Lower GCS is Related to Poor Outcome among Acute Stroke Patients with COVID-19 in A Tertiary Referral Hospital in Indonesia

Mieke Actress Hanna Nelly Kembuan, Arthur Hendrik Philips Mawuntu, Yohanna Yohanna, Feliana Feliana, Melke Joanne Tumboimbela


BACKGROUND: The Coronavirus disease 2019 (COVID-19) pandemic has forced the health workforce to take mitigative measures such as physical distancing, screening, personal protective equipment donning, and confinement on patient care. We aimed to study the outcome of acute stroke patients with suspected, probable, or confirmed COVID-19 in a tertiary referral hospital in Indonesia during the first year of COVID-19 pandemic.

METHODS: This was a retrospective study examining all medical records of adult patients suffering from acute stroke with suspected or confirmed COVID-19 who were admitted to R.D. Kandou Hospital, Manado, Indonesia, between March 2020 to March 2021. Clinical and laboratory parameters were compared between subjects with poor and good outcomes based on Glasgow Outcome Scale (GOS), divided into poor outcome (GOS 1-3) and good outcome (GOS 4-5).

RESULTS: Fourty-six eligible subjects were enrolled in the study. Based on the GOS, 36 subjects (78.3%) were admitted to the hospital with poor prognosis. On admission, the median Glasgow Coma Scale (GCS) was 11, breathlessness was found in 54.3% of subjects, fever was found in only 15 subjects (32.6%), and the lowest oxygen saturation on admission 95%. We found that GCS significantly related to outcome after controlled for other factors using the logistic regression method (p=0.03; 95% CI=1.08-4.78).

CONCLUSION: Lower GCS can be used to predict poor outcome in acute stroke patients with COVID-19.

KEYWORDS: COVID-19, acute stroke, Glasgow Coma Scale, outcome, Indonesia

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Merkler A, Parikh N, Mir S, Gupta A, Kamel H, Lin E, et al. Risk of ischemic stroke in patients with covid-19 vs patients with influenza. JAMA Neurol. 2020; 77: 1-7, CrossRef.

David Spence J, De Freitas GR, Pettigrew LC, Ay H, Liebeskind DS, Kase CS, et al. Mechanisms of stroke in COVID-19. Cerebrovasc Dis. 2020; 49: 451-8, CrossRef.

Ntaios G, Pearce LA, Veltkamp R, Sharma M, Kasner SE, Korompoki E, et al. Potential embolic sources and outcomes in embolic stroke of undetermined source in the NAVIGATE-ESUS Trial. Stroke. 2020; 51: 1797-804, CrossRef.

Tan YK, Goh C, Leow AST, Tambyah PA, Ang A, Yap ES, et al. COVID-19 and ischemic stroke: a systematic review and meta-summary of the literature. J Thromb Thrombolysis. 2020; 50: 587-95, CrossRef.

Wang Z, Yang Y, Liang X, Gao B, Liu M, Li W, et al. COVID-19 Associated ischemic stroke and hemorrhagic stroke: incidence, potential pathological mechanism, and management. Front Neurol. 2020; 11: 571996, CrossRef.

Salahuddin H, Afreen E, Sheikh IS, Lateef S, Dawod G, Daboul J, et al. Neurological predictors of clinical outcomes in hospitalized patients with COVID-19. Front Neurol. 2020; 11: 585944, CrossRef.

Yildiz H, Castanares-Zapatero D, Pierman G, Pothen L, De Greef J, Nana FA, et al. Validattion of neurophil-to-lymphocyte ratio cut-off value associated with high in-hospital mortality in COVID-19 patients. Int J Gen Med. 2021:14: 5111-7, CrossRef.

O’Donnell MJ, Denis X, Liu L, Zhang H, Chin SL, Rao-Melacini P, et al. Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): A case-control study. Lancet. 2010; 376: 112-23, CrossRef.

Sarfo FS, Ovbiagele B, Gebregziabher M, Wahab K, Akinyemi R, Akpalu A, et al. Stroke among young West Africans: Evidence from the SIREN (stroke investigative research and educational network) large multisite case-control study. Stroke. 2018; 49: 1116-20, CrossRef.

He X, Cheng X, Feng X, Wan H, Chen S, Xiong M. Clinical symptom differences between mild and severe COVID-19 patients in China: a meta-analysis. Front Public Heal. 2020; 8: 561264, CrossRef.

Parsay S, Vosoughi A, Khabbaz A, Sadigh-Eteghad S. The incidence and mortality ratio of ischemic cerebrovascular accidents in COVID-19 cases: a systematic review and meta-analysis. J Stroke Cerebrovasc Dis. 2021; 30: 105552, CrossRef.

Bhatia R, Pedapati R, Komakula S, Padma Srivastava MV, Vishnubhatla S, Khurana D. Stroke in coronavirus disease 2019: A systematic review. J Stroke. 2020; 22: 324-35, CrossRef.

Perry RJ, Smith CJ, Roffe C, Simister RJ, Narayanamoorthi S, Marigold R, et al. Characteristics and outcomes of COVID-19-associated stroke: A UK multicentre case-control study. J Neurol Neurosurg Psychiatry. 2021; 92: 242-8, CrossRef.

Yang AP, Liu JP, Tao WQ, Li HM. The diagnostic and predictive role of NLR, d-NLR and PLR in COVID-19 patients. Int Immunopharmacol. 2020; 84: 106504, CrossRef.

Fuad M, Oehadian A, Prihatni D, Marthoenis M. Neutrophil-to-lymphocyte ratio and Covid-19 symptom-based severity at admission. Althea Med J. 2021; 8: 1-6, CrossRef.

Selanno Y, Widaningsih Y, Esa T, Arif M. Analysis of neutrophil lymphocyte ratio and absolute lymphocyte count as predictors of severity of COVID-19 patients. Indones J Clin Pathol Med Lab. 2021; 27: 184-9, CrossRef.

Ciccullo A, Borghetti A, Zileri Dal Verme L, Tosoni A, Lombardi F, Garcovich M, et al. Neutrophil-to-lymphocyte ratio and clinical outcome in COVID-19: a report from the Italian front line. Int J Antimicrob Agents. 2020; 56: 106017, CrossRef.

Paudel SS. A meta-analysis of 2019 novel coronavirus patient clinical characteristics and comorbidities. Research Square. 2020 [PrePrint], CrossRef.

Rees EM, Nightingale ES, Jafari Y, Waterlow NR, Clifford S, Pearson CAB, et al. COVID-19 length of hospital stay: a systematic review and data synthesis. BMC Med. 2020; 18: 270, CrossRef.

Cozzi D, Albanesi M, Cavigli E, Moroni C, Bindi A, Luvarà S, et al. Chest X-ray in new Coronavirus Disease 2019 (COVID-19) infection: findings and correlation with clinical outcome. Radiol Med. 2020; 125: 730-7, CrossRef.

Requena M, Olivé-Gadea M, Muchada M, García-Tornel Á, Deck M, Juega J, et al. COVID-19 and stroke: incidence and etiological description in a high-volume center. J Stroke Cerebrovasc Dis. 2020; 29: 105225, CrossRef.

DOI: https://doi.org/10.18585/inabj.v13i4.1700

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The Prodia Education and Research Institute