Cerebrovascular disease in patients with COVID-19: neuroimaging, histological and clinical description
Cerebrovascular disease in patients with COVID-19: neuroimaging, histological and clinical description
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DOI：
10.1093/brain/awaa239
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发表时间：
2020-10-01
期刊：
影响因子：
14.5
通讯作者：
Segura, Tomas
中科院分区：
文献类型：
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作者：
Hernandez-Fernandez, Francisco;Sandoval Valencia, Hernan;Segura, Tomas
自2019冠状病毒病（COVID-19）首例出现以来，全球已出现影响数百万人的大流行。虽然主要临床表现是呼吸系统疾病，但已发现神经系统疾病，特别是急性脑血管疾病的增加。我们介绍了SARS-CoV-2感染住院患者中脑血管疾病病例的发生率。通过微生物/血清学检测或胸部CT症状学确认患者。对住院期间的合并症、实验室参数、给予的治疗、神经影像学、神经病理学研究和临床进展（采用改良兰金量表测量）的现有数据进行了分析。还设计了一项双变量研究，以确定缺血性和出血性亚型之间的差异。设计了一个二元Logistic回归和敏感性分析的统计模型来研究自变量对预后的影响。在我们的中心，50天内有1683名COVID-19患者入院，其中23名（1.4%）患有脑血管疾病。在这组患者中，所有病例均进行了脑部和胸部CT扫描，6例（26.1%）进行了MRI扫描。在6/23例病例中获得组织学样本（2例脑活检和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例为脑出血（21.7%），1例为后部可逆性脑病型白质脑病。出血患者在卒中时铁蛋白水平较高（1554.3 vs 519.2，P = 0.004）。缺血性卒中在椎基底动脉区域意外频繁（6/17，35.3%）。在出血组中，确定了特征性放射学模式，显示蛛网膜下腔出血、顶枕白质脑病、微出血和单个或多个局灶性血肿。脑活检显示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。73.9%的患者住院期间功能预后不佳（17/23改良兰金量表4-6），年龄是主要预测变量（比值比= 1.5; 95%置信区间1.012-2.225; P = 0.043）。我们的系列研究显示，COVID-19患者的脑血管疾病发病率为1.4%，发病率和死亡率较高。我们描述的病理学和放射学数据与血栓性微血管病引起的内皮病变出血倾向一致。
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.