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Stroke & Covid

Coronavirus disease may increase the risk of acute ischemic stroke similar to the increased risk of 3.2 to 7.8-fold seen in other viral infections. The reported incidence of cerebrovascular disease in patients with SARS-Co-V-2 was from 1-6%. A decrease in mild stroke was seen in the early phase of the pandemic which was largely due to the quarantine and healthy eating habits, isolation and self-quarantine measures. Patients with COVID-19 who had acute ischemic stroke were found to be older and had higher frequency of risk factors such as hypertension, diabetes mellitus II, atrial fibrillation and congestive heart failure in a large US study that analyzed 27,676 patients with COVID-19. They had 103 patients who were COVID positive and had an acute ischemic stroke. Other smaller case series had younger patients with COVID-19 with no cardiovascular risk factors. A mean age in several thrombectomy series in COVID-19 was 52.8 years in a series from New York and 59.5 in a series from Paris.

Proposed mechanisms for stroke include a hypercoaguable state seen with COVID-19, post-infectious immune mediated response, direct viral induced endotheliopathy causing thrombosis. Laboratory findings such as increase in Ddimer levels support the hypercoaguable theory of stroke in COVID-19. Large vessel and cryptogenic strokes were reported more in such patients. Both arterial and venous thromboembolism has been reported with COVID-19. Cardiac involvement with myocarditis, arrythmias and hypotension may cause hypoperfusion and ischemic stroke. The severity of neurological deficits maybe greater and role of mechanical thrombectomy may be limited.

Other vascular events such as cerebral venous sinus thrombosis and intracranial hemorrhage have also been reported with COVID-19. There is no consensus on the use of secondary prophylaxis anti-thrombotic measures in COVID-19. There is a tendency to use anticoagulation than anti-platelets however the risk of intracranial hemorrhage should be weighed against its benefit. Increasing cases of rhino-orbito-cerebral mucormycosis may rarely present with acute ischemic stroke with large artery thrombosis, commonly of internal cerebral artery and portraying a poor prognosis in this setting.

Implications for practice Acute ischemic stroke patients may present without COVID-19 symptoms. Challenges and delays in existing acute stroke protocols may occur from emergency department to angiographic suits due to COVID-19 restrictions.