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For: Padma Srivastava MV, Vishnu VY, Pandit AK. Mucormycosis Epidemic and Stroke in India During the COVID-19 Pandemic. Stroke 2021;52:e622-e623. [PMID: 34525840 DOI: 10.1161/strokeaha.121.036626] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]

For:	Padma Srivastava MV, Vishnu VY, Pandit AK. Mucormycosis Epidemic and Stroke in India During the COVID-19 Pandemic. Stroke 2021;52:e622-e623. [PMID: 34525840 DOI: 10.1161/strokeaha.121.036626] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]

Number

Cited by Other Article(s)

The mucormycosis and stroke: The learning curve during the second COVID-19 pandemic. J Stroke Cerebrovasc Dis 2023;32:106819. [PMID: 36495645 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 09/28/2022] [Accepted: 09/29/2022] [Indexed: 11/07/2022] Open

Abstract

BACKGROUND

The Angio-invasive Rhino-orbito-cerebral mucormycosis (ROCM) producing strokes is a less explored entity. Our hospital, a stroke-ready one, had an opportunity to manage mucormycosis when it was identified as the nodal center for mucormycosis management. We are sharing our experiences and mistakes in managing the cerebrovascular manifestations of ROCM.

METHODS

We conducted a prospective observational study during the second wave of the COVID-19 pandemic from 1st May 2021 to 30th September 2021, where consecutive patients aged more than 18 years with microbiologically confirmed cases of ROCM were included. Clinical details (timing of stroke onset after ROCM symptoms, GCS, NIHSS), imaging findings (ASPECTS, the territory of stroke, the pattern of infarct, hemorrhagic transformation, cavernous sinus thrombosis), angiogram findings, management details (IV thrombolysis), and outcomes (mRS at discharge and duration of hospital stay) were documented. We also compared the demographics, clinical features (NIHSS), radiological findings, treatment details, duration of hospital stay, and functional outcome at the discharge of the ROCM stroke patients with stroke patients without ROCM.

RESULTS

Stroke developed in 42% of patients with ROCM, predominantly anterior circulation border zone ischemic infarcts. Strokes occurred after a median of five days from the onset of ROCM symptoms. The most common vessel involved was the ophthalmic artery, followed by the cavernous ICA. We could not thrombolyse ROCM stroke patients. ROCM patients who developed stroke compared with patients without stroke had a more infiltrative fungal infection and higher inflammatory markers. Mucormycosis associated stroke patients had higher in-hospital mortality and poor functional outcomes.

T CONCLUSION

Due to delayed recognition of stroke symptoms, none received reperfusion strategies, leading to poor functional outcomes. For early stroke detection, ROCM cases need frequent monitoring and education of patients and their relatives about the ALS acronym (loss of ambulation, limb weakness, and loss of speech).

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Pandit AK, Tangri P, Misra S, Srivastava MVP, Bhatnagar S, Thakar A, Sikka K, Panda S, Vishnu VY, Singh RK, Das A, Radhakrishnan DM, Srivastava AK, Subramaniam R, Trikha A, Agarwal A, Rajan R, Upadhyay V, Parikipandla S, Singh A, Kairo A. Mucormycosis in COVID-19 Patients: A Case-Control Study. Microorganisms 2022;10:microorganisms10061209. [PMID: 35744726 PMCID: PMC9229175 DOI: 10.3390/microorganisms10061209] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 05/20/2022] [Accepted: 05/23/2022] [Indexed: 01/27/2023] Open

Affiliation(s)

Awadh Kishor Pandit Department of Neurology, All India Institute of Medical Sciences, New Delhi 110029, India; (P.T.); (S.M.); (M.V.P.S.); (V.Y.V.); (R.K.S.); (A.D.); (D.M.R.); (A.K.S.); (A.A.); (R.R.); (V.U.); (S.P.) Correspondence: ; Tel.: +91-11-26594049
Poorvi Tangri Department of Neurology, All India Institute of Medical Sciences, New Delhi 110029, India; (P.T.); (S.M.); (M.V.P.S.); (V.Y.V.); (R.K.S.); (A.D.); (D.M.R.); (A.K.S.); (A.A.); (R.R.); (V.U.); (S.P.)
Shubham Misra Department of Neurology, All India Institute of Medical Sciences, New Delhi 110029, India; (P.T.); (S.M.); (M.V.P.S.); (V.Y.V.); (R.K.S.); (A.D.); (D.M.R.); (A.K.S.); (A.A.); (R.R.); (V.U.); (S.P.)
Madakasira Vasantha Padma Srivastava Department of Neurology, All India Institute of Medical Sciences, New Delhi 110029, India; (P.T.); (S.M.); (M.V.P.S.); (V.Y.V.); (R.K.S.); (A.D.); (D.M.R.); (A.K.S.); (A.A.); (R.R.); (V.U.); (S.P.)
Sushma Bhatnagar Department of Onco-Anesthesia, Pain and Palliative Care, All India Institute of Medical Sciences, New Delhi 110029, India;
Alok Thakar Department of Otolaryngology and Head-Neck Surgery, All India Institute of Medical Sciences, New Delhi 110029, India; (A.T.); (K.S.); (S.P.); (A.S.); (A.K.)
Kapil Sikka Department of Otolaryngology and Head-Neck Surgery, All India Institute of Medical Sciences, New Delhi 110029, India; (A.T.); (K.S.); (S.P.); (A.S.); (A.K.)
Smriti Panda Department of Otolaryngology and Head-Neck Surgery, All India Institute of Medical Sciences, New Delhi 110029, India; (A.T.); (K.S.); (S.P.); (A.S.); (A.K.)
Venugopalan Y. Vishnu Department of Neurology, All India Institute of Medical Sciences, New Delhi 110029, India; (P.T.); (S.M.); (M.V.P.S.); (V.Y.V.); (R.K.S.); (A.D.); (D.M.R.); (A.K.S.); (A.A.); (R.R.); (V.U.); (S.P.)
Rajesh Kumar Singh Department of Neurology, All India Institute of Medical Sciences, New Delhi 110029, India; (P.T.); (S.M.); (M.V.P.S.); (V.Y.V.); (R.K.S.); (A.D.); (D.M.R.); (A.K.S.); (A.A.); (R.R.); (V.U.); (S.P.)
Animesh Das Department of Neurology, All India Institute of Medical Sciences, New Delhi 110029, India; (P.T.); (S.M.); (M.V.P.S.); (V.Y.V.); (R.K.S.); (A.D.); (D.M.R.); (A.K.S.); (A.A.); (R.R.); (V.U.); (S.P.)
Divya M. Radhakrishnan Department of Neurology, All India Institute of Medical Sciences, New Delhi 110029, India; (P.T.); (S.M.); (M.V.P.S.); (V.Y.V.); (R.K.S.); (A.D.); (D.M.R.); (A.K.S.); (A.A.); (R.R.); (V.U.); (S.P.)
Achal Kumar Srivastava Department of Neurology, All India Institute of Medical Sciences, New Delhi 110029, India; (P.T.); (S.M.); (M.V.P.S.); (V.Y.V.); (R.K.S.); (A.D.); (D.M.R.); (A.K.S.); (A.A.); (R.R.); (V.U.); (S.P.)
Rajeshwari Subramaniam Department of Anesthesiology, Critical Care and Pain Medicine, All India Institute of Medical Sciences, New Delhi 110029, India; (R.S.); (A.T.)
Anjan Trikha Department of Anesthesiology, Critical Care and Pain Medicine, All India Institute of Medical Sciences, New Delhi 110029, India; (R.S.); (A.T.)
Ayush Agarwal Department of Neurology, All India Institute of Medical Sciences, New Delhi 110029, India; (P.T.); (S.M.); (M.V.P.S.); (V.Y.V.); (R.K.S.); (A.D.); (D.M.R.); (A.K.S.); (A.A.); (R.R.); (V.U.); (S.P.)
Roopa Rajan Department of Neurology, All India Institute of Medical Sciences, New Delhi 110029, India; (P.T.); (S.M.); (M.V.P.S.); (V.Y.V.); (R.K.S.); (A.D.); (D.M.R.); (A.K.S.); (A.A.); (R.R.); (V.U.); (S.P.)
Vibhor Upadhyay Department of Neurology, All India Institute of Medical Sciences, New Delhi 110029, India; (P.T.); (S.M.); (M.V.P.S.); (V.Y.V.); (R.K.S.); (A.D.); (D.M.R.); (A.K.S.); (A.A.); (R.R.); (V.U.); (S.P.)
Sathish Parikipandla Department of Neurology, All India Institute of Medical Sciences, New Delhi 110029, India; (P.T.); (S.M.); (M.V.P.S.); (V.Y.V.); (R.K.S.); (A.D.); (D.M.R.); (A.K.S.); (A.A.); (R.R.); (V.U.); (S.P.)
Anup Singh Department of Otolaryngology and Head-Neck Surgery, All India Institute of Medical Sciences, New Delhi 110029, India; (A.T.); (K.S.); (S.P.); (A.S.); (A.K.)
Arvind Kairo Department of Otolaryngology and Head-Neck Surgery, All India Institute of Medical Sciences, New Delhi 110029, India; (A.T.); (K.S.); (S.P.); (A.S.); (A.K.)

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Garg RK, Malhotra HS, Pandey S. Neurological infections in 2021: a spotlight on India. Lancet Neurol 2021;21:17-18. [PMID: 34942126 DOI: 10.1016/s1474-4422(21)00415-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 11/17/2021] [Indexed: 11/26/2022]

Cerebrovascular Involvement in Mucormycosis in COVID-19 Pandemic. J Stroke Cerebrovasc Dis 2021;31:106231. [PMID: 34890962 PMCID: PMC8606282 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106231] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 11/14/2021] [Accepted: 11/16/2021] [Indexed: 12/17/2022] Open

Abstract

Background

Many countries have seen an unprecedented rise of cases of coronavirus disease 2019 (COVID-19) associated mucormycosis (CAM). Cerebrovascular involvement in CAM has not been studied so far. We describe clinico-radiological manifestations of cerebrovascular complications observed in CAM.

Methods

In this multicentric retrospective observational study from India, patients with CAM who developed cerebrovascular involvement were studied. Their demographics, risk factors, clinical manifestations, imaging, laboratory profile and outcomes were noted.

Results

Out of 49 subjects with cerebrovascular involvement, 71.4% were males while average age was 52.9 years. Ischemic stroke was commonest (91.8%) followed by intracranial haemorrhage (6.1%) and subarachnoid haemorrhage (2%). The incidence of cerebrovascular complications in CAM was found to be 11.8% in one center. Cerebrovascular symptoms appeared a median of 8.3 days from the onset of mucormycosis. Commonest presentation of mucormycosis was rhino-orbito-cerebral syndrome in 98%. Diabetes mellitus was present in 81.7%. Forty percent developed stroke despite being on antiplatelet agent and/or heparin. Amongst subjects with ischemic strokes, location of stroke was unilateral anterior circulation (62.2%); bilateral anterior circulation (17.8%); posterior circulation (11.1%) and combined anterior and posterior circulation (8.9%). Vascular imaging revealed intracranial occlusion in 62.1%; extracranial occlusion in 3.4% and normal vessels in 34.5%. Mortality was 51% during hospital stay.

Conclusions

Cerebrovascular involvement was seen in 11.8% patients of CAM. Angio-invasive nature of the fungus, prothrombotic state created by COVID-19, and diabetes were important causative factors. Subjects with CAM should be screened for involvement of the brain as well as its vessel. Antiplatelet agents/heparin did not seem to provide complete protection from this type of stroke.

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