Update Management Ischemic Stroke

Era Pandemic Covid 19

Paryono
OutLine
1.Epidemiology stroke pada Covid 19
2.Patofiology stroke pada Covid 19
3.Kriteria Dx COVID-19 associated stroke
4.Management Stroke iskemik akut pada Era
pandemic covid 19
5.Prognosis stroke iskemik pd Covid 19.
Epidemiologi stroke pada COVID-19
 Rates of ischemic stroke reported in available to date
cohort studies of patients infected with severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2).

Stroke. 2020;51:1924–1926
 Mekanisme patofisiologi stroke pada
COVID-19

Aktivasi sel
Cedera infeksi
Hipoksemia imun dan
direk
badai sitokin

Tromboemboli
Deplesi
dan Vaskulitis
reseptor ACE2
koagulopati

Miokarditis
viral
Definisi COVID-19 associated stroke
(Vogrig et al., 2020)
 Defisit D’Anna Yamakawa et Anne et al., 2020; Morassi et Kwon et al., Ntaios et al., Ashrafi et Tunc et al., Beyrouti
neurologis et al., al., 2020 Jillea et al., 2020; al., 2020 2020 2020 al., 2020; 2020 et al., 2020
2020 Katz et al., 2020; Fatehi et al.,
Reddy et al., 2020; 2020;
Sharifei-
Razifi et al.,
2020
Neglek 12,5%
Afasia 62,5% 23% 20% 20-33% 34%
Hemiparesis 87,5% 67,5% 23% 34% 80% 67,8% 100% 17,5% 67%
Hemihipoestesi 25% 24% 25% 17%
Paresis nervus 25- 34,3% 80% 46% 83,7-100% 25-50% 50-67%
kranial 37,5%
Hemianopia 12,5% 33,4%
Ataksia 12,5%
Penurunan 51,4% 61,5-67,4% 83% 20% 50-66,7% 25%
kesadaran
Gangguan 77,7%
pendengaran
Deviasi 77,7%
konjugat
Ataksia 25%
Kejang 34%
Paraparesis 7,7%
 Karakteristik laboratorium pada stroke dengan
COVID-19
Peningkatan respon inflamasi
- Peningkatan : angka leukosit dan neutrofil, RNL, CRP, IL-6, IL-8, IL-10,
LDH, ferritin
- Penurunan limfosit (limfopenia)

Hiperkoagulabel
- Peningkatan : D-dimer
- Pemanjangan : PT, aPTT
- Penurunan : trombosit
- Antibodi antifosfolipid positif
 Karakteristik neuroimejing pada stroke
dengan COVID-19
Multiple ischemic lesion
(parietal lobe & centrum
semiovale)
Large fronto-insular
ischemic (left MCA)
Infarct in postero-inferior of left
cerebellum hemisphere and inferior
vermis (PICA). Lesion had transformation
large parenchymal hematoma
Left parieto-occipital
Infarction (hyperintense T1,
Bright on DWI, FLAIR edema)
Vogrig et al., (2020)
- Large Vessel Occlusion
- Vertebrobasilar location
- Multi-territory involvement
- Extre-cranial dissection
- PRES or laminar cortical damage
CTA: long stenosis of distal of ICA bilateral;
narrowed eccentric flow surrounded by cresent
shaped subacute mural hematoma  bilateral
carotid dissection
Author Patients Thromboembolic Other findings
events
Cui et al (90) 81 VTE (25%) Elevated D-dimer was a good index to recognize VTE.
Stoneham et al (91) 274 VTE (7.7%) Levels of D-dimer were higher in patients with VTE
than those without VTE.
Helms et al (7) 150 PE (16.7%) Compared with non-COVID-19 ARDS patients,
patients with COVID-19 ARDS were more prone to PE.

Léonard-Lorant et al (92) 106 PE (30%) D-dimer levels >2,660 (ng/ml) indicated PE. The
sensitivity was 100% and the specificity was 67%.

Llitjos et al (93) 26 VTE (69%), PE (23%) COVID-19 patients treated with therapeutic
anticoagulation were more prone to VTE and PE.
Tang et al (5) 183 DIC (8.7%) 71.4% of non-survivors combined with DIC while
0.6% of survivors combined with DIC.
Mao et al (3) 214 AIS (5.7%) Patients with Severe COVID-19 were more likely to
have neurologic manifestations, such as acute
cerebrovascular diseases.

Zhang et al. 2021

 Recommendations for Anticoagulant Tharapy
Authors Recommendations of Anticoagulant therapy
Thachil et al (99) ISTH: Patients admitted to hospital for COVID-19 have no
contraindications (hemorrhage or platelet count <25×109/l) should
receive prophylactic LMWH.

Sardu et al (71) In absence of contraindications, enoxaparin 40 mg/day is

recommended for all patients; enoxaparin 1 mg/kg every 12 h is
recommended for those with D-dimer levels >3 µg/ml.

Connors and For obese patients, UFH 7m500 units 3 times a day or 40 mg
enoxaparin twice a day are recommended.

Levy (100) Given the short half-life and strong ability to be administered
parenterally, LMWH or UFH should be administered to critically ill
patients instead of giving direct oral anticoagulants.

Zhang et al. 2021

 Anti Coagolant for Covid 19

Zhang et al. 2021

Antiplatelet in Acute
Ischemic Stroke
Endovascular therapy (EVT) for stroke before and after coronavirus disease
2019 (COVID-19) (Stroke. 2020;51:2593–2596)
 Methods for the prevention of acute ischemic stroke

Population in question Current recommendation Potential drugs for research

General population Regular physical activity, consumption of None
without risk of COVID-19 sufficient water/liquids, low-fat diet, low-
salt diet
Asymptomatic patients No prophylaxis, regular physical activity, DOACs, aspirin, clopidogrel
screened positive for SARS- consumption of sufficient water/liquids,
CoV-2 low-fat diet, low-salt diet
COVID-19 patients being Individual risk assessment for AIS, regular DOACs, aspirin, clopidogrel
managed at the outpatient physical activity, consumption of sufficient
clinic water/liquids, low-fat diet, low-salt diet

COVID-19 patients Prophylactic LMWH if not contraindicated, DOACs, aspirin, clopidogrel, Tpa,
admitted to hospital in consumption of sufficient water/liquids, tocilizumab, dornase alfa, pirfenidone,
non-ICU setting low-fat diet, low-salt diet tiotropium, colchicine, eculizumab,
HrsACE2
Severe COVID-19 patients Prophylactic LMWH if not contraindicated Tpa, tocilizumab, dornase alfa,
requiring ICU pirfenidone, tiotropium, colchicine,
eculizumab, HrsACE2
Zhang et al. 2021
 RINGKASAN
1. Insidensi stroke Iskemik akut pada COVID-19 bervariasi (1-2%).
2. Patofisiologi : cedera infeksi direk, hipoksemia, aktivasi sel imun dan badai sitokin deplesi reseptor
ACE2, tromboemboli dan koagulopati, vaskulitis, dan miokarditis viral
3. Analisa laboratorium pasien stroke dengan COVID-19 menunjukkan peningkatan respon inflamasi
dan kondisi hiperkoagulabel
4. Defisit neurologis yang sering dijumpai adalah hemiparesis, diikuti paresis nervus kranial, afasia, dan
penurunan kesadaran
5. Neuroimejing stroke iskemi dengan COVID-19 : multipel teritori, paling sering terkena di MCA, LVO.
6. Penangan Stroke ischemic dengan Covid 19 dengan pemberian anticoagulant dan bila melibatkan
membuluh darah besar bisa dilakukan endovascular Thrombectomi.
7. Covid 19 adalah factor independent pemburukan stroke iskemik akut.