Objective
To investigate the incidence and spectrum of neuroimaging findings and their prognostic role in hospitalized COVID-19 patients in New York City.
Methods
This is a retrospective cohort study of 3218 COVID-19 confirmed patients admitted to a major healthcare system (three hospitals) in New York City between March 1, 2020 and April 13, 2020. Clinical data were extracted from electronic medical records, and particularly data of all neurological symptoms were extracted from the imaging reports. Four neuroradiologists evaluated all neuroimaging studies for acute neuroimaging findings related to COVID-19.
Results
14.1% of admitted COVID-19 patients had neuroimaging and this accounted for only 5.5% of the total imaging studies. Acute stroke was the most common finding on neuro-imaging, seen in 92.5% of patients with positive neuro-imaging studies, and present in 1.1% of hospitalized COVID-19 patients. Patients with acute large ischemic and hemorrhagic stroke had much higher mortality risk adjusted for age, BMI and hypertension compared to those COVID-19 patients without neuroimaging. (Odds Ratio 6.02 by LR; Hazard Ratio 2.28 by CRR).
Conclusions
Our study demonstrates acute stroke is the most common neuroimaging finding among hospitalized COVID-19 patients. Detection of an acute stroke is a strong prognostic marker of poor outcome. Our study also highlights the fact there is limited use of neuroimaging in these patients due to multiple logistical constraints.
This study describes the spectrum of acute neuroimaging findings in admitted COVID-19 patients evaluated in a large tertiary hospital system in NYC. The acute stroke incidence was 1.1% among all hospitalized COVID-19 patients. Our study also demonstrates that an acute stroke finding on neuroimaging is a strong prognostic marker of poor outcome. Only 5.4% of the total imaging examinations performed on COVID-19 patients were neuroimaging studies. Neuroimaging studies have tended to constitute a larger percentage of overall diagnostic imaging use in hospital admitted patients. However, COVID-19 being a pandemic associated primarily with pulmonary disease, has led to the chest being the predominant organ imaged. Neurological manifestations attributed to COVID-19 infection include headache, encephalopathy or delirium, stroke, and seizures. Our incidence of stroke as determined by neuroimaging findings is lower than 2.8% incidence found in patients admitted through an emergency department. A recent publication has also shown a decrease in the use of stroke imaging both in patients with severe strokes and in nonelderly patients who may have been at low risk for Covid-19 complications. Nonetheless, it may be difficult to obtain the true incidence of neurological manifestations related to COVID-19 due to the following factors. First, most neurologic complications, such as delirium, encephalopathy, inflammatory neuropathy and autonomic dysfunction, may or may not be associated with abnormalities on neuroimaging. The reported yield of neuroimaging for hospitalized patients with delirium ranges from 2.7% to 14.5% across studies. Second, strict patient isolation and need for extreme contact precautions and stringent infection control measures may have limited the ability to perform detailed neurological examinations and obtain neuroimaging especially MRI, which is the mainstay of acute stroke diagnosis. Moreover, critically ill, intubated patients are difficult to transport and image and hence may have been underdiagnosed. Finally, critically ill patients are often sedated, making it difficult to identify new neurologic complications. Hence, obtaining more expert neurology consultations, detailed neurological examinations and neuroimaging for early and accurate diagnosis of these often fatal neurological complications could improve our understanding of the disease and its neurological manifestations.Community acquired pneumonias are known to be associated with hypercoaguability. It is no surprise that emerging evidence shows that COVID-19 may also predispose patients to both venous and arterial thromboembolism due to diffuse intravascular coagulation, hypoxia, cytokine storm and immobilization . High D-dimer levels, a marker of inflammation, are known to be associated with poor outcome in COVID-19.
Acute strokes seen in the current study are also likely related to thromboembolic disease and majority were present at the initial admission. Most importantly, our data demonstrates for the first time, that when a neuroimaging shows acute large ischemic stroke or hemorrhagic stroke in admitted COVID-19 patients, it is one of the strongest prognostic markers of poor outcome, even more than age and other previously reported co-morbidities such as hypertension and obesity. COVID-19 patients who have a large ischemic or hemorrhagic stroke on imaging have a 50% mortality in the current study.
In conclusion, our study demonstrates that acute stroke is the most common COVID-19 related neuroimaging finding and its incidence is 1.1% in hospitalized COVID-19 patients. The discovery of acute stroke by neuroimaging is a strong prognostic marker of poor outcome. Our study also highlights the fact there is restricted use of neuroimaging in COVID-19 patients due to multiple logistical constraints including the severity of their illness and the concern for spread of infection.
Reference & Source information: https://www.jns-journal.com/
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