Stroke in Patients with COVID 19
Introduction[edit | edit source]
Even though primary covid infection has taken a back seat in most of the countries, the after effects of covid 19 are still encountered in quiet a lot of patients who had the infection in the first place. One such complication is stroke. Stroke was demonstrated in about 1-3% of hospitalised patients and in about 6 % of ICU admitted patients.[1] It has been established that COVID 19 infection is associated with thrombotic events such as ischaemic stroke (IS).[2] As compared to age matched controls , patients with COVID 19 tend to affected more severely and demonstrate higher mortality when encountered with IS.[3]
IS is prevalent in patients with medical comorbidities as well as in healthy individuals under the age of 55 years.[4] It has been stated by multiple studies that IS associated with COVID 19 are mostly cryptogenic or is an embolic stroke of undetermined significance ( ESUS) , which is subtype of stroke with results due to undiagnosed cardioembolic source.[5] In landmark trial -ESUS , 73% of ESUS were attributed to a cardiac cause , where about 37% had an association with atrial cardiopathy and about 36% were associated with ventricular disease. The major cardiac complications associated with COVID 19 infection include, atrial arrythmias , myocardial injury , acute coronary syndrome and cardiac myopathy.[6][7] [8] All of these complications become a source for embolic sources from a thrombi formation resulting in ESUS. The underlying pathophysiology for development of these complications is an inflammatory response or “cytokine storm” which leads to cardiac complications and sympathetic surge.[7] [8]
The cardiac damage resulting due to COVID 19 infection remains long standing even after recovering from the primary infection. Therefore it is important to consider the cardiac damage and its association with cryptogenic/ESUS stroke.[8]
Typical features includes , involvement of multiple vascular territories, occlusion of large vessels , severe neurological deficits at presentation , concurrent deep vein thrombosis and pulmonary embolism[9]
Implications for Rehabilitation[edit | edit source]
Post covid stroke patients present with additional disabling challenges such as severe fatigue , low endurance tolerance , musculoskeletal changes , reduce cardiovascular and pulmonary functions.[10]
Pre Exercise Screening[edit | edit source]
Patients with a history of covid infection should be screened though COVID 19 pre screening and eligibility for exercise rehabilitation questionnaire for eligibility to participate in rehabilitation. In addition to this qualified health care professionals should assess for graded exercise stress testing with or without ECG monitoring and metabolic gas exchange.[10][11]
Graded exercise stress testing is a gold standard test which should be routinely done for individuals post covid post stroke as it provides with a clear picture of the physiological capacity of a stroke patient to adapt to graded aerobic exercises. In addition to this graded exercise stress testing provides with other valuable information for COVID induced cardiac pathologies such as suspected myocarditis, exercise associated oxygen desaturation, hypoxemia, intolerance and exertional dyspnoea.[12][13]
Parameters to continuously monitor exercise stress testing
- Heart rate and rhythm
- Blood pressure
- Oxygen saturation and uptake
- Rate of perceived exertion [14]
Exercise Prescription for Post Covid Stroke Patients[edit | edit source]
In addition to physiotherapy protocol addressing sensorimotor, gait and balance deficits post stroke, it is important to introduce aerobic exercise as a routine for post covid post stroke patients.
Aerobic exercises tend to improve the cardiorespiratory fitness address symptoms such as exertional dyspnea and fatigue, reduces the cardiovascular risk factors , enhances peripheral, central cardiovascular and cerebrovascular function. Aerobic exercises are know to induce neuroplastic changes which help in better motor recovery. It has been found that higher cardiorespiratory fitness and participation in physical activity preserves grey and white matter structures in geriatric population and improves cognitive function post stroke. Aerobic exercises can be initiated at a low to moderate intensity with about 50% of frequency, intensity and time. The clinical decision regarding progression can be made following an objective stress testing, clinical judgement and severity of symptoms.[14]
References[edit | edit source]
- ↑ 1. Anrather J, Kamel H. Effects of COVID-19 on the Nervous System. Cell. 2020;183(1):16-27.
- ↑ Centers for Disease Control and Prevention. National center for immunization and respiratory diseases (NCIRD). In2019-2020 US Flu Season: Preliminary In-Season Burden Estimates 2020. CDC.
- ↑ Ntaios G, Michel P, Georgiopoulos G, Guo Y, Li W, Xiong J, Calleja P, Ostos F, González-Ortega G, Fuentes B, Alonso de Leciñana M. Characteristics and outcomes in patients with COVID-19 and acute ischemic stroke: the global COVID-19 stroke registry. Stroke. 2020 Sep;51(9):e254-8.
- ↑ Elfasi A, Echevarria FD, Rodriguez R, Casul YA, Khanna AY, Mankowski RT, Simpkins AN. Impact of COVID-19 on future ischemic stroke incidence. Eneurologicalsci. 2021 Mar 1;22:100325.
- ↑ Spence JD, De Freitas GR, Pettigrew LC, Ay H, Liebeskind DS, Kase CS, Del Brutto OH, Hankey GJ, Venketasubramanian N. Mechanisms of stroke in COVID-19. Cerebrovascular Diseases. 2020;49(4):451-8.
- ↑ Ntaios G, Pearce LA, Veltkamp R, Sharma M, Kasner SE, Korompoki E, Milionis H, Mundl H, Berkowitz SD, Connolly SJ, Hart RG. Potential embolic sources and outcomes in embolic stroke of undetermined source in the NAVIGATE-ESUS trial. Stroke. 2020 Jun;51(6):1797-804.
- ↑ 7.0 7.1 Guo T, Fan Y, Chen M, Wu X, Zhang L, He T, Wang H, Wan J, Wang X, Lu Z. Cardiovascular implications of fatal outcomes of patients with coronavirus disease 2019 (COVID-19). JAMA cardiology. 2020 Jul 1;5(7):811-8.
- ↑ 8.0 8.1 8.2 Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, Wang B, Xiang H, Cheng Z, Xiong Y, Zhao Y. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus–infected pneumonia in Wuhan, China. jama. 2020 Mar 17;323(11):1061-9.
- ↑ Asirvatham T, Abubacker M, Isaac Chandran P, Boppana A, Salim Al Abdulla S, Mohammed Saad R. Post-COVID-19 Stroke Rehabilitation in Qatar: A Retrospective, Observational Pilot Study. Qatar Medical Journal. 2022 Feb 28;2022(1):10.
- ↑ 10.0 10.1 Moncion K, Rodrigues L, MacKay-Lyons M, Eng JJ, Billinger SA, Ploughman M, Bailey DM, Trivino M, Bayley M, Thiel A, Roig M. Exercise-based stroke rehabilitation: clinical considerations following the COVID-19 pandemic. Neurorehabilitation and Neural Repair. 2022 Jan;36(1):3-16
- ↑ MacKay-Lyons M, Billinger SA, Eng JJ, Dromerick A, Giacomantonio N, Hafer-Macko C, Macko R, Nguyen E, Prior P, Suskin N, Tang A. Aerobic exercise recommendations to optimize best practices in care after stroke: AEROBICS 2019 update. Physical therapy. 2020 Jan;100(1):149-56.
- ↑ Mihalick VL, Canada JM, Arena R, Abbate A, Kirkman DL. Cardiopulmonary exercise testing during the COVID-19 pandemic. Progress in Cardiovascular Diseases. 2021 Jul 1;67:35-9.
- ↑ Faghy MA, Sylvester KP, Cooper BG, Hull JH. Cardiopulmonary exercise testing in the COVID-19 endemic phase. British journal of anaesthesia. 2020 Oct 1;125(4):447-9.
- ↑ 14.0 14.1 Moncion K, Rodrigues L, MacKay-Lyons M, Eng JJ, Billinger SA, Ploughman M, Bailey DM, Trivino M, Bayley M, Thiel A, Roig M. Exercise-based stroke rehabilitation: clinical considerations following the COVID-19 pandemic. Neurorehabilitation and Neural Repair. 2022 Jan;36(1):3-16.
