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1.
J Med Vasc ; 45(5): 260-267, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32862983

RESUMO

OBJECTIVE: Carotid endarterectomy has traditionally been the strategy for the surgical management of carotid stenosis. Alongside the usual techniques, this study presents another technique: endarterectomy with systematized resection-anastomosis. MATERIAL AND METHODS: A retrospective study from January 2006 to December 2018, included all patients managed for carotid stenosis at Meaux hospital with the "endarterectomy with systematized resection-anastomosis" technique. The perioperative death and stroke rate were evaluated according to the judgment criterion "homolateral ischemic stroke and any stroke or perioperative death". Statistical analysis of the data was performed using SPSS software. RESULTS: For 415 carotids operated, we identified 240 managed with this technique. The average age was 71.7±9.6 years, 70% men and 30% women. The main cardiovascular risk factor was hypertension (76.7%), 24.2% of patients had an ischemic heart disease history, 43.7% homolateral ischemic stroke and 29% transient ischemic attack. Bilateral lesions were diagnosed in 6.2% of patients and 7.5% had contralateral occlusion. Carotid stenosis was symptomatic in 52.9% of patients. The average stenosis rate observed was 82.9±8.1% on computed tomography angiogram and 83.7±7.7% on magnetic resonance angiogram. The shunt was used in 45.4% of procedures. The average length of stay was 5.9±2.3 days. All patients had satisfactory results in terms of patency and anatomical appearance on the 1st check. In the post-operative period during the first month, complications occurred in 12.5% of patients (1.6% acute coronary syndrome, 0.8% neurological event, 0.8% death, 0.4% infection, 12.1% hematoma, 1.6% recovery for bleeding). The overall perioperative death and stroke rate was 2.6%. Myocardial infarction and sepsis were the causes of death for the 2 patients in the peri operative period. The mean duration of follow-up was 21.2 months, without any restenosis or occurrence of neurological complications. One patient died beyond the 1st month of follow-up without established cause, and the overall mortality rate was 1.3%. CONCLUSION: Thromboendarterectomy with "systematized" anastomosis resection represents an angioplasty method for carotid stenosis surgical management under visual control.


Assuntos
Artérias Carótidas/cirurgia , Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas , Idoso , Idoso de 80 Anos ou mais , Anastomose Cirúrgica , Isquemia Encefálica/etiologia , Artérias Carótidas/diagnóstico por imagem , Estenose das Carótidas/complicações , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/mortalidade , Endarterectomia das Carótidas/efeitos adversos , Endarterectomia das Carótidas/mortalidade , Feminino , Humanos , Ataque Isquêmico Transitório/etiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Fatores de Tempo , Resultado do Tratamento
2.
PLoS One ; 15(9): e0239443, 2020.
Artigo em Inglês | MEDLINE | ID: covidwho-781671

RESUMO

OBJECTIVE: In the setting of the Coronavirus Disease 2019 (COVID-19) global pandemic caused by SARS-CoV-2, a potential association of this disease with stroke has been suggested. We aimed to describe the characteristics of patients who were admitted with COVID-19 and had an acute ischemic stroke (AIS). METHODS: This is a case series of PCR-confirmed COVID-19 patients with ischemic stroke admitted to an academic health system in metropolitan Atlanta, Georgia (USA) between March 24th, 2020 and July 17th, 2020. Demographic, clinical, and radiographic characteristics were described. RESULTS: Of 396 ischemic stroke patients admitted during this study period, 13 (2.5%) were also diagnosed with COVID-19. The mean age of patients was 61.6 ± 10.8 years, 10 (76.9%) male, 8 (61.5%) were Black Americans, mean time from last normal was 4.97 ± 5.1 days, and only one received acute reperfusion therapy. All 13 patients had at least one stroke-associated co-morbidity. The predominant pattern of ischemic stroke was embolic with 4 explained by atrial fibrillation. COVID-19 patients had a significantly higher rate of cryptogenic stroke than non-COVID-19 patients during the study period (69% vs 17%, p = 0.0001). CONCLUSIONS: In our case series, ischemic stroke affected COVID-19 patients with traditional stroke risk factors at an age typically seen in non-COVID populations, and mainly affecting males and Black Americans. We observed a predominantly embolic pattern of stroke with a higher than expected rate of cryptogenic strokes, a prolonged median time to presentation and symptom recognition limiting the use of acute reperfusion treatments. These results highlight the need for increased community awareness, early identification, and management of AIS in COVID-19 patients.


Assuntos
Betacoronavirus , Isquemia Encefálica/etiologia , Infecções por Coronavirus/complicações , Pneumonia Viral/complicações , Acidente Vascular Cerebral/etiologia , Afro-Americanos , Idoso , Fibrilação Atrial/complicações , Isquemia Encefálica/etnologia , Isquemia Encefálica/virologia , Comorbidade , Infecções por Coronavirus/etnologia , Gerenciamento Clínico , Diagnóstico Precoce , Embolia/complicações , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/etnologia , Acidente Vascular Cerebral/etnologia , Acidente Vascular Cerebral/virologia
3.
PLoS One ; 15(9): e0239443, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32946512

RESUMO

OBJECTIVE: In the setting of the Coronavirus Disease 2019 (COVID-19) global pandemic caused by SARS-CoV-2, a potential association of this disease with stroke has been suggested. We aimed to describe the characteristics of patients who were admitted with COVID-19 and had an acute ischemic stroke (AIS). METHODS: This is a case series of PCR-confirmed COVID-19 patients with ischemic stroke admitted to an academic health system in metropolitan Atlanta, Georgia (USA) between March 24th, 2020 and July 17th, 2020. Demographic, clinical, and radiographic characteristics were described. RESULTS: Of 396 ischemic stroke patients admitted during this study period, 13 (2.5%) were also diagnosed with COVID-19. The mean age of patients was 61.6 ± 10.8 years, 10 (76.9%) male, 8 (61.5%) were Black Americans, mean time from last normal was 4.97 ± 5.1 days, and only one received acute reperfusion therapy. All 13 patients had at least one stroke-associated co-morbidity. The predominant pattern of ischemic stroke was embolic with 4 explained by atrial fibrillation. COVID-19 patients had a significantly higher rate of cryptogenic stroke than non-COVID-19 patients during the study period (69% vs 17%, p = 0.0001). CONCLUSIONS: In our case series, ischemic stroke affected COVID-19 patients with traditional stroke risk factors at an age typically seen in non-COVID populations, and mainly affecting males and Black Americans. We observed a predominantly embolic pattern of stroke with a higher than expected rate of cryptogenic strokes, a prolonged median time to presentation and symptom recognition limiting the use of acute reperfusion treatments. These results highlight the need for increased community awareness, early identification, and management of AIS in COVID-19 patients.


Assuntos
Betacoronavirus , Isquemia Encefálica/etiologia , Infecções por Coronavirus/complicações , Pneumonia Viral/complicações , Acidente Vascular Cerebral/etiologia , Afro-Americanos , Idoso , Fibrilação Atrial/complicações , Isquemia Encefálica/etnologia , Isquemia Encefálica/virologia , Comorbidade , Infecções por Coronavirus/etnologia , Gerenciamento Clínico , Diagnóstico Precoce , Embolia/complicações , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/etnologia , Acidente Vascular Cerebral/etnologia , Acidente Vascular Cerebral/virologia
5.
Mol Neurobiol ; 57(12): 4921-4928, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32813238

RESUMO

The global pandemic of novel coronavirus disease 2019 (COVID-19) has taken the entire human race by surprise and led to an unprecedented number of mortalities worldwide so far. Current clinical studies have interpreted that angiotensin-converting enzyme 2 (ACE2) is the host receptor for severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2). In addition, ACE2 is the major component of the renin-angiotensin system. ACE2 deteriorates angiotensin II, a peptide that is responsible for the promotion of stroke. The downregulation of ACE2 further activates an immunological cascade. Thus, researchers need to explore and examine the possible links between COVID-19 and ischemic stroke (IS). Human ACE2 expression level and pattern in various tissues might be decisive for the vulnerability, symptoms, and treatment outcomes of the SARS-CoV-2 infection. The swift increase in the knowledge of SARS-CoV-2 has given creditable evidence that SARS-CoV-2 infected patients also encounter neurological deficits. As the SARS-CoV-2 binds to ACE2, it will hamper the activity of ACE2 in providing neuroprotection, especially in the case of stroke patients. Due to the downregulation of ACE2, the inflammatory response is activated in the ischemic penumbra. The COVID-19 pandemic has affected people with various pre-existing diseases, including IS, in such a way that these patients need special care and attention for their survival. Several clinical trials are currently ongoing worldwide as well as many other projects are in different stages of conceptualization and planning to facilitate the effective management of stroke patients with COVID-19 infection.


Assuntos
Betacoronavirus , Isquemia Encefálica/etiologia , Infecções por Coronavirus/fisiopatologia , Pandemias , Pneumonia Viral/fisiopatologia , Sistema Renina-Angiotensina/fisiologia , Acidente Vascular Cerebral/etiologia , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Betacoronavirus/patogenicidade , Betacoronavirus/fisiologia , Barreira Hematoencefálica , Isquemia Encefálica/epidemiologia , Isquemia Encefálica/imunologia , Isquemia Encefálica/fisiopatologia , Quimiotaxia de Leucócito , Comorbidade , Infecções por Coronavirus/complicações , Infecções por Coronavirus/epidemiologia , Síndrome da Liberação de Citocina/etiologia , Síndrome da Liberação de Citocina/fisiopatologia , Citocinas/fisiologia , Encefalite Viral/complicações , Encefalite Viral/fisiopatologia , Hemodinâmica , Humanos , Inflamação , Modelos Imunológicos , Modelos Neurológicos , Insuficiência de Múltiplos Órgãos/etiologia , Insuficiência de Múltiplos Órgãos/fisiopatologia , Doenças do Sistema Nervoso/epidemiologia , Doenças do Sistema Nervoso/etiologia , Peptidil Dipeptidase A/fisiologia , Pneumonia Viral/complicações , Pneumonia Viral/epidemiologia , Receptores Virais/fisiologia , Risco , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/imunologia , Acidente Vascular Cerebral/fisiopatologia
6.
AJNR Am J Neuroradiol ; 41(10): 1849-1855, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32819897

RESUMO

BACKGROUND AND PURPOSE: Chest CT is a rapid, useful additional screening tool for coronavirus disease 2019 (COVID-19) in emergent procedures. We describe the feasibility and interim outcome of implementing a modified imaging algorithm for COVID-19 risk stratification across a regional network of primary stroke centers in the work-up of acute ischemic stroke referrals for time-critical mechanical thrombectomy. MATERIALS AND METHODS: We undertook a retrospective review of 49 patients referred to the regional neuroscience unit for consideration of mechanical thrombectomy between April 14, 2020, and May 21, 2020. During this time, all referring units followed a standard imaging protocol that included a chest CT in addition to a head CT and CT angiogram to identify Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) infective pulmonary changes. RESULTS: Overall, 2 patients had typical COVID-19 radiologic features and tested positive, while 7 patients had indeterminate imaging findings and tested negative. The others had normal or atypical changes and were not diagnosed with or suspected of having COVID-19. There was an overall sensitivity of 100%, specificity of 74.1%, negative predictive value of 100%, and positive predictive value of 22.2% when using chest CT to diagnose COVID-19 in comparison with the real-time reverse transcriptase-polymerase chain reaction test. The mean additional time and radiation dose incurred for the chest CT were 184 ± 65.5 seconds and 2.47 ± 1.03 mSv. Multiple cardiovascular and pulmonary incidental findings of clinical relevance were identified in our patient population. CONCLUSIONS: Chest CT provides a pragmatic, rapid additional tool for COVID-19 risk stratification among patients referred for mechanical thrombectomy. Its inclusion in a standardized regional stroke imaging protocol has enabled efficient use of hospital resources with minimal compromise or delay to the overall patient treatment schedule.


Assuntos
Betacoronavirus , Isquemia Encefálica/diagnóstico por imagem , Infecções por Coronavirus/complicações , Pneumonia Viral/complicações , Acidente Vascular Cerebral/diagnóstico por imagem , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/etiologia , Isquemia Encefálica/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Estudos Retrospectivos , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/cirurgia , Trombectomia , Tomografia Computadorizada por Raios X
7.
Cochrane Database Syst Rev ; 8: CD013267, 2020 Aug 11.
Artigo em Inglês | MEDLINE | ID: mdl-32789891

RESUMO

BACKGROUND: Intracranial atherosclerotic stenosis (ICAS) is an arterial narrowing in the brain that can cause stroke. Endovascular therapy and medical management may be used to prevent recurrent ischaemic stroke caused by ICAS. However, there is no consensus on the best treatment for people with ICAS. OBJECTIVES: To compare the safety and efficacy of endovascular therapy (ET) plus conventional medical treatment (CMT) with CMT alone for the management of symptomatic ICAS. SEARCH METHODS: We searched the Cochrane Stroke Group Trials Register (30 August 2019), Cochrane Central Register of Controlled Trials (CENTRAL: to 30 August 2019), MEDLINE Ovid (1946 to 30 August 2019), Embase Ovid (1974 to 30 August 2019), Scopus (1960 to 30 August 2019), Science Citation Index Web of Science (1900 to 30 July 2019), Academic Source Complete EBSCO (ASC: 1982 to 30 July 2019), and China Biological Medicine Database (CBM: 1978 to 30 July 2019). We also searched the following trial registers: ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, and Stroke Trials Registry. We also contacted trialists and researchers where additional information was required. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing ET plus CMT with CMT alone for the treatment of symptomatic ICAS. ET modalities included angioplasty alone, balloon-mounted stent, and angioplasty followed by placement of a self-expanding stent. CMT included antiplatelet therapy in addition to control of risk factors such as hypertension, hyperlipidaemia, and diabetes. DATA COLLECTION AND ANALYSIS: Two review authors independently screened trials to select potentially eligible RCTs and extracted data. Any disagreements were resolved by discussing and reaching consensus decisions with the full team. We assessed risk of bias and applied the GRADE approach to assess the quality of the evidence. The primary outcome was death of any cause or non-fatal stroke of any type within three months of randomisation. Secondary outcomes included any-cause death or non-fatal stroke of any type more than three months of randomisation, ipsilateral stroke, type of recurrent event, death, restenosis, dependency, and health-related quality of life. MAIN RESULTS: We included three RCTs with 632 participants who had symptomatic ICAS with an age range of 18 to 85 years. The included trials had high risks of performance bias and other potential sources of bias due to the impossibility of blinding of the endovascular intervention and early termination of the trials. Moreover, one trial had a high risk of attrition bias because of the high rate of loss of one-year follow-up and the high proportion of participants transferred from endovascular therapy to medical management. The quality of evidence ranged from low to moderate, downgraded for imprecision. Compared to CMT, ET probably results in a higher rate of 30-day death or stroke (risk ratio (RR) 3.07, 95% confidence interval (CI) 1.80 to 5.24; 3 RCTs, 632 participants, moderate-quality evidence), 30-day ipsilateral stroke (RR 3.54, 95% CI 1.98 to 6.33; 3 RCTs, 632 participants, moderate-quality evidence), 30-day ischaemic stroke (RR 2.52, 95% CI 1.37 to 4.62; 3 RCTs, 632 participants, moderate-quality evidence), and 30-day haemorrhagic stroke (RR 15.53, 95% CI 2.10 to 115.16; 3 RCTs, 632 participants, low-quality evidence). ET was also likely associated with a worse outcome in one-year death or stroke (RR 1.69, 95% CI 1.21 to 2.36; 3 RCTs, 632 participants, moderate-quality evidence), one-year ipsilateral stroke (RR 2.28, 95% CI 1.52 to 3.42; 3 RCTs, 632 participants, moderate-quality evidence), one-year ischaemic stroke (RR 2.07, 95% CI 1.37 to 3.13; 3 RCTs, 632 participants, moderate-quality evidence), and one-year haemorrhagic stroke (RR 10.13, 95% CI 1.31 to 78.51; 2 RCTs, 521 participants, low-quality evidence). There were no significant differences between ET and CMT in 30-day transient ischaemic attacks (TIA) (RR 0.52, 95% CI 0.11 to 2.35, P = 0.39; 2 RCTs, 181 participants, moderate-quality evidence), 30-day death (RR 5.53, 95% CI 0.98 to 31.17, P = 0.05; 3 RCTs, 632 participants, low-quality evidence), one-year TIA (RR 0.82, 95% CI 0.32 to 2.12; 2 RCTs, 181 participants, moderate-quality evidence), one-year death (RR 1.20, 95% CI 0.50 to 2.86, P = 0.68; 3 RCTs, 632 participants, moderate-quality evidence), and one-year dependency (RR 1.90, 95% CI 0.91 to 3.97, P = 0.09; 3 RCTs, 613 participants, moderate-quality evidence). No data on restenosis and health-related quality of life for meta-analysis were available from the included trials. Two RCTs are ongoing. AUTHORS' CONCLUSIONS: This systematic review provides moderate-quality evidence showing that ET, compared with CMT, in people with recent symptomatic severe intracranial atherosclerotic stenosis probably does not prevent recurrent stroke and appears to carry an increased hazard. The impact of delayed ET intervention (more than three weeks after a qualifying event) is unclear and may warrant further study.


Assuntos
Isquemia Encefálica/terapia , Procedimentos Endovasculares/métodos , Arteriosclerose Intracraniana/complicações , Inibidores da Agregação de Plaquetas/uso terapêutico , Adulto , Idoso , Idoso de 80 Anos ou mais , Angioplastia/efeitos adversos , Angioplastia/métodos , Viés , Isquemia Encefálica/etiologia , Isquemia Encefálica/mortalidade , Humanos , Ataque Isquêmico Transitório/epidemiologia , Ataque Isquêmico Transitório/etiologia , Pessoa de Meia-Idade , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Risco , Stents Metálicos Autoexpansíveis , Stents , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia
8.
Stroke ; 51(9): e227-e231, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32757751

RESUMO

BACKGROUND AND PURPOSE: Coronavirus disease 2019 (COVID-19) evolved quickly into a global pandemic with myriad systemic complications, including stroke. We report the largest case series to date of cerebrovascular complications of COVID-19 and compare with stroke patients without infection. METHODS: Retrospective case series of COVID-19 patients with imaging-confirmed stroke, treated at 11 hospitals in New York, between March 14 and April 26, 2020. Demographic, clinical, laboratory, imaging, and outcome data were collected, and cases were compared with date-matched controls without COVID-19 from 1 year prior. RESULTS: Eighty-six COVID-19-positive stroke cases were identified (mean age, 67.4 years; 44.2% women). Ischemic stroke (83.7%) and nonfocal neurological presentations (67.4%) predominated, commonly involving multivascular distributions (45.8%) with associated hemorrhage (20.8%). Compared with controls (n=499), COVID-19 was associated with in-hospital stroke onset (47.7% versus 5.0%; P<0.001), mortality (29.1% versus 9.0%; P<0.001), and Black/multiracial race (58.1% versus 36.9%; P=0.001). COVID-19 was the strongest independent risk factor for in-hospital stroke (odds ratio, 20.9 [95% CI, 10.4-42.2]; P<0.001), whereas COVID-19, older age, and intracranial hemorrhage independently predicted mortality. CONCLUSIONS: COVID-19 is an independent risk factor for stroke in hospitalized patients and mortality, and stroke presentations are frequently atypical.


Assuntos
Transtornos Cerebrovasculares/etiologia , Infecções por Coronavirus/complicações , Pneumonia Viral/complicações , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/etiologia , Isquemia Encefálica/terapia , Angiografia Cerebral , Transtornos Cerebrovasculares/mortalidade , Transtornos Cerebrovasculares/terapia , Infecções por Coronavirus/mortalidade , Infecções por Coronavirus/terapia , Grupos Étnicos , Feminino , Mortalidade Hospitalar , Humanos , Hemorragias Intracranianas/complicações , Hemorragias Intracranianas/mortalidade , Masculino , Pessoa de Meia-Idade , Neuroimagem , New York/epidemiologia , Pandemias , Pneumonia Viral/mortalidade , Pneumonia Viral/terapia , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/terapia , Resultado do Tratamento
9.
Stroke ; 51(9): e227-e231, 2020 09.
Artigo em Inglês | MEDLINE | ID: covidwho-695959

RESUMO

BACKGROUND AND PURPOSE: Coronavirus disease 2019 (COVID-19) evolved quickly into a global pandemic with myriad systemic complications, including stroke. We report the largest case series to date of cerebrovascular complications of COVID-19 and compare with stroke patients without infection. METHODS: Retrospective case series of COVID-19 patients with imaging-confirmed stroke, treated at 11 hospitals in New York, between March 14 and April 26, 2020. Demographic, clinical, laboratory, imaging, and outcome data were collected, and cases were compared with date-matched controls without COVID-19 from 1 year prior. RESULTS: Eighty-six COVID-19-positive stroke cases were identified (mean age, 67.4 years; 44.2% women). Ischemic stroke (83.7%) and nonfocal neurological presentations (67.4%) predominated, commonly involving multivascular distributions (45.8%) with associated hemorrhage (20.8%). Compared with controls (n=499), COVID-19 was associated with in-hospital stroke onset (47.7% versus 5.0%; P<0.001), mortality (29.1% versus 9.0%; P<0.001), and Black/multiracial race (58.1% versus 36.9%; P=0.001). COVID-19 was the strongest independent risk factor for in-hospital stroke (odds ratio, 20.9 [95% CI, 10.4-42.2]; P<0.001), whereas COVID-19, older age, and intracranial hemorrhage independently predicted mortality. CONCLUSIONS: COVID-19 is an independent risk factor for stroke in hospitalized patients and mortality, and stroke presentations are frequently atypical.


Assuntos
Transtornos Cerebrovasculares/etiologia , Infecções por Coronavirus/complicações , Pneumonia Viral/complicações , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/etiologia , Isquemia Encefálica/terapia , Angiografia Cerebral , Transtornos Cerebrovasculares/mortalidade , Transtornos Cerebrovasculares/terapia , Infecções por Coronavirus/mortalidade , Infecções por Coronavirus/terapia , Grupos Étnicos , Feminino , Mortalidade Hospitalar , Humanos , Hemorragias Intracranianas/complicações , Hemorragias Intracranianas/mortalidade , Masculino , Pessoa de Meia-Idade , Neuroimagem , New York/epidemiologia , Pandemias , Pneumonia Viral/mortalidade , Pneumonia Viral/terapia , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/terapia , Resultado do Tratamento
10.
AJNR Am J Neuroradiol ; 41(10): 1849-1855, 2020 10.
Artigo em Inglês | MEDLINE | ID: covidwho-724309

RESUMO

BACKGROUND AND PURPOSE: Chest CT is a rapid, useful additional screening tool for coronavirus disease 2019 (COVID-19) in emergent procedures. We describe the feasibility and interim outcome of implementing a modified imaging algorithm for COVID-19 risk stratification across a regional network of primary stroke centers in the work-up of acute ischemic stroke referrals for time-critical mechanical thrombectomy. MATERIALS AND METHODS: We undertook a retrospective review of 49 patients referred to the regional neuroscience unit for consideration of mechanical thrombectomy between April 14, 2020, and May 21, 2020. During this time, all referring units followed a standard imaging protocol that included a chest CT in addition to a head CT and CT angiogram to identify Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) infective pulmonary changes. RESULTS: Overall, 2 patients had typical COVID-19 radiologic features and tested positive, while 7 patients had indeterminate imaging findings and tested negative. The others had normal or atypical changes and were not diagnosed with or suspected of having COVID-19. There was an overall sensitivity of 100%, specificity of 74.1%, negative predictive value of 100%, and positive predictive value of 22.2% when using chest CT to diagnose COVID-19 in comparison with the real-time reverse transcriptase-polymerase chain reaction test. The mean additional time and radiation dose incurred for the chest CT were 184 ± 65.5 seconds and 2.47 ± 1.03 mSv. Multiple cardiovascular and pulmonary incidental findings of clinical relevance were identified in our patient population. CONCLUSIONS: Chest CT provides a pragmatic, rapid additional tool for COVID-19 risk stratification among patients referred for mechanical thrombectomy. Its inclusion in a standardized regional stroke imaging protocol has enabled efficient use of hospital resources with minimal compromise or delay to the overall patient treatment schedule.


Assuntos
Betacoronavirus , Isquemia Encefálica/diagnóstico por imagem , Infecções por Coronavirus/complicações , Pneumonia Viral/complicações , Acidente Vascular Cerebral/diagnóstico por imagem , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/etiologia , Isquemia Encefálica/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Estudos Retrospectivos , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/cirurgia , Trombectomia , Tomografia Computadorizada por Raios X
11.
Mol Neurobiol ; 57(12): 4921-4928, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: covidwho-722661

RESUMO

The global pandemic of novel coronavirus disease 2019 (COVID-19) has taken the entire human race by surprise and led to an unprecedented number of mortalities worldwide so far. Current clinical studies have interpreted that angiotensin-converting enzyme 2 (ACE2) is the host receptor for severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2). In addition, ACE2 is the major component of the renin-angiotensin system. ACE2 deteriorates angiotensin II, a peptide that is responsible for the promotion of stroke. The downregulation of ACE2 further activates an immunological cascade. Thus, researchers need to explore and examine the possible links between COVID-19 and ischemic stroke (IS). Human ACE2 expression level and pattern in various tissues might be decisive for the vulnerability, symptoms, and treatment outcomes of the SARS-CoV-2 infection. The swift increase in the knowledge of SARS-CoV-2 has given creditable evidence that SARS-CoV-2 infected patients also encounter neurological deficits. As the SARS-CoV-2 binds to ACE2, it will hamper the activity of ACE2 in providing neuroprotection, especially in the case of stroke patients. Due to the downregulation of ACE2, the inflammatory response is activated in the ischemic penumbra. The COVID-19 pandemic has affected people with various pre-existing diseases, including IS, in such a way that these patients need special care and attention for their survival. Several clinical trials are currently ongoing worldwide as well as many other projects are in different stages of conceptualization and planning to facilitate the effective management of stroke patients with COVID-19 infection.


Assuntos
Betacoronavirus , Isquemia Encefálica/etiologia , Infecções por Coronavirus/fisiopatologia , Pandemias , Pneumonia Viral/fisiopatologia , Sistema Renina-Angiotensina/fisiologia , Acidente Vascular Cerebral/etiologia , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Betacoronavirus/patogenicidade , Betacoronavirus/fisiologia , Barreira Hematoencefálica , Isquemia Encefálica/epidemiologia , Isquemia Encefálica/imunologia , Isquemia Encefálica/fisiopatologia , Quimiotaxia de Leucócito , Comorbidade , Infecções por Coronavirus/complicações , Infecções por Coronavirus/epidemiologia , Síndrome da Liberação de Citocina/etiologia , Síndrome da Liberação de Citocina/fisiopatologia , Citocinas/fisiologia , Encefalite Viral/complicações , Encefalite Viral/fisiopatologia , Hemodinâmica , Humanos , Inflamação , Modelos Imunológicos , Modelos Neurológicos , Insuficiência de Múltiplos Órgãos/etiologia , Insuficiência de Múltiplos Órgãos/fisiopatologia , Doenças do Sistema Nervoso/epidemiologia , Doenças do Sistema Nervoso/etiologia , Peptidil Dipeptidase A/fisiologia , Pneumonia Viral/complicações , Pneumonia Viral/epidemiologia , Receptores Virais/fisiologia , Risco , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/imunologia , Acidente Vascular Cerebral/fisiopatologia
13.
Neurol India ; 68(3): 560-572, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32643664

RESUMO

COVID-19, in most patients, presents with mild flu-like illness. Elderly patients with comorbidities, like hypertension, diabetes, or lung and cardiac disease, are more likely to have severe disease and deaths. Neurological complications are frequently reported in severely or critically ill patients with comorbidities. In COVID-19, both central and peripheral nervous systems can be affected. The SARS-CoV-2 virus causes the disease COVID-19 and has the potential to invade the brain. The SARS-CoV-2 virus enters the brain either via a hematogenous route or olfactory system. Angiotensin-converting enzyme two receptors, present on endothelial cells of cerebral vessels, are a possible viral entry point. The most severe neurological manifestations, altered sensorium (agitation, delirium, and coma), are because of hypoxic and metabolic abnormalities. Characteristic cytokine storm incites severe metabolic changes and multiple organ failure. Profound coagulopathies may manifest with ischemic or hemorrhagic stroke. Rarely, SARS-CoV-2 virus encephalitis or pictures like acute disseminated encephalomyelitis or acute necrotizing encephalopathy have been reported. Nonspecific headache is a commonly experienced neurological symptom. A new type of headache "personal protection equipment-related headache" has been described. Complete or partial anosmia and ageusia are common peripheral nervous system manifestations. Recently, many cases of Guillain-Barré syndrome in COVID-19 patients have been observed, and a postinfectious immune-mediated inflammatory process was held responsible for this. Guillain-Barré syndrome does respond to intravenous immunoglobulin. Myalgia/fatigue is also common, and elevated creatine kinase levels indicate muscle injury. Most of the reports about neurological complications are currently from China. COVID-19 pandemic is spreading to other parts of the world; the spectrum of neurological complications is likely to widen further.


Assuntos
Ageusia/fisiopatologia , Infecções por Coronavirus/fisiopatologia , Síndrome da Liberação de Citocina/imunologia , Encefalite/fisiopatologia , Síndrome de Guillain-Barré/fisiopatologia , Cefaleia/fisiopatologia , Transtornos do Olfato/fisiopatologia , Pneumonia Viral/fisiopatologia , Acidente Vascular Cerebral/fisiopatologia , Ageusia/etiologia , Betacoronavirus , Transtornos da Coagulação Sanguínea/sangue , Transtornos da Coagulação Sanguínea/etiologia , Barreira Hematoencefálica , Isquemia Encefálica/sangue , Isquemia Encefálica/etiologia , Isquemia Encefálica/imunologia , Isquemia Encefálica/fisiopatologia , Coma/etiologia , Coma/fisiopatologia , Infecções por Coronavirus/sangue , Infecções por Coronavirus/complicações , Infecções por Coronavirus/imunologia , Delírio/etiologia , Delírio/fisiopatologia , Encefalite/etiologia , Encefalite/imunologia , Encefalomielite Aguda Disseminada/etiologia , Encefalomielite Aguda Disseminada/imunologia , Encefalomielite Aguda Disseminada/fisiopatologia , Fadiga/etiologia , Fadiga/fisiopatologia , Síndrome de Guillain-Barré/etiologia , Cefaleia/etiologia , Humanos , Hemorragias Intracranianas/sangue , Hemorragias Intracranianas/etiologia , Hemorragias Intracranianas/fisiopatologia , Leucoencefalite Hemorrágica Aguda/etiologia , Leucoencefalite Hemorrágica Aguda/imunologia , Leucoencefalite Hemorrágica Aguda/fisiopatologia , Mialgia/etiologia , Mialgia/fisiopatologia , Transtornos do Olfato/etiologia , Pandemias , Equipamento de Proteção Individual/efeitos adversos , Pneumonia Viral/sangue , Pneumonia Viral/complicações , Pneumonia Viral/imunologia , Acidente Vascular Cerebral/sangue , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/imunologia
15.
Medicine (Baltimore) ; 99(28): e21044, 2020 Jul 10.
Artigo em Inglês | MEDLINE | ID: mdl-32664115

RESUMO

Ischemic stroke subtypes such as patients with large artery atherosclerosis, cardioembolism, and embolic stroke of undetermined source were investigated. This study was performed aimed to determine mean platelet volume (MPV) and mean platelet volume/platelet count (MPV/Plt) ratio in nonvalvular atrial fibrillation (AF) stroke and large artery atherosclerosis (LAA) stroke.We conducted a retrospective study of consecutive patients for treatment of acute ischemic stroke at Ruian People's Hospital from March 2017 to October 2018. The patients with ischemic stroke caused by AF and LAA were recruited to this study. Ischemic stroke was confirmed by magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA), ischemic lesions on diffusion-weighted imaging were measured in terms of size, composition, and pattern. MPV and platelet count were examined and (MPV/Plt) ratio was calculated.Three hundred seventy one patients were enrolled composing of 177 (47.7%) nonvalvular AF and 194 (52.2%) with LAA. The MPV (11.3 ±â€Š1.3 vs 10.8 ±â€Š1.0, P < .001) and MPV/Plt ratio (0.066 ±â€Š0.025 vs 0.055 ±â€Š0.20, P < .001) were much higher in AF group than LAA group. Receiver-operating characteristic (ROC) analysis showed MPV (AUC: 0.624, confidence interval: 0.567-0.68, P < .001) and MPV/Plt (AUC: 0.657, confidence interval: 0.601-0.713, P < .001) predicted AF between the 2 groups. MPV/Plt ratio was negatively associated with lesion volume (r = -0.161, P = .033) in AF. The analyses of subtypes of composition of infarcts and infarct pattern showed that MPV/Plt ratio was almost higher in AF than LAA except for subcortical-only pattern. Multivariable regression analyses demonstrated National Institutes of Health Stroke Scale (NIHSS) score (r = 2.74; P < .001), LAD (r = -1.15; P = .025) and MPV/Plt ratio (r = -180.64; P = .021) were correlated with lesion volume.Our results indicated elevated MPV and MPV/Plt ratio for the identification of difference between AF and LAA in patients with ischemic stroke.


Assuntos
Aterosclerose/complicações , Fibrilação Atrial/complicações , Volume Plaquetário Médio , Contagem de Plaquetas , Acidente Vascular Cerebral/sangue , Acidente Vascular Cerebral/etiologia , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/sangue , Isquemia Encefálica/etiologia , Imagem de Difusão por Ressonância Magnética , Feminino , Humanos , Angiografia por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Fatores de Risco
16.
Neurol India ; 68(3): 560-572, 2020.
Artigo em Inglês | MEDLINE | ID: covidwho-640338

RESUMO

COVID-19, in most patients, presents with mild flu-like illness. Elderly patients with comorbidities, like hypertension, diabetes, or lung and cardiac disease, are more likely to have severe disease and deaths. Neurological complications are frequently reported in severely or critically ill patients with comorbidities. In COVID-19, both central and peripheral nervous systems can be affected. The SARS-CoV-2 virus causes the disease COVID-19 and has the potential to invade the brain. The SARS-CoV-2 virus enters the brain either via a hematogenous route or olfactory system. Angiotensin-converting enzyme two receptors, present on endothelial cells of cerebral vessels, are a possible viral entry point. The most severe neurological manifestations, altered sensorium (agitation, delirium, and coma), are because of hypoxic and metabolic abnormalities. Characteristic cytokine storm incites severe metabolic changes and multiple organ failure. Profound coagulopathies may manifest with ischemic or hemorrhagic stroke. Rarely, SARS-CoV-2 virus encephalitis or pictures like acute disseminated encephalomyelitis or acute necrotizing encephalopathy have been reported. Nonspecific headache is a commonly experienced neurological symptom. A new type of headache "personal protection equipment-related headache" has been described. Complete or partial anosmia and ageusia are common peripheral nervous system manifestations. Recently, many cases of Guillain-Barré syndrome in COVID-19 patients have been observed, and a postinfectious immune-mediated inflammatory process was held responsible for this. Guillain-Barré syndrome does respond to intravenous immunoglobulin. Myalgia/fatigue is also common, and elevated creatine kinase levels indicate muscle injury. Most of the reports about neurological complications are currently from China. COVID-19 pandemic is spreading to other parts of the world; the spectrum of neurological complications is likely to widen further.


Assuntos
Ageusia/fisiopatologia , Infecções por Coronavirus/fisiopatologia , Síndrome da Liberação de Citocina/imunologia , Encefalite/fisiopatologia , Síndrome de Guillain-Barré/fisiopatologia , Cefaleia/fisiopatologia , Transtornos do Olfato/fisiopatologia , Pneumonia Viral/fisiopatologia , Acidente Vascular Cerebral/fisiopatologia , Ageusia/etiologia , Betacoronavirus , Transtornos da Coagulação Sanguínea/sangue , Transtornos da Coagulação Sanguínea/etiologia , Barreira Hematoencefálica , Isquemia Encefálica/sangue , Isquemia Encefálica/etiologia , Isquemia Encefálica/imunologia , Isquemia Encefálica/fisiopatologia , Coma/etiologia , Coma/fisiopatologia , Infecções por Coronavirus/sangue , Infecções por Coronavirus/complicações , Infecções por Coronavirus/imunologia , Delírio/etiologia , Delírio/fisiopatologia , Encefalite/etiologia , Encefalite/imunologia , Encefalomielite Aguda Disseminada/etiologia , Encefalomielite Aguda Disseminada/imunologia , Encefalomielite Aguda Disseminada/fisiopatologia , Fadiga/etiologia , Fadiga/fisiopatologia , Síndrome de Guillain-Barré/etiologia , Cefaleia/etiologia , Humanos , Hemorragias Intracranianas/sangue , Hemorragias Intracranianas/etiologia , Hemorragias Intracranianas/fisiopatologia , Leucoencefalite Hemorrágica Aguda/etiologia , Leucoencefalite Hemorrágica Aguda/imunologia , Leucoencefalite Hemorrágica Aguda/fisiopatologia , Mialgia/etiologia , Mialgia/fisiopatologia , Transtornos do Olfato/etiologia , Pandemias , Equipamento de Proteção Individual/efeitos adversos , Pneumonia Viral/sangue , Pneumonia Viral/complicações , Pneumonia Viral/imunologia , Acidente Vascular Cerebral/sangue , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/imunologia
17.
AJNR Am J Neuroradiol ; 41(9): 1677-1682, 2020 09.
Artigo em Inglês | MEDLINE | ID: covidwho-631034

RESUMO

Coronavirus disease 2019 (COVID-19) is associated with a severe inflammatory response. Inflammation affects atherosclerotic plaque vulnerability and promotes a thrombogenic environment. We report a series of 6 patients with COVID-19 with acute ischemic stroke due to intraluminal carotid artery thrombus presenting during an 8-day period. Six patients were included (5 men) with a mean age of 65.8 years (range, 55-78 years). COVID-19 was diagnosed by detection of Severe Acute Respiratory Syndrome coronavirus 2 in 5 patients and was presumed due to typical clinical and imaging findings in 1 patient. All patients had vascular risk factors including diabetes (83%), hyperlipidemia (100%), and smoking (17%). Four patients presented with large infarcts with initial NIHSS scores of 24-30. During their hospitalization, all patients had elevated D-dimer and C-reactive protein levels, 5 patients had elevated lactate dehydrogenase and ferritin levels, 3 had elevated interleukin-6 levels, and 2 had elevated troponin levels. Inflammation related to COVID-19 may result in rupture of vulnerable atherosclerotic plaques, resulting in thrombosis and acute ischemic stroke.


Assuntos
Betacoronavirus , Isquemia Encefálica/etiologia , Artérias Carótidas/diagnóstico por imagem , Infecções por Coronavirus/complicações , Citocinas/imunologia , Pneumonia Viral/complicações , Acidente Vascular Cerebral/etiologia , Trombose/etiologia , Idoso , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/imunologia , Angiografia por Tomografia Computadorizada , Infecções por Coronavirus/imunologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/imunologia , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/imunologia , Trombose/diagnóstico por imagem , Trombose/imunologia
18.
Neurology ; 95(6): e708-e717, 2020 08 11.
Artigo em Inglês | MEDLINE | ID: mdl-32636330

RESUMO

OBJECTIVE: To determine whether increased risk of acute ischemic stroke (AIS) following herpes zoster (HZ) might be modified by the status of zoster vaccine live (ZVL) vaccination and antiviral treatment following HZ. METHODS: We included 87,405 Medicare fee-for-service beneficiaries aged ≥66 years diagnosed with HZ and AIS from 2008 to 2017. We used a self-controlled case series design to examine the association between HZ and AIS, and estimated incidence rate ratios (IRRs) by comparing incidence of AIS in risk periods vs control periods. To examine effect modification by ZVL and antiviral treatment, beneficiaries were classified into 4 mutually exclusive groups: (1) no vaccination and no antiviral treatment; (2) vaccination only; (3) antiviral treatment only; and (4) both vaccination and antiviral treatment. We tested for interaction to examine changes in IRRs across 4 groups. RESULTS: Among 87,405 beneficiaries with HZ and AIS, 22.0%, 2.0%, 70.1%, and 5.8% were in groups 1 to 4, respectively. IRRs in 0-14, 15-30, 31-90, and 91-180 days following HZ were 1.89 (95% confidence interval [CI], 1.77-2.02), 1.58 (95% CI, 1.47-1.69), 1.36 (95% CI, 1.31-1.42), and 1.19 (95% CI, 1.15-1.23), respectively. There was no evidence of effect modification by ZVL and antiviral treatment on AIS (p = 0.067 for interaction). The pattern of association between HZ and risk for AIS was largely consistent across age group, sex, and race. CONCLUSIONS: Risk of AIS increased significantly following HZ, and this increased risk was not modified by ZVL and antiviral treatment. Our findings suggest the importance of following recommended HZ vaccination in prevention of HZ and HZ-associated AIS.


Assuntos
Antivirais/uso terapêutico , Isquemia Encefálica/etiologia , Vacina contra Herpes Zoster , Herpes Zoster/complicações , Distribuição por Idade , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/epidemiologia , Isquemia Encefálica/prevenção & controle , Grupos Étnicos/estatística & dados numéricos , Herpes Zoster/tratamento farmacológico , Herpes Zoster/prevenção & controle , Humanos , Masculino , Medicare/estatística & dados numéricos , Distribuição por Sexo , Acidente Vascular Cerebral/etiologia , Estados Unidos/epidemiologia
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