Etiologic Subtypes of Ischemic Stroke in SARS-COV-2 Virus patients in a cohort of New York City hospitals

  1. Ketevan Berekashvili
  2. Adam A Dmytriw
  3. Volodomyr Vulkanov
  4. Shashank Agarwal
  5. Amit Khaneja
  6. David Turkel-Parella
  7. Jeremy Liff
  8. Jeffrey Farkas
  9. Thambinajar Nandakumar
  10. Ting Zhou
  11. Jennnifer Frontera
  12. David E Kahn
  13. Sun Kim
  14. Kelly A Humbert
  15. Matthew D Sanger
  16. Shadi Yaghi
  17. Aaron Lord
  18. Karthikeyan Arcot
  19. Ambooj Tiwari
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Abstract

Objective

To describe the ischemic stroke subtypes related to COVID-19 in a cohort of NYC hospitals and explore their etiopathogenesis.

Background

Extra-pulmonary involvement of COVID-19 has been reported in the hepatic, renal and hematological systems. Most neurological manifestations are non-focal, but few have reported the characteristics of ischemic strokes or investigated its pathophysiology.

Methods

Data were collected prospectively from March 15 to April 15, 2020 from four centers in New York City to review possible ischemic stroke types seen in COVID-19 positive patients. Patient presentation, demographics, other related vascular risk factors, associated laboratory and coagulation markers, as well as imaging and outcomes for consecutive stroke patients positive for SARS-COV2 infection over the period studied were collected.

Results

In our study, the age range of patients was 25-75 with no significant male preponderance. The median age of LVO patients was 48. Stroke was the presenting and hospitalizing event in 70%. One fifth of patients did not have common risk factors for ischemic stroke and none had atrial fibrillation, coronary or cerebrovascular disease, or were smokers. Half had a poor outcome with 40% ending in mortality (60% in LVO group) and one in a critical condition due ARDS. All had high neutrophil/lymphocyte ratio except one who demonstrated some neurological recovery. D-dimer levels showed mild to severe elevation when collected. None of the LVO cases had known cardiac risk factors but two out of five were found to have cardiac abnormalities during their hospitalization. All LVOs had hypercoagulable lab markers especially elevated D-dimer and/or fibrinogen. The LVO patients were younger and sicker with a median age of 46 and mean NIHSS of 24 as opposed to non-LVOs with a median age of 62 and mean NIHSS of 6 respectively.

Conclusion

COVID-19 related ischemic events can be small vessel, branch emboli or large vessel occlusions. The latter is often associated with either a hypercoagulable state or cardio-embolism. Patient outcomes were worse when multi-organ or pulmonary system failure prevailed.

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