Stroke Among SARS-CoV-2 Vaccine Recipients in Mexico: A Nationwide Descriptive Study

BACKGROUND AND OBJECTIVES

Information on stroke among severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines remains scarce. We report stroke incidence as an adverse event following immunization (AEFI) among recipients of 79,399,446 doses of 6 different SARS-CoV-2 vaccines (BNT162b2, ChAdOx1 nCov-19, Gam-COVID-Vac, CoronaVac, Ad5-nCoV, and Ad26.COV2-S) between December 24, 2020, and August 31, 2021, in Mexico.

METHODS

This retrospective descriptive study analyzed stroke incidence per million doses among hospitalized adult patients (≥18 years) during an 8-month interval. According to the World Health Organization, AEFIs were defined as clinical events occurring within 30 days after immunization and categorized as either nonserious or serious, depending on severity, treatment, and hospital admission requirements. Acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), and cerebral venous thrombosis (CVT) cases were collected through a passive epidemiologic surveillance system in which local health providers report potential AEFI to the Mexican General Board of Epidemiology. Data were captured with standardized case report formats by an ad hoc committee appointed by the Mexican Ministry of Health to evaluate potential neurologic AEFI against SARS-COV-2.

RESULTS

We included 56 patients (31 female patients [55.5%]) for an overall incidence of 0.71 cases per 1,000,000 administered doses (95% CI 0.54-0.92). Median age was 65 years (interquartile range [IQR] 55-76 years); median time from vaccination to stroke (of any subtype) was 2 days (IQR 1-5 days). In 27 (48.2%) patients, the event was diagnosed within the first 24 hours after immunization. The most frequent subtype was AIS in 43 patients (75%; 0.54 per 1,000,000 doses, 95% CI 0.40-0.73), followed by ICH in 9 (16.1%; 0.11 per 1,000,000 doses, 95% CI 0.06-0.22) and SAH and CVT, each with 2 cases (3.6%; 0.03 per 1,000,000 doses, 95% CI 0.01-0.09). Overall, the most common risk factors were hypertension in 33 (58.9%) patients and diabetes in 22 (39.3%). Median hospital length of stay was 6 days (IQR 4-13 days). At discharge, functional outcome was good (modified Rankin Scale score 0-2) in 41.1% of patients; in-hospital mortality rate was 21.4%.

DISCUSSION

Stroke is an exceedingly rare AEFI against SARS-CoV-2. Preexisting stroke risk factors were identified in most patients. Further research is needed to evaluate causal associations between SARS-COV-2 vaccines and stroke.

Endovascular Treatment of Ischemic Stroke in a Developing Country

BACKGROUND

There is inequality in access to recent advancements in endovascular treatment of acute ischemic stroke (AIS), and Mexico is unusually sensitive to such inequality.

AIMS

To report the initial experience of the Mexican Endovascular Reperfusion Registry (MERR).

METHODS

The MERR is an academic, independent, prospective, multicenter, observational registry of patients treated with endovascular reperfusion techniques in Mexican hospitals. The registry includes information on demographic and clinical characteristics, diagnostic procedures, treatments, selected time metrics, and outcomes.

RESULTS

In all, 49 (57.1% female) patients from 8 centers were included and had the following characteristics: median National Institute of Health Stroke Scale score, 16; median Alberta Stroke Program Early CT Score score, 9; received intravenous tissue-type plasminogen activator, 49%; and treated with mechanical devices, 39 (79.6%), including 20 treated with stent retriever alone, 2 with retriever and intra-arterial thrombolysis (IAt), 10 with catheter aspiration (4 in combination with IAt), 6 with a combination of catheter aspiration and stent retriever, and 1 with IAt followed by balloon angioplasty. Recanalization (TICI 2b or better) was achieved in 69.4% of the patients. The median clot to recanalization time was 30 minutes. A modified Rankin scale ≤2 was achieved in 44.9% of the patients, and 68.2% of these were treated with stent retriever (P = .011). Procedure-related morbidity was 12.2%, 7 patients presented intracerebral hemorrhage (71.4% asymptomatic), and all-cause mortality was 6.1%.

CONCLUSIONS

Endovascular treatment of AIS in Mexico is feasible and has an efficacy comparable to that of other countries. Still, many challenges remain, especially pertaining to high costs and difficulties in equality in access to treatment.

Mexican-National Institute of Neurology and Neurosurgery-Stroke Registry: Results of a 25-Year Hospital-Based Study

Background and purpose

Stroke has been scarcely studied in Latin America (LA). The Mexican Institute of Neurology Stroke Registry was established in 1990 as a prospective computer-based database to register data obtained from patients admitted with stroke. Using this data, we attempted to define the profile of risk factors and outcomes.

Methods

The demographic data, stroke description, ancillary tests, vascular risk factors, and modified Rankin scale (mRs) were registered. Ischemic stroke subtyping was based on the Trial of Org 10,172 of the Acute Stroke Treatment classification. We followed-up patients using multiple overlapping methods. Primary outcomes included mRs, recurrence, and death at 30 days and at the end of follow-up.

Results

We included 4,481 patients with a median follow-up of 27 months, (17,281 person-years follow-up). The mean age was 52.8 ± 18 years. There were 2,229 males (50%) included in the study. CI was present in 64.9%, intracerebral hemorrhage (ICH) in 25.6%, and cerebral venous thrombosis (CVT) in 6.3%. Hypertension was the major risk factor (46.5%). The most common cause of CI was atherosclerosis (27%). ICH was mainly hypertensive (58%), and 60% of CVT were puerperal. Overall, the mortality rate was 24.5%. The recurrence rate was 16.9%. Poor outcome (mRs ≥ 3) was found in 56.2% of patients. The best outcomes were observed in CVT patients (74.5% mRs ≤ 2), whereas 72.1% ICH patients had mRs ≥3.

Conclusion

This is one of the largest hospital-based registries in LA and shows significant differences with other previously published registries, including a younger age, relatively less hypertension, and larger proportion of CVT. Poor functional outcome was common. This study adds to the understanding of geographic differences in stroke characteristics and outcomes.

[Acute motor axonal neuropathy with hyperreflexia and central demyelination associated to anti-GA1 antibodies]

CASE REPORT

We report the case of a 37-year-old male who presented signs of acute motor axonal polyradiculoneuropathy that began three weeks after a three-day bout of gastroenteritis and was accompanied by a stiff neck, hyperreflexia and anti-GA1 antibodies. The symptoms developed within 12 hours, after beginning with the patient waking up in the middle of the night with a headache; the following morning he presented general weakness and cranial neuropathy and therefore decided to go to hospital. The neurological examination showed multiple cranial neuropathy, quadriparesis with hyperreflexia, bilateral Babinski and a stiff neck. Following treatment, first with methylprednisolone and then with gamma globulin, the development of the illness was halted. Neuroinfection due to lumbar puncture was ruled out and acute motor axonal polyradiculoneuropathy was confirmed in a second neuroconduction study performed seven days after admission. Magnetic resonance imaging revealed an area of demyelination in the white matter and the presence of anti-GA1 antibodies was detected in the serological analysis. Two years later, the patient performs activities of daily living, walks with assistance and has gone back to work.

CONCLUSIONS

Acute motor axonal polyradiculoneuropathy with hyperreflexia, a stiff neck and central demyelination can be associated to anti-GA1 antibodies. Treatment with gamma globulin appears to curb development of the disease.

[Non-valvular atrial fibrillation and completed stroke: factors determining mortality, recurrence and prognosis after a first event in the Mexican population]

AIMS

Non-valvular atrial fibrillation (NVAF) accounts for 25% of completed strokes (CS) of a cardioembolic origin in patients over 60 years old. Our aim was to define the predictors of a good and poor prognosis after a CS secondary to an NVAF in our milieu.

PATIENTS AND METHODS

We evaluated the risk factors (RF) and severity of CS in relation to death, functionality and recurrence at 5 years. 81 patients between the ages of 49 and 88 were followed up consecutively for 1 to 90 months; 38 (46.9%) of them were males. Multivariate analysis was performed with the following independent variables: age, gender, smoking, hypertension, heart disease, diabetes mellitus and characteristics of the stroke. The severity of the CS was assessed by means of the modified Rankin scale, which was dichotomised into a good prognosis (0-2) and a poor prognosis (> or = 3), both basal and at the end of the clinical control. We also evaluated the secondary preventive treatment used and its relation with recurrence, prognosis, death and complications.

RESULTS

No RF was linked to a poor prognosis or recurrence; 88% had a poor prognosis. Antiplatelet drugs were used in 42% of cases and 39% received anticoagulants. A good final progression was observed in 9.5% of the patients treated with antiplatelet drugs versus 35% of those receiving anticoagulation therapy (p = 0.004). Severity of the CS on admission was worse in the aspirin group, with no differences in recurrence and mortality. A better prognosis was observed in patients from urban areas.

CONCLUSIONS

Use of antiplatelet drugs, living in a rural area and a Rankin score of > or = 3 on admission are factors suggesting a poor prognosis in the clinical control at 5 years.

[Cavernous angioma. Clinical observations and prognosis of 133 patients]

BACKGROUND

Cavernous angiomas represent 9% of the vascular malformations that affect nervous system. The principal mode of onset is cerebral hemorrhage and epilepsy, and can be sporadic of multiple. In the last, there is a familiar factor specially found in Mexician-American. In our Country there is no data of the clinical or demographic characteristics of the disease. The aim of this study is to describe the clinical characteristics and prognosis of 133 patients with cavernous angiomas consecutively attended in the National Institute of Neurology of Mexico City.

PATIENTS AND METHODS

Since 1988 we evaluated a total of 146 cases of cavernous angiomas, 133 were confirmed by MRI and included in the analysis of this study. In every case we registered the demographic characteristic, neurological manifestations, and prognosis divided in good o bad outcome, according to the Glasgow outcome scale (1 and > or = 2 respectively). Data were analyzed with descriptive statistics with the Chi square test, and p was set at 0.05 level.

RESULTS

The mean age was 34.3 +/- 14.6 years; 50.4% in male. Eighty seven percent were unique, and the principal manifestation was supratentorial in 65%, infratentorial in 24.8%, supra-infratentorial in 6.8%, and spinal in 3.8%. The clinical manifestations were intracerebral hemorrhage in 58.7%, epilepsy in 48.1%, headache in 37.6%, neurological focalization not secondary to hemorrhage in 8.3%, and incidental in 2.3%. The 6 month outcome was good in 80% of patient assessed by the Glasgow outcome scale.

CONCLUSIONS

In our serie the mean age or presentation was 34 years old, the mean neurological manifestations were cerebral hemorrhage and epilepsy, and the outcome was good in the majority of the cases.