Department of Neurology, Hospital General Universitario de Albacete, Albacete, Spain.
Department of Neurosurgery, Hospital General Universitario de Albacete, Albacete, Spain.
Brain. 2020 Oct 1;143(10):3089-3103. doi: 10.1093/brain/awaa239.
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.
自 2019 年冠状病毒病 (COVID-19) 首例病例出现以来，已出现大流行，影响了全球数百万人。尽管主要的临床表现是呼吸道，但已发现神经系统疾病，特别是急性脑血管病有所增加。我们介绍了 SARS-CoV-2 感染住院患者的脑血管病发病情况。通过微生物学/血清学检测或胸部 CT 半定量检查确认患者。分析了合并症、实验室参数、给予的治疗、神经影像学、神经病理学研究和住院期间通过改良 Rankin 量表测量的临床演变等方面的可用数据。还设计了双变量研究来确定缺血性和出血性亚型之间的差异。设计了二元逻辑回归统计模型和敏感性分析，以研究独立变量对预后的影响。在我们中心，在 50 天内有 1683 例 COVID-19 患者入院，其中 23 例(1.4%)发生了脑血管病。在这组患者中，所有患者均进行了脑和胸部 CT 扫描，6 例(26.1%)进行了 MRI。在 23 例患者中获得了 6 例组织学样本(2 例脑活检，4 例动脉血栓)。17 例患者被归类为脑缺血(73.9%，有 2 例动脉夹层)，5 例为颅内出血(21.7%)，1 例为后部可逆性脑病综合征样的脑白质病。出血性卒中患者在卒中时铁蛋白水平更高(1554.3 比 519.2，P=0.004)。缺血性卒中在椎基底动脉区域出乎意料地频繁(17/17，35.3%)。在出血组中，发现了具有蛛网膜下腔出血、顶枕叶脑白质病、微出血和单发或多发局灶性血肿的特征性放射学模式。进行的脑活检显示出血栓性微血管病和内皮损伤的迹象，没有血管炎或坏死性脑炎的证据。住院期间的功能预后不佳，73.9%(23 例改良 Rankin 量表 4-6)，年龄是主要的预测变量(比值比=1.5；95%置信区间 1.012-2.225；P=0.043)。我们的系列研究表明，COVID-19 患者的脑血管病发病率为 1.4%，发病率和死亡率均较高。我们描述了与内皮病引起的血栓性微血管病一致的病理和放射学数据，具有出血倾向。
