve, or the brain-gut-axis. Being two the mechanisms of brain affectation most cited: a direct affectation of the virus in the brain through neuroinvasion and an indirect mechanism of action due to the effects of the systemic infection. Both processes include the triggering of inflammation, hypoxia and the increased likelihood of secondary infections. This topic supposes a major novel challenge for neuroscience. Therefore, the aim of this review is to provide summarized information about the neurological symptomatology and the brain pathogenic mechanisms involved and reported in COVID-19.
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Affiliation(s)
- Fiorella Sarubbo
- Research Unit, University Hospital Son Llàtzer, Health Research Institute of the Balearic Islands (IdISBa), Crta, Manacor Km 4, 07198, Palma, Spain
- University of the Balearic Islands (UIB), Biology Department, Mallorca, Spain
- University of the Balearic Islands (UIB), Medicine Faculty, Mallorca, Spain
| | - Khaoulah El Haji
- Research Unit, University Hospital Son Llàtzer, Health Research Institute of the Balearic Islands (IdISBa), Crta, Manacor Km 4, 07198, Palma, Spain
| | - Aina Vidal-Balle
- Research Unit, University Hospital Son Llàtzer, Health Research Institute of the Balearic Islands (IdISBa), Crta, Manacor Km 4, 07198, Palma, Spain
| | - Joan Bargay Lleonart
- Research Unit, University Hospital Son Llàtzer, Health Research Institute of the Balearic Islands (IdISBa), Crta, Manacor Km 4, 07198, Palma, Spain
- University of the Balearic Islands (UIB), Medicine Faculty, Mallorca, Spain
- Hematology Department, University Hospital Son Llàtzer, Crta, Manacor Km 4, 07198, Palma, Spain
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21
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Imaging features and ultraearly hematoma growth in intracerebral hemorrhage associated with COVID-19. Neuroradiology 2022; 64:1367-1372. [PMID: 35034151 PMCID: PMC8761086 DOI: 10.1007/s00234-021-02861-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 11/11/2021] [Indexed: 11/21/2022]
Abstract
Purpose Intracerebral hemorrhage (ICH) is an uncommon but deadly event in patients with COVID-19 and its imaging features remain poorly characterized. We aimed to describe the clinical and imaging features of COVID-19-associated ICH. Methods Multicenter, retrospective, case–control analysis comparing ICH in COVID-19 patients (COV19 +) versus controls without COVID-19 (COV19 −). Clinical presentation, laboratory markers, and severity of COVID-19 disease were recorded. Non-contrast computed tomography (NCCT) markers (intrahematoma hypodensity, heterogeneous density, blend sign, irregular shape fluid level), ICH location, and hematoma volume (ABC/2 method) were analyzed. The outcome of interest was ultraearly hematoma growth (uHG) (defined as NCCT baseline ICH volume/onset-to-imaging time), whose predictors were explored with multivariable linear regression. Results A total of 33 COV19 + patients and 321 COV19 − controls with ICH were included. Demographic characteristics and vascular risk factors were similar in the two groups. Multifocal ICH and NCCT markers were significantly more common in the COV19 + population. uHG was significantly higher among COV19 + patients (median 6.2 mL/h vs 3.1 mL/h, p = 0.027), and this finding remained significant after adjustment for confounding factors (systolic blood pressure, antiplatelet and anticoagulant therapy), in linear regression (B(SE) = 0.31 (0.11), p = 0.005). This association remained consistent also after the exclusion of patients under anticoagulant treatment (B(SE) = 0.29 (0.13), p = 0.026). Conclusions ICH in COV19 + patients has distinct NCCT imaging features and a higher speed of bleeding. This association is not mediated by antithrombotic therapy and deserves further research to characterize the underlying biological mechanisms.
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22
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Cristian D, Bagatto D. Severe stroke in patients admitted to intensive care unit after COVID-19 infection: pictorial essay of a case series. BRAIN HEMORRHAGES 2021; 3:29-35. [PMID: 34927033 PMCID: PMC8667478 DOI: 10.1016/j.hest.2021.12.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 12/06/2021] [Accepted: 12/08/2021] [Indexed: 12/21/2022] Open
Abstract
Patients infected by COVID-19 could require intensive care unit admission especially due to acute respiratory failure. However, neurological manifestations are very common. Among these, ischemic stroke or cerebral hemorrhage may have unfavorable outcome. The mechanisms leading to cerebral damage by SARS-CoV2 are still under debate. One of the most accepted theories implies an endothelial activation which in turns increase the risk of thrombus formation with the development of stroke, either ischemic or hemorrhagic. The more severe the COVID-19 disease, the higher the risk of stroke. Stroke in ICU patients are not frequent, but cerebral hemorrhage has devastating effects with high mortality. In these pictorial essay of case reports, main clinical aspects are discussed, along with a summary of the evidence about pathophysiology and treatment of these patients.
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Affiliation(s)
- Deana Cristian
- Department of Anesthesia and Intensive Care, Health Integrated Agency of Friuli Centrale, Udine, Italy
| | - Daniele Bagatto
- Department of Neuroradiology, Health Integrated Agency of Friuli Centrale, Udine, Italy
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23
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Vuorio A, Lassila R, Kovanen PT. Hypercholesterolemia and COVID-19: Statins for Lowering the Risk of Venous Thromboembolism. Front Cardiovasc Med 2021; 8:711923. [PMID: 34722654 PMCID: PMC8548371 DOI: 10.3389/fcvm.2021.711923] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 09/09/2021] [Indexed: 12/22/2022] Open
Affiliation(s)
- Alpo Vuorio
- Department of Forensic Medicine, University of Helsinki, Helsinki, Finland.,Mehiläinen Airport Health Centre, Vantaa, Finland
| | - Riitta Lassila
- Research Program Unit in Systems Oncology, Coagulation Disorders Unit, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Petri T Kovanen
- Wihuri Research Institute, Biomedicum Helsinki 1, Helsinki, Finland
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24
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Stevens LM, de Lemos JA, Das SR, Rutan C, Alger HM, Elkind MSV, Zhao J, Iyer K, Figueroa CA, Hall JL. American Heart Association Precision Medicine Platform Addresses Challenges in Data Sharing. Circ Cardiovasc Qual Outcomes 2021; 14:e007949. [PMID: 34517729 PMCID: PMC8452247 DOI: 10.1161/circoutcomes.121.007949] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Laura M Stevens
- Department of Cardiology and Computational Bioscience Program, University of Colorado, Aurora (L.M.S.).,Quality, Outcomes Research and Analytics, American Heart Association, Dallas, TX (L.M.S., C.R., H.A., J.L.H.)
| | | | - Sandeep R Das
- UT Southwestern Medical Center, Dallas, TX (J.A.d.L., S.R.D.).,Center for Innovation and Value at Parkland, Dallas, TX (S.R.D.)
| | - Christine Rutan
- Quality, Outcomes Research and Analytics, American Heart Association, Dallas, TX (L.M.S., C.R., H.A., J.L.H.)
| | - Heather M Alger
- Quality, Outcomes Research and Analytics, American Heart Association, Dallas, TX (L.M.S., C.R., H.A., J.L.H.)
| | - Mitchell S V Elkind
- Vagelos College of Physicians and Surgeons and Mailman School of Public Health, Columbia University, NewYork-Presbyterian Hospital (M.S.V.E.)
| | - Juan Zhao
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN (J.Z.)
| | - Kritika Iyer
- Departments of Biomedical Engineering (K.I. and C.A.F.), University of Michigan, Ann Arbor
| | - C Alberto Figueroa
- Departments of Biomedical Engineering (K.I. and C.A.F.), University of Michigan, Ann Arbor.,Surgery (C.A.F.), University of Michigan, Ann Arbor
| | - Jennifer L Hall
- Quality, Outcomes Research and Analytics, American Heart Association, Dallas, TX (L.M.S., C.R., H.A., J.L.H.).,Department of Medicine, Lillehei Heart Institute, University of Minnesota, Minneapolis (J.L.H.)
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Atillasoy J, Leasure AC, Sheth KN. Intracerebral Hemorrhage in COVID-19 Infection. World Neurosurg 2021; 153:142-143. [PMID: 34420767 PMCID: PMC8376376 DOI: 10.1016/j.wneu.2021.06.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Jem Atillasoy
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Audrey C Leasure
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Kevin N Sheth
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
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26
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Aphasia seven days after second dose of an mRNA-based SARS-CoV-2 vaccine. BRAIN HEMORRHAGES 2021; 2:165-167. [PMID: 34192245 PMCID: PMC8223021 DOI: 10.1016/j.hest.2021.06.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 06/19/2021] [Accepted: 06/19/2021] [Indexed: 01/05/2023] Open
Abstract
Objectives Though rare, neurological side effects of SARS-CoV-2 vaccinations are increasingly reported. Even if the first dosage goes uncomplicated, the second dose may be complicated by severe adverse reactions as in the following case. Case report A 52yo male developed sudden-onset reading difficulty and aphasia 7d after the second dose of an mRNA-based SARS-CoV-2 vaccine. He had a previous history of myocardial infarction, arterial hypertension, hyperlipidemia, and nephrolithiasis. Blood pressure was slightly elevated on admission. Blood tests revealed mildly elevated D-dimer, pre-diabetes and hyperuricemia. Cerebral magnetic resonance imaging revealed an intracerebral bleeding (ICB) in the left temporal lobe. Aphasia resolved almost completely within a few days. Blood pressure values were normal throughout hospitalisation. Whether there was a causal relation between the ICB and the vaccination remains speculative but cannot be definitively excluded. Conclusions A second dose of a SARS-CoV-2 vaccination may be followed by ICB. Though the pathophysiology of ICB remains unexplained a causal relation between ICB and the vaccination cannot be excluded. Risk factors for ICB should be carefully monitored in patients undergoing SARS-CoV-2 vaccination.
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