COVID-19 Respiratory Illness and Subsequent Cerebrovascular Events, the Initial Iranian Experience

Sabayan, Behnam; Moghadami, Mohsen; Assarzadegan, Farhad; Komachali, Sahar Hojjat-Anasri; Poordast, Leila; Babaeepour, Zabihollah; Ebrahimzadeh, Seyed Amir; Hamidi, Ava; Hasheminejad, Zeinab; Mohammadi-Vosough, Elahe; Mirkarimi, Hamid Reza; Paybast, Sepideh; Rahimian, Nasrin; Safari, Anahid; Sepehrnia, Mercede; Nematollahi, Reza; Shahripour, Reza Bavarsad; Batra, Ayush; Sorond, Farzaneh; Borhani-Haghighi, Afshin

COVID-19 disproportionately affects older adults and individuals with cardiovascular co-morbidities. This report presents fifteen patients who had COVID-19 respiratory illness followed by cerebrovascular events. A call by the Iranian Neurological Association gathered cases accros the country who developed neurological symptoms attributed to hemorrhagic or ischemic stroke after a definite or probable COVID-19 respiratory illness. Definite cases were those with a typical respiratory illness, positive nasopharyngeal COVID-19 PCR test and chest CT consistent with COVID-19 infection. Probable cases were defined by a typical respiratory illness, history of contacts with a COVID-19 case and chest CT charachteristic for COVID-19 infection. Fifteen patients (12 men and 3 women) with age range of 38 to 93 years-old (median: 65 years-old) were included. Fourteen patients had first ever acute ischemic stroke and one patient had subarachnoid hemorrhage. Eleven patients (73%) had previous cardiovascular comorbidities. Median time between respiratory symptoms and neurological symptoms was seven days (range 1-16 days). Stroke severity in two patients was mild (NIHSS ≤ 6), in six patients moderate (NIHSS: 7-12) and in seven patients severe (NIHSS ≥13). One patient received intravenous tissue plasminogen activator (IV-tPA) with improved neurological symptoms. Six out of 15 patients (40%) died. All but one of those who survived had significant disability assessed by modified ranking scale >2. The majority of patients in this case series had vascular risk factors and their stroke was associated with severe disability and death. This report highlights the need for further investigation on the links between COVID-19 and cerebrovascular events.