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The mucormycosis and stroke: The learning curve during the second COVID-19 pandemic
Dileep Ramachandran1, Aravind R2, Praveen Panicker3
1Associate Professor, Department of Neurology, Government Medical College, Thiruvananthapuram, Kerala, India.
Background:
The Angio-invasive Rhino-orbito-cerebral mucormycosis (ROCM) producing strokes is a less explored entity. Our hospital, a stroke-ready one, had an opportunity to manage mucormycosis when it was identified as the nodal center for mucormycosis management. We are sharing our experiences and mistakes in managing the cerebrovascular manifestations of ROCM.
Methods:
We conducted a prospective observational study during the second wave of the COVID-19 pandemic from 1st May 2021 to 30th September 2021, where consecutive patients aged more than 18 years with microbiologically confirmed cases of ROCM were included. Clinical details (timing of stroke onset after ROCM symptoms, GCS, NIHSS), imaging findings (ASPECTS, the territory of stroke, the pattern of infarct, hemorrhagic transformation, cavernous sinus thrombosis), angiogram findings, management details (IV thrombolysis), and outcomes (mRS at discharge and duration of hospital stay) were documented. We also compared the demographics, clinical features (NIHSS), radiological findings, treatment details, duration of hospital stay, and functional outcome at the discharge of the ROCM stroke patients with stroke patients without ROCM.
Results:
Stroke developed in 42% of patients with ROCM, predominantly anterior circulation border zone ischemic infarcts. Strokes occurred after a median of five days from the onset of ROCM symptoms. The most common vessel involved was the ophthalmic artery, followed by the cavernous ICA. We could not thrombolyse ROCM stroke patients. ROCM patients who developed stroke compared with patients without stroke had a more infiltrative fungal infection and higher inflammatory markers. Mucormycosis associated stroke patients had higher in-hospital mortality and poor functional outcomes.
T Conclusion:
Due to delayed recognition of stroke symptoms, none received reperfusion strategies, leading to poor functional outcomes. For early stroke detection, ROCM cases need frequent monitoring and education of patients and their relatives about the ALS acronym (loss of ambulation, limb weakness, and loss of speech).
Insights
Angio-invasive Rhino-orbito-cerebral mucormycosis (ROCM) frequently causes strokes, leading to high mortality. Early stroke detection and monitoring are crucial for better outcomes in ROCM patients, as reperfusion strategies were not feasible.
Area of Science:
- Neurology
- Infectious Diseases
- Vascular Medicine
Background:
- Angio-invasive Rhino-orbito-cerebral mucormycosis (ROCM) leading to cerebrovascular events is under-researched.
- This study shares experiences from a designated mucormycosis management center during the COVID-19 pandemic.
- Focuses on the cerebrovascular complications of ROCM.
Purpose of the Study:
- To investigate the incidence, characteristics, and outcomes of strokes in patients with ROCM.
- To compare ROCM-stroke patients with non-stroke ROCM patients.
- To identify factors associated with poor outcomes in ROCM-related strokes.
Main Methods:
- Prospective observational study of microbiologically confirmed ROCM cases (May-September 2021).
- Collected data on clinical presentation, stroke timing, imaging, and management.
- Compared ROCM patients with and without stroke.
Main Results:
- 42% of ROCM patients developed stroke, primarily anterior circulation border zone infarcts.
- Strokes occurred median 5 days post-ROCM onset; ophthalmic artery and cavernous internal carotid artery were most affected.
- ROCM stroke patients had higher mortality and poorer functional outcomes; none received thrombolysis due to delayed recognition.
Conclusions:
- Delayed stroke recognition in ROCM hinders reperfusion, leading to poor outcomes.
- Frequent monitoring and patient/family education on stroke symptoms (ALS: ambulation, limb weakness, speech loss) are vital for early detection.
