Global stroke challenges: From COVID-19 to intracerebral hemorrhage and atrial fibrillation

Abstract

With the COVID-19 pandemic still raging, and further disease waves affecting many countries worldwide, this month’s IJS contains a particularly timely review on stroke associated with COVID-19 infection. COVID19 has had a major impact on stroke services, particularly in delayed presentation, and impaired access to stroke services worldwide, as highlighted in the World Stroke Organization survey. However, there has also been concern that COVID-19 infection itself might cause stroke. In this issue, in a comprehensive systematic review, Nannoni et al. identified acute cerebrovascular disease as occurring in 1.4% of 108,571 patients with COVID-19 infection. Compared to individuals who experienced stroke without COVID-19 infection, patients with COVID-19 and stroke were younger, had more severe stroke, and a higher hospital mortality rate. They conclude that COVID-19 infection may act as a trigger or risk factor for stroke at least in a proportion of cases. This is supported by a characteristic pattern of stroke in individuals with COVID-19, with an increased proportion of large artery occlusion, infarction involving multiple territories, and increased cryptogenic etiology, which would all be consistent with a causal relationship in at least a proportion of patients. It is also relevant that COVID-19 infection appears more likely to cause thrombotic vascular events including stroke than other coronavirus and seasonal infectious diseases, with a 7.5-fold increase in the odds of stroke with COVID-19 compared with influenza. Intracerebral hemorrhage remains a devastating condition with an outcome worse than ischemic stroke. Despite this, we have little in the way of specific treatments and most treatment trials have been negative. There is increasing interest in repurposing existing therapeutic agents for novel disease applications, and in this issue, Crilly et al. review the existing literature to identify potentially repurposable drugs which may be of benefit in intracerebral haemorrhage. They suggest that perhaps the most promising new candidates for future translation are inhibition of HNGB1 release and agonism of the Nrf2 antioxidant pathway. Let us hope that some of these translate into better care for this devastating disease. Secondary analysis of large clinical trial databases can often lead to potentially important findings. This is illustrated in this issue by secondary analysis of the HeadPoST trial. This trial was designed to assess positioning following stroke. However, the authors also analyzed associations between an indwelling urinary catheter and outcome. Of 11,093 patients randomized, 1167 (12%) had an indwelling urinary catheter, with the frequency and duration varying widely across different regions worldwide. Indwelling catheter use was independently associated with a poor outcome after adjustment for any antibiotic treatment for UTI and stroke severity. Although only a secondary analysis, this does suggest that urinary catheters should be avoided if not absolutely necessary. In many parts of the world, stroke due to atherosclerotic carotid disease is reducing in incidence, but stroke due to atrial fibrillation remains a major worldwide problem. In this issue, Lippi et al. provide comprehensive and updated statistics on the worldwide epidemiology of atrial fibrillation and present data, suggesting that its incidence and prevalence had increased over the last 20 years, and will continue to increase over the next 30 years especially in countries with middle sociodemographic index. This makes it one of the largest public health challenges worldwide. Lastly and importantly, I would like to thank Carmen Lahiff-Jenkins for her contribution to the journal. She was the founding Managing Editor, and with Professor Geoff Donnan, created the IJS and brought it to where it is now. She will be finishing as Managing Editor from 1 February 2021 when the editorial office moves to the UK. I am sure you would all wish to join me in thanking her for her enormous contribution.