Singh, Tarun D.

OBJECTIVES: To describe the prevalence, associated risk factors, and outcomes of serious neurologic manifestations (encephalopathy, stroke, seizure, and meningitis/encephalitis) among patients hospitalized with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. DESIGN: Prospective observational study. SETTING: One hundred seventy-nine hospitals in 24 countries within the Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study COVID-19 Registry. PATIENTS: Hospitalized adults with laboratory-confirmed SARS-CoV-2 infection. INTERVENTIONS: None. RESULTS: Of 16,225 patients enrolled in the registry with hospital discharge status available, 2,092 (12.9%) developed serious neurologic manifestations including 1,656 (10.2%) with encephalopathy at admission, 331 (2.0%) with stroke, 243 (1.5%) with seizure, and 73 (0.5%) with meningitis/encephalitis at admission or during hospitalization. Patients with serious neurologic manifestations of COVID-19 were older with median (interquartile range) age 72 years (61.0–81.0 yr) versus 61 years (48.0–72.0 yr) and had higher prevalence of chronic medical conditions, including vascular risk factors. Adjusting for age, sex, and time since the onset of the pandemic, serious neurologic manifestations were associated with more severe disease (odds ratio [OR], 1.49; p < 0.001) as defined by the World Health Organization ordinal disease severity scale for COVID-19 infection. Patients with neurologic manifestations were more likely to be admitted to the ICU (OR, 1.45; p < 0.001) and require critical care interventions (extracorporeal membrane oxygenation: OR, 1.78; p = 0.009 and renal replacement therapy: OR, 1.99; p < 0.001). Hospital, ICU, and 28-day mortality for patients with neurologic manifestations was higher (OR, 1.51, 1.37, and 1.58; p < 0.001), and patients had fewer ICU-free, hospital-free, and ventilator-free days (estimated difference in days, –0.84, –1.34, and –0.84; p < 0.001). CONCLUSIONS: Encephalopathy at admission is common in hospitalized patients with SARS-CoV-2 infection and is associated with worse outcomes. While serious neurologic manifestations including stroke, seizure, and meningitis/encephalitis were less common, all were associated with increased ICU support utilization, more severe disease, and worse outcomes.

Objective: To determine the effect of Selective Serotonin Reuptake Inhibitor (SSRI)/Selective Norepinephrine Reuptake Inhibitor (SNRI) use prior to or during admission for aneurysmal subarachnoid hemorrhage (aSAH) on the risk of symptomatic vasospasm and diffuse cerebral ischemia (DCI). Methods: Review of electronic records at Mayo Clinic, Rochester from Jan. 2001 to Dec. 2013 of consecutive patients with aSAH. The variables collected and analyzed were: age, sex, active smoking, transfusion, modified Fisher score, WFNS grade, and outcome at discharge. Multivariate logistic regression analysis was used to evaluate factors associated with DCI, symptomatic vasospasm, and poor outcome (modified Rankin score 3-6) within 1 year. Results: 583 [females 367 (63%)] patients with a median age of 55 (47-65) years were admitted with aSAH during the study period. WFNS at nadir was IV-V in 243 (41.6%) and modified Fisher score was 3-4 in 438 (75.2%). Eighty one (14.6%) patients were taking SSRI or SNRI prior to admission and these medications were continued in all of them. Symptomatic vasospasm was present in 154 (27.7%), radiological infarction in 172(29.5%), and DCI in 250(42.9%) patients. SSRI/SNRI use was not associated with the occurrence of DCI (p=0.458), symptomatic vasospasm (p=0.097), radiological infarction (p=0.972), or poor functional outcome (p=0.376). Conclusions: The use of SSRI/SNRI prior to admission and/or during hospitalization in patients with aSAH was not associated with symptomatic vasospasm or DCI.

Background: Given the uncertainty regarding clinical applicability of early treatment trials and lack of data on long-term disease progression, we evaluated the progression of stenosis and development of symptoms on patients with asymptomatic carotid artery stenosis (ACAS) treated with contemporary medical therapy over a prolonged follow up. Methods: Retrospective review of bilateral carotid arteries from consecutive patients diagnosed with moderate or severe ACAS, at our institution between 2000 and 2001. Patient vascular risk factors and treatments, cerebrovascular imaging, ipsilateral symptoms, and revascularization were recorded. Progression of stenosis was defined by change category of stenosis. Factors associated with symptomatic carotid disease were sought using univariate and multivariate logistic regression analysis. Results: We identified 214 patients (58.8% men; median age 70 years) and collected data on 349 vessels. Severe stenosis (>70%) upon diagnosis was present in 92(26.4%) vessels. All patients were on antithrombotics, 97% on antihypertensives, and 95% on statins. Median length of follow up was 13 years (range 5-14) and the mean number of time points with follow-up imaging was 8.1±3.9. Progression of stenosis was observed in 237(67.9%) vessels. 72(20.6%) patients developed symptomatic carotid stenosis (TIA in 14.4%, non-disabling stroke in 4%, and disabling stroke in 2.2%). Median time to appearance of first symptom was 6 years (range 1-13). Revascularization procedures were performed in 118(33.8%) vessels, including 73(61.9%) vessels which had become symptomatic. On multivariate analysis, baseline stenosis (OR 1.65, 95%CI 1.12-2.44), intracranial stenosis > 50% (OR 2.87, 95%CI 1.46-5.62), plaque ulceration (OR 3.41, 95%CI 1.34-8.69), silent infarction (OR 4.25, 95%CI 2.30-7.83), and previous history of TIA/stroke (OR 2.73, 95%CI 1.14-6.54) were associated with development of TIA/stroke ipsilateral to the carotid stenosis. Conclusions: There is a substantial rate of progression of stenosis in patients with asymptomatic carotid atherosclerosis over time despite adequate medical therapy. Over long-term follow up, one in five patients with ACAS developed ipsilateral TIA/stroke.

Abstract Background SMART (stroke‐like migraine attacks after radiation therapy) is a rare, delayed complication of brain radiation. In this study, we wanted to review the spectrum of symptoms, neuroradiological findings, autoimmune status, and outcomes in SMART syndrome patients. Methods We conducted a retrospective cohort study of all consecutive adult patients (≥18 years) diagnosed with SMART syndrome at Mayo Clinic, Rochester between January 1995 and December 2018. Results We identified 25 unique patients with SMART syndrome and a total of 31 episodes and 15 (60%) patients were male. The median age at onset was 46 (interquartile range [IQR] 43–55) years and the median latency of onset after the initial radiation was 21.6 (IQR 14.4–28.2) years. Magnetic resonance imaging (MRI) showed gyral edema and enhancement in all cases with the temporal (25, 80.6%) and parietal (23, 74.2%) lobes being the most commonly affected. The median follow‐up of the patients in our cohort was 10 (IQR 6–32) weeks. On univariate analysis, factors associated with an increased risk of recurrent SMART episodes were female gender (odds ratio [OR] 8.1, 95% confidence interval [95% CI] 1.1–52.6, p = 0.019) and absence of electrographic seizure discharges during initial symptoms (OR 7.4, 95% CI 1.1–45.9, p = 0.032). We could not identify an autoimmune etiology. Longer duration of symptoms (>10 weeks) correlated with an older age ( p = 0.049), temporal lobe involvement ( p < 0.001), and diffusion restriction ( p = 0.043). Conclusions SMART is a syndrome with characteristic imaging findings and clinical features. Incomplete recovery by 10 weeks occurred in one‐third of individuals and was associated with older age, temporal lobe involvement, and restricted diffusion on MRI.