Document Type : Original Article
Isfahan Neurosciences Research Center, Alzahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran Department of Neurology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
Department of Radiology, Division of Neuroradiology, Children’s Hospital of Philadelphia, Philadelphia, USA
Background: Cerebrovascular diseases comprise a significant portion of neurological disorders related to coronavirus disease 2019 (COVID-19). We evaluated the clinical and imaging characteristics of a cohort of COVID-19 patients with stroke and also identified patients with watershed infarcts.
Methods: In this cross-sectional study, seventy-three COVID-19 patients with ischemic stroke were included between October 2020 and January 2021. Patients were evaluated based on the following clinical and imaging features: severity of COVID-19 (critical/non-critical), stroke type, presence/absence of clinical suspicion of stroke, medical risk factors, Fazekas scale, atherothrombosis, small vessel disease, cardiac pathology, other causes, and dissection (ASCOD) criteria classification, and presence or absence of watershed infarction. Clinical outcomes were assessed based on Modified Rankin Scale (MRS) and mortality.
Results: Most cases of ischemic stroke were due to undetermined etiology (52.1%) and cardioembolism (32.9%). In terms of imaging pattern, 17 (23.0%) patients had watershed infarction. Watershed infarction was associated with the clinically non-suspicious category [odds ratio (OR) = 4.67, P = 0.007] and death after discharge (OR = 7.1, P = 0.003).
Patients with watershed infarction had a higher odds of having high Fazekas score (OR = 5.17, P = 0.007) which was also shown by the logistic regression model (adjusted OR = 6.87, P = 0.030). Thirty-one (42%) patients were clinically non-suspected for ischemic stroke. Critical COVID-19 was more common among patients with watershed infarct and clinically non-suspicious patients (P = 0.020 and P = 0.005, respectively). Patients with chronic kidney disease (CKD) were more prone to having stroke with watershed pattern (P = 0.020).
Conclusion: Watershed infarct is one of the most common patterns of ischemic stroke in patients with COVID-19, for which clinicians should maintain a high index of suspicion in patients with critical COVID-19 without obvious clinical symptoms of stroke.
- Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020; 395(10223): 497-506.
- WHO Health Organization. WHO Coronavirus (COVID-19) Dashboard. WHO Coronavirus (COVID-19) Dashboard with Vaccination Data [Online]. [cited 2022 July 23]; Available from: URL: https://covid19.who.int/
- Montalvan V, Lee J, Bueso T, De Toledo J, Rivas K. Neurological manifestations of COVID-19 and other coronavirus infections: A systematic review. Clin Neurol Neurosurg 2020; 194: 105921.
- Qureshi AI, Baskett WI, Huang W, Shyu D, Myers D, Raju M, et al. Acute ischemic stroke and COVID-19: An analysis of 27 676 patients. Stroke 2021; 52(3): 905-12.
- Moonis G, Filippi CG, Kirsch CFE, Mohan S, Stein EG, Hirsch JA, et al. The spectrum of neuroimaging findings on CT and MRI in adults with COVID-19. AJR Am J Roentgenol 2021; 217(4): 959-74.
- Khorvash F, Najafi MA, Kheradmand M, Saadatnia M, Chegini R, Najafi F. New-onset acute ischemic stroke following COVID-19: A case-control study. J Res Med Sci 2022; 27: 31.
- Connors JM, Levy JH. COVID-19 and its implications for thrombosis and anticoagulation. Blood 2020; 135(23): 2033-40.
- Bhatia R, Pedapati R, Komakula S, Srivastava MVP, Vishnubhatla S, Khurana D. Stroke in coronavirus disease 2019: A systematic review. J Stroke 2020; 22(3): 324-35.
- Jillella DV, Janocko NJ, Nahab F, Benameur K, Greene JG, Wright WL, et al. Ischemic stroke in COVID-19: An urgent need for early identification and management. PLoS One 2020; 15(9): e0239443.
- Spence JD, de Freitas GR, Pettigrew LC, Ay H, Liebeskind DS, Kase CS, et al. Mechanisms of stroke in COVID-19. Cerebrovasc Dis 2020; 49(4): 451-8.
- Sawlani V, Scotton S, Nader K, Jen JP, Patel M, Gokani K, et al. COVID-19-related intracranial imaging findings: A large single-centre experience. Clin Radiol 2021; 76(2): 108-16.
- Katz JM, Libman RB, Wang JJ, Filippi CG, Sanelli P, Zlochower A, et al. COVID-19 severity and stroke: Correlation of imaging and laboratory markers. AJNR Am J Neuroradiol 2021; 42(2): 257-61.
- Li Y, Li M, Wang M, Zhou Y, Chang J, Xian Y, et al. Acute cerebrovascular disease following COVID-19: A single center, retrospective, observational study. Stroke Vasc Neurol 2020; 5(3): 279-84.
- von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: Guidelines for reporting observational studies. Epidemiology 2007; 18(6): 800-4.
- National Institutes of Health (NIH). Clinical Spectrum of SARS-CoV-2 Infection. COVID-19 Treatment Guidelines 2021 [Online]. [cited 2021 June 1]; Available from: URL: https://www.covid19treatmentguidelines.nih.gov/overview/clinical-spectrum/
- Fazekas F, Chawluk JB, Alavi A, Hurtig HI, Zimmerman RA. MR signal abnormalities at 1.5 T in Alzheimer's dementia and normal aging. AJR Am J Roentgenol 1987; 149(2): 351-6.
- Amarenco P, Bogousslavsky J, Caplan LR, Donnan GA, Wolf ME, Hennerici MG. The ASCOD phenotyping of ischemic stroke (Updated ASCO Phenotyping). Cerebrovasc Dis 2013; 36(1): 1-5.
- Broderick JP, Adeoye O, Elm J. Evolution of the modified rankin scale and its use in future stroke trials. Stroke 2017; 48(7): 2007-12.
- Tiwari A, Berekashvili K, Vulkanov V, Agarwal S, Khaneja A, Turkel-Parella D, et al. Etiologic subtypes of ischemic stroke in SARS-CoV-2 patients in a cohort of New York City hospitals. Front Neurol 2020; 11: 1004.
- Khorvash F, Khalili M, Rezvani HR, Sarafzadegan N, Givi M, Roohafza H, et al. Comparison of acute ischemic stroke evaluation and the etiologic subtypes between university and nonuniversity hospitals in Isfahan, Iran. Int J Stroke 2019; 14(6): 613-9.
- Dad T, Weiner DE. Stroke and chronic kidney disease: Epidemiology, pathogenesis, and management across kidney disease stages. Semin Nephrol 2015; 35(4): 311-22.
- Cherian L, Conners J, Cutting S, Lee VH, Song S. Periprocedural risk of stroke is elevated in patients with end-stage renal disease on hemodialysis. Cerebrovasc Dis Extra 2015; 5(3): 91-4.
- Liou LM, Chen CF, Guo YC, Cheng HL, Lee HL, Hsu JS, et al. Cerebral white matter hyperintensities predict functional stroke outcome. Cerebrovasc Dis 2010; 29(1): 22-7.
- Donnelly JP, Wang XQ, Iwashyna TJ, Prescott HC. Readmission and death after initial hospital discharge among patients with COVID-19 in a large multihospital system. JAMA 2021; 325(3): 304-6.
- Pourhoseingholi MA, Jafari R, Jafari NJ, Rahimi-Bashar F, Nourbakhsh M, Vahedian-Azimi A, et al. Predicting 1-year post-COVID-19 mortality based on chest computed tomography scan. J Med Virol 2021; 93(10): 5694-6.