Portola Scientia Journal- Issue 1 (2020-2021)

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Klara Parang Portola Scientia Journal Relations between Stroke and COVID-19 Exposure Background Overall, the purpose of this study is to briefly go into depth and prove whether the neurological complications resulting from COVID-19 can lead to an isolated stroke event. Although stroke cases have been reported in the elderly as a complication of COVID-19, information on the incidence of strokes or other neurological complications in young or middle-aged adults is lacking. I hypothesized that stroke is associated with COVID-19 in several patients during the course of infection, as demonstrated by different inflammatory and coagulation factors. Several studies have shown that cytokine storm and intravascular coagulation in stroke patients with a higher D-dimer and CRP than the controls. Thus, increased inflammation predicted by CRP and D-dimer levels may contribute to ischemia and stroke formation. Furthermore, both ischemic and hemorrhagic lesions are possible in SARS-COV2 patients because of the delicate balance between thrombophilic state and coagulopathy. Understanding the following data is critical to developing a therapeutic intervention using anti-inflammatory agents for stroke-associated COVID-19 treatment and a better prognosis.

Methods The following study was conducted through numerous databases known as Pubmed, Google Scholar, and Sci-Hub. To find reviews concerning the topic of COVID-19 and stroke, keywords such as “stroke,” “COVID-19”, and “neurological complications” were used. As a result of this search, 413 research articles were found. Among those, individually, 8 were selected. The inclusion criteria were based on the case studies and reports of patients who became infected with SARS-COV-2 and demonstrated stroke symptoms. Other inclusion criteria were the presence of young and middle-aged adult patients, patients who presented to the hospital with neurological symptoms for their admission, diagnostic methods, reporting of neurological and cardiovascular effects, MRI imaging, and the D-Dimer levels. Exclusion criteria were those studies that clinical aspects of stroke-associated COVID-19 were not discussed. After accomplishing the search of research studies that matched all the inclusion criteria, a spreadsheet was created, and all the relevant information was added during a period of one week (June 30 - July 7).

Results After reviewing the studies of 31 Covid-19 young adult patients (less than 60 years old), it was indicated that the NIHSS score upon admission for the reported cases (25/31) was in the range of 10.6 to 19, showing moderately severe to severe stroke conditions. About 30 (96%) of the patients were diagnosed with a stroke on admission and one on day 4 of hospitalization. 25 patients (81%) showed respiratory symptoms, and 6 patients(19%) exhibited hemiparesis symptoms. Hemiplegia was observed in one patient. Hypertension was observed in 11 patients (35%), and 9 (29%) patients had diabetes. Other cardiovascular history included hyperlipidemia (7, 22%)) and congestive heart failure (1). MRI findings demonstrated various infarctions, such as right middle (4, 13%) and left middle (5, 16%) cerebral artery, right carotid artery (3, 9.7%), right posterior cerebral artery (1), bilateral cerebral stenosis (1). Other neurological findings were observed in the left basal ganglia (1), large vessel stenosis (1), basilar artery, and right superior cerebellar artery (1).

Discussion The eight case series review demonstrated that ischemic cerebrovascular diseases or stroke might simultaneously occur in COVID-19 young adults. In general, COVID-19 positive patients had higher admission National Institutes of Health Stroke Scale (NIHSS) scores and higher peak D-dimer levels. Higher NIHSS scores and enhanced levels of C-reactive protein (CRP) and D-Dimer contributing to enhanced inflammatory responses can be used for diagnosis. CRP and D-Dimer may contribute to thrombotic events and stroke. Stroke may also appear in different forms, as shown by Yaghi 2020 results, such as cryptogenic, cardioembolic, or large vessel. Liver enzyme activity and enhanced lactate dehydrogenase (LDH) were found in some cases. However, its correlation with COVID-19-associated stroke needs further investigation to determine its use as a prognostic factor. The patients with a high troponin level and NIHSS score were mostly younger men, as shown by Yaghi et al. Preexisting hypertension and diabetes were common among the patients. Most of the patients showed respiratory symptoms associated with COVID-19 patients. However, hemiparesis was observed in 19% of patients related to ischemic disorder or stroke. MRI findings were diverse with any damage to the cerebral artery in different regions.

Conclusion Through a sequence of case studies and reports, it has been proven that stroke is prevalent in young adult COVID-19 patients. There are many parameters, such as NIHSS score, D-Dimer, and CRP levels, that physicians can use to diagnose stroke patients upon admission. Preexisting cardiovascular conditions contribute to stroke development, as they were observed in many patients. Neurological infractions in stroke patients are diverse but are mostly present observed in the cerebral artery. Some biological factors, such as inflammatory response-associated to COVID-19, could contribute to stroke. It can be concluded that more studies are required to determine the correlation between stroke and COVID-19.

Bibliography Morassi M, Bagatto D, Cobelli M, D'Agostini S, Gigli GL, Bnà C, Vogrig A. Stroke in patients with SARS-CoV-2 infection: case series. J Neurol. 2020 Aug;267(8):2185-2192. doi: 10.1007/s00415-020-09885-2. Epub 2020 May 20. PMID: 32436105; PMCID: PMC7238403.

TunÇ A, ÜnlÜbaŞ Y, Alemdar M, AkyÜz E. Coexistence of COVID-19 and acute ischemic stroke report of four cases. J Clin Neurosci. 2020 Jul;77:227-229. doi: 10.1016/j.jocn.2020.05.018. Epub 2020 May 6. PMID: 32409210; PMCID: PMC7200342.

Wang A, Mandigo GK, Yim PD, Meyers PM, Lavine SD. Stroke and mechanical thrombectomy in patients with COVID-19: technical observations and patient characteristics. J Neurointerv Surg. 2020 Jul;12(7):648-653. doi: 10.1136/neurintsurg-2020-016220. Epub 2020 May 25. PMID: 32451359.

Yaghi S, Ishida K, Torres J, Mac Grory B, Raz E, Humbert K, Henninger N, Trivedi T, Lillemoe K, Alam S, Sanger M, Kim S, Scher E, Dehkharghani S, Wachs M, Tanweer O, Volpicelli F, Bosworth B, Lord A, Frontera J. SARS-CoV-2 and Stroke in a New York Healthcare System. Stroke. 2020 Jul;51(7):2002-2011. doi: 10.1161/STROKEAHA.120.030335. Epub 2020 May 20. Erratum in: Stroke. 2020 Aug;51(8):e179. PMID: 32432996; PMCID: PMC72587

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