Acute ischemic stroke as a major neurologic complication of SARS-CoV-2 infection

Severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) is the reason for coronavirus disease 2019 (COVID-19), which was first diagnosed in Wuhan, China. COVID-19 has since led to a worldwide pandemic. SARS-CoV-2 infection increases the risk of thrombotic events, including ischemic strokes. There are limited data on ischemic stroke associated with COVID-19. The aim of our study was to determine the effects of SARS-CoV-2 infection on ischemic stroke. A total of 248 ischemic stroke and transient ischemic attack (TIA) patients hospitalized in our neurology intensive care and stroke units between March 2020 and January 2022 were retrospectively analyzed. Two hundred and five stroke patients were diagnosed with COVID-19-negative strokes. COVID-19-positive patients were first isolated from the relevant units, and neurological follow-up was performed. Forty-three patients who were diagnosed with COVID-19-related ischemic stroke and survived at the end of the isolation period were transferred and followed up in the neurology intensive care and stroke unit. Stroke classifications, vascular risk factors, clinical course, disease severity, laboratory parameters, recanalization treatment results, and mortality rates of ischemic strokes in patients with positive or negative COVID-19 infection were evaluated. COVID-19-positive and COVID-19-negative stroke patients had similar characteristics of age, gender, vascular risk factors and stroke subtype. Cryptogenic stroke was the most common type of stroke in both groups. TIA and small vessel diseases were detected only in the COVID-19-negative group. COVID-19-positive stroke patients had lower lymphocyte counts and higher procalcitonin, troponin and fibrinogen levels. Ischemic strokes had similar clinical characteristics and did not show a different course or prognosis in COVID-19-positive and COVID-19-negative stroke patients.

COVID-19; SARS-CoV-2 infection; Acute ischemic stroke

[1] Payus AO, Liew Sat Lin C, Mohd Noh M, Jeffree MS, Ali RA. SARS-CoV-2 infection of the nervous system: a review of the literature on neurological involvement in novel coronavirus disease-(COVID-19). Bosnian Journal of Basic Medical Sciences. 2020; 20: 283–292.

[2] World Health Organization. Coronavirus disease 2019 ( COVID-19): situation report, 51. 2020. Available at: https://apps.who.int/ iris/handle/10665/331475 (Accessed: 17 April 2021).

[3] Harapan BN, Yoo HJ. Neurological symptoms, manifestations, and complications associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease 19 (COVID-19). Journal of Neurology. 2021; 268: 3059–3071.

[4] Chen X, Laurent S, Onur OA, Kleineberg NN, Fink GR, Schweitzer F, et al. A systematic review of neurological symptoms and complications of COVID-19. Journal of Neurology. 2021; 268: 392–402.

[5] Khatoon F, Prasad K, Kumar V. Neurological manifestations of COVID-19: available evidences and a new paradigm. Journal of NeuroVirology. 2020; 26: 619–630.

[6] Kumar M, Thakur AK. Neurological manifestations and comorbidity associated with COVID-19: an overview. Neurological Sciences. 2020; 41: 3409–3418.

[7] Favas TT, Dev P, Chaurasia RN, Chakravarty K, Mishra R, Joshi D, et al. Neurological manifestations of COVID-19: a systematic review and meta-analysis of proportions. Neurological Sciences. 2020; 41: 3437–3470.

[8] Chen X, Laurent S, Onur OA, Kleineberg NN, Fink GR, Schweitzer F, et al. A systematic review of neurological symptoms and complications of COVID-19. Journal of Neurology. 2021; 268: 392–402.

[9] Favas TT, Dev P, Chaurasia RN, Chakravarty K, Mishra R, Joshi D, et al. Neurological manifestations of COVID-19: a systematic review and meta-analysis of proportions. Neurological Sciences. 2020; 41: 3437–3470.

[10] Sagris D, Papanikolaou A, Kvernland A, Korompoki E, Frontera JA, Troxel AB, et al. COVID‐19 and ischemic stroke. European Journal of Neurology. 2021; 28: 3826–3836.

[11] Vogrig A, Gigli GL, Bnà C, Morassi M. Stroke in patients with COVID-19: clinical and neuroimaging characteristics. Neuroscience Letters. 2021; 743: 135564.

[12] World Health Organization. Clinical management of COVID-19: interim guidance, 27 May 2020. 2020.

[13] National Institutes of Health. COVID-19 Treatment Guidelines Panel. Coronavirus disease 2019 (COVID-19). Treatment guidelines. Available at: https://www.covid19treatmentguidelines.nih.gov/ (Accessed: 01 March 2020).

[14] Adams HP, Biller J. Classification of subtypes of ischemic stroke: history of the trial of org 10172 in acute stroke treatment classification. Stroke. 2015; 46: e114–117.

[15] Brott T, Adams HP, Olinger CP, Marler JR, Barsan WG, Biller J, et al. Measurements of acute cerebral infarction: a clinical examination scale. Stroke. 1989; 20: 864–870.

[16] Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidism NC, Becker K, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019; 50: 344–418.

[17] Hacke W. Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke. JAMA. 1995; 274: 1017.

[18] Ganesh A, Luengo-Fernandez R, Pendlebury ST, Rothwell PM. Weights for ordinal analyses of the modified Rankin Scale in stroke trials: a population-based cohort study. EClinicalMedicine. 2020; 23: 100415.

[19] Akhtar N, Abid FB, Kamran S, Singh R, Imam Y, AlJerdi S, et al. Characteristics and comparison of 32 COVID-19 and non-COVID-19 ischemic strokes and historical stroke patients. Journal of Stroke and Cerebrovascular Diseases. 2021; 30: 105435.

[20] Galea M, Agius M, Vassallo N. Neurological manifestations and pathogenic mechanisms of COVID-19. Neurological Research. 2022; 44: 571–582.

[21] Collantes MEV, Espiritu AI, Sy MCC, Anlacan VMM, Jamora RDG. Neurological manifestations in COVID-19 infection: a systematic review and meta-analysis. Canadian Journal of Neurological Sciences. 2021; 48: 66–76.

[22] Rahman A, Niloofa R, De Zoysa IM, Cooray AD, Kariyawasam J, Seneviratne SL. Neurological manifestations in COVID-19: a narrative review. SAGE Open Medicine. 2020; 8: 205031212095792.

[23] Pranata R, Huang I, Lim MA, Wahjoepramono EJ, July J. Impact of cerebrovascular and cardiovascular diseases on mortality and severity of COVID-19—systematic review, meta-analysis, and meta-regression. Journal of Stroke and Cerebrovascular Diseases. 2020; 29: 104949.

[24] Syahrul S, Maliga HA, Ilmawan M, Fahriani M, Mamada SS, Fajar JK, et al. Hemorrhagic and ischemic stroke in patients with coronavirus disease 2019: incidence, risk factors, and pathogenesis—a systematic review and meta-analysis. F1000Research. 2021; 10: 34.

[25] Yassin A, Ghzawi A, Al-Mistarehi A, El-Salem K, Y Benmelouka A, M Sherif A, et al. Mortality rate and biomarker expression within COVID-19 patients who develop acute ischemic stroke: a systematic review and meta-analysis. Future Science OA. 2021; 7: FSO713.

[26] Tsivgoulis G, Palaiodimou L, Zand R, Lioutas VA, Krogias C, Katsanos AH, et al. COVID-19 and cerebrovascular diseases: a comprehensive overview. Therapeutic Advances in Neurological Disorders. 2020; 13: 175628642097800.

[27] Carneiro T, Dashkoff J, Leung LY, Nobleza COS, Marulanda-Londono E, Hathidara M, et al. Intravenous tPA for acute ischemic stroke in patients with COVID-19. Journal of Stroke and Cerebrovascular Diseases. 2020; 29: 105201.