By the start of year 2020, the whole world was attacked by a rapidly spreading epidemic of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2(SARS-CoV-2) which later was classified by WHO as Pandemic. some physicians reported multiple neurological manifestations including cerebrovascular strokes in patients with severe infection.
to assess the incidence of admitted stroke cases during 2019 in comparison to 2020 during COVID-19 pandemic in King Fahd Hospital, Saudi Arabia.
A record based retrospective comparative study was conducted by reviewing all medical records for patients who admitted with stroke at King Fahd Hospital during March and April 2019 and March and April 2020. All data were extracted from patients’ medical files included personal data, nationality, date of admission, and stroke related data.
The study included 121 patients whose ages ranged from 33 to 98 years with mean age of 59.9 years. At March 2019, there were 45 cases compared to 26 in March 2020. In April 2019 there were 20 admitted stroke cases compared to 30 in April 2020. Regarding clinical features of admitted stroke cases, Table 3 illustrates that 36.9% of stroke cases in 2019 were small vessel stroke compared to 58.9% of 2020 cases.
Conclusions & Recommendations
In conclusion, the study revealed there was no recorded significant change in the trend of admitted cases with stroke before and during COVID-19 pandemic.
Academic Editor: Sasho Stoleski, Institute of Occupational Health of R. Macedonia, WHO CC and Ga2len CC, Macedonia.
Checked for plagiarism: Yes
Review by: Single-blind
Copyright © 2021 Mosab Alguthmi, et al.
The authors have declared that no competing interests exist.
By the end of year 2019 and start of 2020, the world was faced by a rapidly spreading epidemic of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2(SARS-CoV-2) which later was classified by WHO as Pandemic.1 The outbreak started in Wuhan, Hubei province, China, in December 2019. The World Health Organization (WHO) classified the disease as a Public Health Emergency of International Concern on 30 January 2020 and recognized it as a pandemic on 11 March 2020.2,3
Recently, some physicians reported multiple neurological manifestations including cerebrovascular strokes in patients with severe infection.4 So far, there are many reported cases of COVID-19 presenting with strokes in the literature.
Most patients with stroke need immediate hospital admission as their neurological condition may worsen within the first few days, they may develop non-neurological complications such as aspiration pneumonia, and urgent investigations (like CT scan) may be crucial.5 During COVID-19 pandemic, all priories were given for COVID-19 cases as the pandemic flow of cases may exceed the health care system capacity. This was in the expense of many other non COVID cases who need emergent hospitalization including stroke cases. Up till now, physicians reported different clinical features for COVID-19 cases. Stroke may be one of the first presenting features.6 The current study aimed to assess the incidence of admitted stroke cases during March and April 2019 in comparison to March and April 2020 during COVID-19 pandemic in King Fahd Hospital - Jeddah, Saudi Arabia.
A record based retrospective comparative study was conducted by reviewing all medical records for patients who admitted with stroke at King Fahd Hospital during March and April 2019 and March and April 2020. All data were extracted from patients’ medical files included personal data, nationality, and date of admission. Stroke related data included mechanism of stroke, stroke territory, and acute therapy given. Comparison at admitted case rate between 2019 and 2020 was considered based on date of admission.
After data were extracted, it was revised, coded and fed to statistical software IBM SPSS version 22(SPSS, Inc. Chicago, IL). All statistical analysis was done using two tailed tests. P value less than 0.05 was statistically significant. Descriptive analysis based on frequency and percent distribution was done for all variables including student’s personal data and stroke clinical data. Crosstabluation was used to assess compare the incidence and different clinical features for stroke cases during 2019 and 2020 (COVID-19 pandemic). Pearson chi-square and Exact probability test was used to test for distribution difference significance.
The study included 121 patients whose ages ranged from 33 to 98 years with mean age of 59.9 12.5 years. During year 2019, 20% of the stroke cases aged less than 50 years compared to 16.1% during year 2020. Also, 27.7% of the cases during 2019 aged 70 years or more compared to 12.5% of stroke cases in 2020. As for gender, the majority of cases were males in 2019 and 2020 (67.7% and 62.5%, respectively). Saudi patients constituted 55.4% of 2019 cases compared to 57.1% of 2020 cases. All these differences were found to be statistically insignificant (Table 1).Table 1. Personal data of patients with stroke in King Fahd Hospital - Jeddah, Saudi Arabia.
|Age in years||.133|
|< 50 years||22 (18.2%)||13||20.0%||9||16.1%|
(Table 2) demonstrates the incidence of rate of stroke cases during March and April during years 2019 and 2020. At March 2019, there were 45 cases compared to 26 in March 2020. In April 2019 there were 20 admitted stroke cases compared to 30 in April 2020. These differences in cases distribution was found to be statically significant (P=.011). These findings were illustrated in more details in line graph (Figure 1) which showed the distribution of admitted stroke cases per date of admission. The graph showed decreased trend in the number of admitted cases from 2019 to 2020.Table 2. Distribution of stroke cases according to month and year of diagnosis
Regarding clinical features of admitted stroke cases, Table 3 illustrates that 36.9% of stroke cases in 2019 were small vessel stroke compared to 58.9% of 2020 cases. Also, large vessel stroke was diagnosed among 30.8% of 2019 cases compared to 28.6% of 2020 cases. One case with vasculitis was diagnosed among 2020 cases. This was associated with statiscal significance (P=.007). Regarding stroke territory, MCA was the affected vessel in 68.3% of 2019 cases compared to 53.8% of 2020 cases. ACA was affected among 1.7% of 2019 cases compared to 28.2% of 2020 cases (P=.001). As for acute therapy, IV tPA was given for 7.7% of 2019 cases compared to 5.4% of 2020 cases while 3.1% of 2019 cases undergone mechanical thrombectomy compared to none of 2020 cases (P=.356).Table 3. Distribution of stroke data among cases by date in King Fahd Hospital - Jeddah, Saudi Arabia.
|Stroke data||Total (%)||Year||P-value|
|Stroke type||Bilateral cerebellar and old ischemic||1 (0.8%)||0||0.0%||1||1.8%||.007*|
|Large vessel||36 (29.8%)||20||30.8%||16||28.6%|
|Not known||20 (16.5%)||18||27.7%||2||3.6%|
|Small vessel||57 (47.1%)||24||36.9%||33||58.9%|
|Stroke territory||MCA||62 (62.6%)||41||68.3%||21||53.8%||.001*|
|Acute therapy||None||111 (91.7%)||58||89.2%||53||94.6%||.356|
|IV tPA||8 (6.6%)||5||7.7%||3||5.4%|
|IV tPA + mechanical thrombectomy||2 (1.7%)||2||3.1%||0||0.0%|
COVID-19 is the new pandemic striking the whole world since the initials of 2020. The common symptoms of COVID-19 include fever, cough, shortness of breath and sometimes develops into pneumonia. It may cause severe complications in persons with immunodeficiency, the elderly, and persons with chronic diseases such as cancer, diabetes and lung diseases.7 The most frequent symptoms of COVID-19 are like those of other viruses that attack the respiratory system. However, while some people develop mild or no symptoms, others have no choice but to seek treatment at hospital. Loss of smell, dizziness, and rash were of the reported symptoms of COVID-19 cases. Cardiovascular blood clotting also a problem identified among cases with confirmed COVID-19 infection.8
The current study aimed to compare the incidence of admitted stroke cases in King Fahd Hospital – Jeddah, Saudi Arabia during 2019 with the incidence during the same months in 2020 in concordance with COVID-19 pandemic. The study revealed that the total number of stroke cases admitted in King Fahd hospital during March and April 2019 were 65 cases compared to 56 cases in 2020. This decreased trend may be explained by that all hospitals including the current study hospitals give the priority for COVID-19 cases who presented with the classical signs and symptoms. So, stroke cases as a clinical feature of COVID-19 infection are mostly misdiagnosed and were not admitted. The trend shown in Figure 1 indicates minimal non-significant reduction in the admitted cases. Regarding demographic features of admitted cases during the two time periods (2019 vs. 2020), no significant difference was recorded which means no discrimination was done. Regarding clinical features of stroke, the most recorded type of stroke during 2019 was due to small and large vessels affection (more than two thirds of the cases). More than half of the cases during 2020 were due to small vessel affection besides one case with vasculitis. Regarding affected artery, MCA was the most affected during 2019 and 2020 admissions. Among cases admitted at 2020, ACA was the second most diagnosed affected artery compared to only one cases in 2019. As for acute therapy given for the cases, more than 90% of the stroke cases admitted to the hospital in 2020 had no acute therapy and none of them undergone mechanical thrombectomy compared to 89% and 3.1% for cases admitted during 2019, respectively. This confirm the theory that even the cases were admitted, surgical intervention was limited, and emergency care may be delayed due to the overload on hospitals because of high rate of COVID-19 cases. Figure 2.
This issue of connecting COVID-19 infection with the probability of having stroke was addressed by Oxley et.6 The authors reported five cases of large-vessel stroke in patients younger than 50 years of age who presented to our health system in New York City. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was diagnosed in all five patients. Klok et al assessed incidence of thrombotic complications in critically ill ICU patients with COVID-19. 9 The study was conducted by evaluating the incidence of the composite outcome of symptomatic acute pulmonary embolism (PE), deep-vein thrombosis, ischemic stroke, myocardial infarction or systemic arterial embolism among all COVID-19 cases admitted to the ICU of two Dutch university hospitals and one Dutch teaching hospital. The incidence of the composite outcome was 31%, of which CTPA and/or ultrasonography confirmed VTE in 27% and arterial thrombotic results in 3.7%. PE was the most diagnosed thrombotic complication (n = 25, 81%). COVID-19 presenting as stroke was reported by Avula et al.10 Researchers searched all hospitals database to find patients that presented with acute stroke and concomitant features of suspected COVID-19 infection. Four identified patients who presented with radiographic confirmation of acute stroke and PCR-confirmed SARS-CoV-2 infection. We elucidate the clinical characteristics, imaging findings, and the clinical course.
Limitations of the Study
Although the novelty of the topic but there are some reported limitations. First, the study was conducted in only one hospital which may affect study conclusion generalizability, but it is the available hospital due to lockdown and pandemic precautions. Second, The reported incidence during 2020 may be underestimated due to overutilization of hospitals and resources for classical COVID-19 infections and stopping deal with cold or even some emergent cases in the study hospital.
Conclusions and Recommendations
In conclusion, the study revealed that there was no recorded significant change in the trend of admitted cases with stroke before and after COVID-19 pandemic. The reported differences were in the affected arteries and type of stroke. Although habitually considered a lung disease, COVID-19 has been reported to cause blood clots that can lead to severe stroke. Experts say that this can happen in any patients regardless of age, and even in those with few or no symptoms. COVID-19 may cause to both venous and arterial thromboembolism because of excessive inflammation, hypoxia, immobilisation, and diffuse intravascular coagulation. Reports on the incidence of thrombotic complications are however not highly available. More large-scale studies are required to confirm the relation between COVID-19 and stroke attacks.
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- 2. (2005) Statement on the second meeting of the International Health Regulations Emergency Committee regarding the outbreak of novel coronavirus (2019-nCoV).Accessed November17,2020.https://www.who.int/news/item/30-01-2020-statement-on-the-second-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-outbreak-of-novel-coronavirus-(2019-ncov).
- 3. (2020) WHO Director-General’s opening remarks at the media briefing on. COVID-19 - 11 March. Accessed https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020 .
- 4.Mao L, Jin H, Wang M.. Neurologic Manifestations of Hospitalized Patients with Coronavirus Disease 2019 in Wuhan, China.JAMA Neurol 77(6), 683-690.
- 5.Alberts M J, Hademenos G, Latchaw R E. (2000) Recommendations for the establishment of primary stroke centers.J. , Am Med Assoc 283(23), 3102-3109.
- 6.Oxley T J, Mocco J, Majidi S. (2020) Large-Vessel Stroke as a Presenting Feature of. , Covid-19 in the Young.N Engl J Med 382(20), 60.
- 7.Rothan H A, Byrareddy S N. (2020) The epidemiology and pathogenesis of coronavirus disease (COVID-19) outbreak.J Autoimmun. 109.
- 8. (2020) The Unusual COVID-19 Symptoms You Can Miss. Accessed. https://www.healthline.com/health-news/the-covid-19-symptoms-most-people-could-miss#Stopping-the-spread-of-infection
- 9.Klok F A, MJHA Kruip, NJM van der Meer. (2020) Incidence of thrombotic complications in critically ill ICU patients with COVID-19.Thromb Res. 191, 145-147.