Author response: Neurologic complications of coronavirus infections
AvindraNath, Neurologist, National Institute of Neurological Disorders and Stroke, National Institutes of Heath
Submitted June 22, 2020
I thank Bandeo et al. for the interest in my article.1 They correctly point out the importance of stroke as a complication of COVID-19. Since I wrote the editorial, the association of stroke in COVID-19 patients has become much stronger, the pathophysiology seems complex, and treatment guidelines are being developed (Table). Stroke may be the presenting symptom of the infection,1 and it may occur during the acute phase or days and weeks after the resolution of the acute viral phase. It is abundantly clear that during the acute phase, patients have a hypercoagulable state2 and hence can get multiple arterial or venous occlusions that may involve not only the cerebral vasculature but also multiple organ systems. The hypercoagulable state is thought to be related to the acute inflammation and is associated with increased D-dimer levels.2 Some patients may present with benign intracranial hypertension, presumably due to venous sinus occlusions.3 The virus is also known to infect endothelial cells, which can lead to an inflammatory response in the vasculature.4 This may result in microthrombi or microhemorrhages. Cerebral hemorrhages may also occur due to reperfusion injury. Myocardial injury can occur in these patients due to inflammation of the heart and due to autonomic dysfunction.5 This may result in embolic infarcts to the brain. Patients with premorbid conditions such as hypertension and diabetes are at particular risk for stroke. However, in patients who develop strokes after recovery from the acute viral phase, the possibility of an autoimmune phenomenon such as antiphospholipid antibodies should be considered.6
Table: Strokes in patients infected with SARS-CoV-2
Presentation
Venous occlusion
Multiple arterial occlusions
Watershed infarcts
Microvascular thrombosis
Microhemorrhages
Pathophysiology
Coagulopathy
Endothelialitis
Antiphospholipid antibodies
Embolism from heart
Risk factors
Myocarditis
Known vascular risk factors
Acute respiratory distress syndrome and multiorgan impairment
Disclosure
The author reports no relevant disclosures. Contact [email protected] for full disclosures.
References
Oxley TJ, Mocco J, Majidi S, et al. Large-Vessel Stroke as a Presenting Feature of Covid-19 in the Young. N Engl J Med 2020;382:e60.
Spiezia L, Boscolo A, Poletto F, et al. COVID-19-Related Severe Hypercoagulability in Patients Admitted to Intensive Care Unit for Acute Respiratory Failure. Thromb Haemost 2020;120:998–1000.
Noro F, Cardoso FM, Marchiori E. COVID-19 and benign intracranial hypertension: A case report. Rev Soc Bras Med Trop 2020;53:e20200325.
Varga Z, Flammer AJ, Steiger P, et al. Endothelial cell infection and endotheliitis in COVID-19. Lancet 2020;395:1417–1418.
Kochi AN, Tagliari AP, Forleo GB, Fassini GM, Tondo C. Cardiac and arrhythmic complications in patients with COVID-19. J Cardiovasc Electrophysiol 2020;31:1003–1008.
Zhang Y, Xiao M, Zhang S, et al. Coagulopathy and Antiphospholipid Antibodies in Patients with Covid-19. N Engl J Med 2020;382:e38.
I thank Bandeo et al. for the interest in my article.1 They correctly point out the importance of stroke as a complication of COVID-19. Since I wrote the editorial, the association of stroke in COVID-19 patients has become much stronger, the pathophysiology seems complex, and treatment guidelines are being developed (Table). Stroke may be the presenting symptom of the infection,1 and it may occur during the acute phase or days and weeks after the resolution of the acute viral phase. It is abundantly clear that during the acute phase, patients have a hypercoagulable state2 and hence can get multiple arterial or venous occlusions that may involve not only the cerebral vasculature but also multiple organ systems. The hypercoagulable state is thought to be related to the acute inflammation and is associated with increased D-dimer levels.2 Some patients may present with benign intracranial hypertension, presumably due to venous sinus occlusions.3 The virus is also known to infect endothelial cells, which can lead to an inflammatory response in the vasculature.4 This may result in microthrombi or microhemorrhages. Cerebral hemorrhages may also occur due to reperfusion injury. Myocardial injury can occur in these patients due to inflammation of the heart and due to autonomic dysfunction.5 This may result in embolic infarcts to the brain. Patients with premorbid conditions such as hypertension and diabetes are at particular risk for stroke. However, in patients who develop strokes after recovery from the acute viral phase, the possibility of an autoimmune phenomenon such as antiphospholipid antibodies should be considered.6
Table: Strokes in patients infected with SARS-CoV-2
Presentation
Pathophysiology
Risk factors
Disclosure
The author reports no relevant disclosures. Contact [email protected] for full disclosures.
References