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Cerebrovascular disease in patients with COVID-19: neuroimaging, histological and clinical description
Open accessAbstract
Since the appearance of the first case of coronavirus disease 2019 (COVID-19) a pandemic has emerged affecting millions of individuals worldwide. Although the main clinical manifestations are respiratory, an increase in neurological conditions, specifically acute cerebrovascular disease, has been detected. We present cerebrovascular disease case incidence in hospitalized patients with SARS-CoV-2 infection. Patients were confirmed by microbiological/serological testing, or on chest CT semiology. Available data on co-morbidity, laboratory parameters, treatment administered, neuroimaging, neuropathological studies and clinical evolution during hospitalization, measured by the modified Rankin scale, were analysed. A bivariate study was also designed to identify differences between ischaemic and haemorrhagic subtypes. A statistical model of binary logistic regression and sensitivity analysis was designed to study the influence of independent variables over prognosis. In our centre, there were 1683 admissions of patients with COVID-19 over 50 days, of which 23 (1.4%) developed cerebrovascular disease. Within this group of patients, cerebral and chest CT scans were performed in all cases, and MRI in six (26.1%). Histological samples were obtained in 6/23 cases (two brain biopsies, and four arterial thrombi). Seventeen patients were classified as cerebral ischaemia (73.9%, with two arterial dissections), five as intracerebral haemorrhage (21.7%), and one leukoencephalopathy of posterior reversible encephalopathy type. Haemorrhagic patients had higher ferritin levels at the time of stroke (1554.3 versus 519.2, P = 0.004). Ischaemic strokes were unexpectedly frequent in the vertebrobasilar territory (6/17, 35.3%). In the haemorrhagic group, a characteristic radiological pattern was identified showing subarachnoid haemorrhage, parieto-occipital leukoencephalopathy, microbleeds and single or multiple focal haematomas. Brain biopsies performed showed signs of thrombotic microangiopathy and endothelial injury, with no evidence of vasculitis or necrotizing encephalitis. The functional prognosis during the hospital period was unfavourable in 73.9% (17/23 modified Rankin scale 4-6), and age was the main predictive variable (odds ratio = 1.5; 95% confidence interval 1.012-2.225; P = 0.043). Our series shows cerebrovascular disease incidence of 1.4% in patients with COVID-19 with high morbidity and mortality. We describe pathological and radiological data consistent with thrombotic microangiopathy caused by endotheliopathy with a haemorrhagic predisposition.
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“Consistent with several other reports,23, 24 the risk of cerebrovascular events (ischaemic stroke and intracranial haemorrhage) was elevated after COVID-19, with the incidence of ischaemic stroke rising to almost one in ten (or three in 100 for a first stroke) in patients with encephalopathy.”
From 6-month neurological and psychiatric outcomes in 236 379 survivors of COVID-19: a retrospective cohort study using electronic health records (2021) · cites this paper as [24]
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Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China
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Neurologic manifestations of hospitalized patients with coronavirus disease 2019 in Wuhan, China
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Endothelial cell infection and endotheliitis in COVID-19
Varga, Z., Flammer, A. J., Steiger, P., Haberecker, M., Andermatt, R., Zinkernagel, A. S., Mehra, M. R., Schuepbach, R. A., Ruschitzka, F., & Moch, H. (2020) · The Lancet · doi:10.1016/s0140-6736(20)30937-5 · Cited by 6,358
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Sensitivity of Chest CT for COVID-19: Comparison to RT-PCR
Fang, Y., Zhang, H., Xie, J., Lin, M., Ying, L., Pang, P., & Ji, W. (2020) · Radiology · doi:10.1148/radiol.2020200432 · Cited by 3,340
Neurologic features in severe SARS-CoV-2 infection
Helms, J., Kremer, S., Merdji, H., Clere-Jehl, R., Schenck, M., Kummerlen, C., Collange, O., Boulay, C., Fafi-Kremer, S., Ohana, M., et al. (2020) · New England Journal of Medicine · doi:10.1056/nejmc2008597 · Cited by 2,674
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Large-Vessel Stroke as a Presenting Feature of Covid-19 in the Young
Oxley, T. J., Mocco, J., Majidi, S., Kellner, C. P., Shoirah, H., Singh, I. P., Leacy, R. A. D., Shigematsu, T., Ladner, T. R., Yaeger, K., et al. (2020) · New England Journal of Medicine · doi:10.1056/nejmc2009787 · Cited by 2,114
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Taquet, M., Geddes, J. R., Husain, M., Luciano, S., & Harrison, P. J. (2021) · The Lancet Psychiatry · doi:10.1016/s2215-0366(21)00084-5 · Cited by 2,189
“Consistent with several other reports, 23,24 the risk of cerebrovascular events (ischaemic stroke and intracranial haemorrhage) was elevated after COVID-19, with the incidence of ischaemic stroke rising to almost one in ten (or three in 100 for a first stroke) in patients with encephalopathy.”
Ferritin in the coronavirus disease 2019 (COVID‐19): A systematic review and meta‐analysis
Cheng, L., Li, H., Li, L., Liu, C., Yan, S., Chen, H., & Li, Y. (2020) · Journal of Clinical Laboratory Analysis · doi:10.1002/jcla.23618 · Cited by 413
Bushnell, C., Kernan, W. N., Sharrief, A. Z., Chaturvedi, S., Cole, J. W., Cornwell, W. K., Cosby-Gaither, C., Doyle, S., Goldstein, L. B., Lennon, O. C., et al. (2024) · Stroke · doi:10.1161/str.0000000000000475 · Cited by 443
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A Prospective Study of Neurologic Disorders in Hospitalized Patients With COVID-19 in New York City
Frontera, J. A., Sabadia, S. B., Lalchan, R., Fang, T., Flusty, B., Vernetti, P. M., Snyder, T. E., Berger, S. L., Yang, D., Granger, A., et al. (2020) · Neurology · doi:10.1212/wnl.0000000000010979 · Cited by 288
Metadata
- Authors
- Hernández-Fernández, F., Sandoval Valencia, H., Barbella-Aponte, R. A., Collado-Jiménez, R., Ayo-Martín, Ó., Barrena, C., Molina-Nuevo, J. D., García-García, J., Lozano-Setién, E., Alcahut-Rodriguez, C., Martínez-Martín, Á., Sánchez-López, A., & Segura, T.
- Affiliations
- Department of Neurology, Hospital General Universitario de Albacete, Albacete, Spain
- Department of Neurosurgery, Hospital General Universitario de Albacete, Albacete, Spain
- Hospital General Universitario de Albacete (ES)
- Department of Radiology, Hospital General Universitario de Albacete, Albacete, Spain
- Anaesthesia Intensive Care Unit, Hospital General Universitario de Albacete, Albacete, Spain
- ORCID
- Venue
- Brain
- Publisher
- Oxford University Press (OUP)
- Published
- 2020-07-09
- Volume
- 143
- Issue
- 10
- Pages
- 3089-3103
- ISSN
- 0006-8950 (ISSN-L)
- 1460-2156
- PMC
- PMC7454411
- OpenAlex
- W3041271257
- Cited by
- 280
- References
- 47
- Citations by year
- 2026: 5 · 2025: 11 · 2024: 20 · 2023: 41 · 2022: 48 · 2021: 105 · 2020: 49
- FWCI
- 26.29
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model (vor)
- Locations
- Brain (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Clinical Neurology › Long-Term Effects of COVID-19
- Health Sciences › Medicine › Infectious Diseases › COVID-19 Clinical Research Studies
- Health Sciences › Medicine › Clinical Neurology › Acute Ischemic Stroke Management
- Keywords
- COVID-19 pandemic, SARS-CoV-2, cerebrovascular disease, stroke, ischemic stroke, intracerebral hemorrhage, posterior circulation stroke, cerebral microbleeds, subarachnoid hemorrhage, leukoencephalopathy, posterior reversible encephalopathy syndrome, thrombotic microangiopathy, endothelial injury, ferritin, brain biopsy, arterial thrombus, age as prognostic factor
- MeSH terms
- Betacoronavirus, COVID-19, SARS-CoV-2, Age Factors, Aged, Brain, Cerebral Hemorrhage, Brain Ischemia, Female, Ferritins, Humans, Magnetic Resonance Imaging, Male, Pneumonia, Viral, Spain, Tomography, X-Ray Computed, Comorbidity, Incidence, Coronavirus Infections, Leukoencephalopathies, Pandemics, Neuroimaging
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