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Cerebrovascular Involvement in Mucormycosis in COVID-19 Pandemic
Rahul Kulkarni1, Shripad S Pujari2, Dulari Gupta1
1Department of Neurology, Deenanath Mangeshkar Hospital and Research Center, Pune, India.
Insights
Coronavirus disease 2019 (COVID-19) associated mucormycosis (CAM) can lead to cerebrovascular complications, with ischemic stroke being most common. Early screening for brain and vessel involvement is crucial in CAM patients due to high mortality.
Area of Science:
- Neurology
- Infectious Diseases
- Vascular Medicine
Background:
- An unprecedented rise in COVID-19 associated mucormycosis (CAM) has been observed globally.
- Cerebrovascular involvement in CAM remains understudied, necessitating detailed investigation.
Purpose of the Study:
- To describe the clinico-radiological manifestations of cerebrovascular complications in patients with CAM.
- To identify risk factors and outcomes associated with cerebrovascular events in CAM.
Main Methods:
- A multicentric retrospective observational study was conducted in India.
- Data on demographics, risk factors, clinical presentation, imaging, laboratory findings, and outcomes were collected from CAM patients with cerebrovascular involvement.
Main Results:
- Cerebrovascular complications occurred in 11.8% of CAM patients, with ischemic stroke being the most frequent (91.8%).
- Diabetes mellitus was a prevalent comorbidity (81.7%), and 40% of patients developed stroke despite antiplatelet or heparin therapy.
- Mortality during hospital stay was high at 51%.
Conclusions:
- Cerebrovascular involvement is a significant complication of CAM, driven by the angio-invasive nature of the fungus, COVID-19-induced prothrombotic state, and diabetes.
- Routine screening for neurological and vascular involvement is recommended for CAM patients.
- Standard antiplatelet or anticoagulant therapies may not offer complete protection against stroke in CAM.
Background:
Many countries have seen an unprecedented rise of cases of coronavirus disease 2019 (COVID-19) associated mucormycosis (CAM). Cerebrovascular involvement in CAM has not been studied so far. We describe clinico-radiological manifestations of cerebrovascular complications observed in CAM.
Methods:
In this multicentric retrospective observational study from India, patients with CAM who developed cerebrovascular involvement were studied. Their demographics, risk factors, clinical manifestations, imaging, laboratory profile and outcomes were noted.
Results:
Out of 49 subjects with cerebrovascular involvement, 71.4% were males while average age was 52.9 years. Ischemic stroke was commonest (91.8%) followed by intracranial haemorrhage (6.1%) and subarachnoid haemorrhage (2%). The incidence of cerebrovascular complications in CAM was found to be 11.8% in one center. Cerebrovascular symptoms appeared a median of 8.3 days from the onset of mucormycosis. Commonest presentation of mucormycosis was rhino-orbito-cerebral syndrome in 98%. Diabetes mellitus was present in 81.7%. Forty percent developed stroke despite being on antiplatelet agent and/or heparin. Amongst subjects with ischemic strokes, location of stroke was unilateral anterior circulation (62.2%); bilateral anterior circulation (17.8%); posterior circulation (11.1%) and combined anterior and posterior circulation (8.9%). Vascular imaging revealed intracranial occlusion in 62.1%; extracranial occlusion in 3.4% and normal vessels in 34.5%. Mortality was 51% during hospital stay.
Conclusions:
Cerebrovascular involvement was seen in 11.8% patients of CAM. Angio-invasive nature of the fungus, prothrombotic state created by COVID-19, and diabetes were important causative factors. Subjects with CAM should be screened for involvement of the brain as well as its vessel. Antiplatelet agents/heparin did not seem to provide complete protection from this type of stroke.
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