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      Current Recommendations for the Management of Stroke Patients in the Middle East in the Era of COVID-19 Pandemic; Statement from the MENA SINO

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          Abstract

          COVID-19 pandemic has led to a change in the way we manage acute medical illnesses. This pandemic had a negative impact on stroke care worldwide. The World Stroke Organization (WSO) has raised concerns due to the lack of available care and compromised acute stroke services globally. The numbers of thrombolysis and thrombectomy therapies are declining. As well as, the rates and door-to treatment times for thrombolysis and thrombectomy therapies are increasing. The stroke units are being reallocated to serve COVID-19 patients, and stroke teams are being redeployed to COVID-19 centers.

          Covid 19 confirmed cases and deaths are rising day by day. This pandemic clearly threatened and threatening all stroke care achievements regionally. Managing stroke patients during this pandemic is even more challenging at our region. The Middle East and North Africa Stroke and Interventional Neurotherapies Organization (MENA-SINO) is the main stroke organization regionally. MENA-SINO urges the need to developing new strategies and recommendations for stroke care during this pandemic. This will require multiple channels of interventions and create a protective code stroke with fast triaging path. Developing and expanding the tele-stroke programs are urgently required. There is an urgent need for enhancing collaboration and cooperation between stroke expertise regionally and internationally. Integrating such measures will inevitably lead to an improvement and upgrading of the services to a satisfactory level.

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          Most cited references8

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          Cardiovascular Implications of Fatal Outcomes of Patients With Coronavirus Disease 2019 (COVID-19)

          This case series study evaluates the association of underlying cardiovascular disease and myocardial injury on fatal outcomes in patients with coronavirus disease 2019 (COVID-19).
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            The pathogenicity of SARS-CoV-2 in hACE2 transgenic mice

            Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of coronavirus disease 2019 (COVID-19), which has become a public health emergency of international concern1. Angiotensin-converting enzyme 2 (ACE2) is the cell-entry receptor for severe acute respiratory syndrome coronavirus (SARS-CoV)2. Here we infected transgenic mice that express human ACE2 (hereafter, hACE2 mice) with SARS-CoV-2 and studied the pathogenicity of the virus. We observed weight loss as well as virus replication in the lungs of hACE2 mice infected with SARS-CoV-2. The typical histopathology was interstitial pneumonia with infiltration of considerable numbers of macrophages and lymphocytes into the alveolar interstitium, and the accumulation of macrophages in alveolar cavities. We observed viral antigens in bronchial epithelial cells, macrophages and alveolar epithelia. These phenomena were not found in wild-type mice infected with SARS-CoV-2. Notably, we have confirmed the pathogenicity of SARS-CoV-2 in hACE2 mice. This mouse model of SARS-CoV-2 infection will be valuable for evaluating antiviral therapeutic agents and vaccines, as well as understanding the pathogenesis of COVID-19.
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              SARS2-CoV-2 and Stroke in a New York Healthcare System

              Background and Purpose: With the spread of coronavirus disease 2019 (COVID-19) during the current worldwide pandemic, there is mounting evidence that patients affected by the illness may develop clinically significant coagulopathy with thromboembolic complications including ischemic stroke. However, there is limited data on the clinical characteristics, stroke mechanism, and outcomes of patients who have a stroke and COVID-19. Methods: We conducted a retrospective cohort study of consecutive patients with ischemic stroke who were hospitalized between March 15, 2020, and April 19, 2020, within a major health system in New York, the current global epicenter of the pandemic. We compared the clinical characteristics of stroke patients with a concurrent diagnosis of COVID-19 to stroke patients without COVID-19 (contemporary controls). In addition, we compared patients to a historical cohort of patients with ischemic stroke discharged from our hospital system between March 15, 2019, and April 15, 2019 (historical controls). Results: During the study period in 2020, out of 3556 hospitalized patients with diagnosis of COVID-19 infection, 32 patients (0.9%) had imaging proven ischemic stroke. Cryptogenic stroke was more common in patients with COVID-19 (65.6%) as compared to contemporary controls (30.4%, P=0.003) and historical controls (25.0%, P<0.001). When compared with contemporary controls, COVID-19 positive patients had higher admission National Institutes of Health Stroke Scale score and higher peak D-dimer levels. When compared with historical controls, COVID-19 positive patients were more likely to be younger men with elevated troponin, higher admission National Institutes of Health Stroke Scale score, and higher erythrocyte sedimentation rate. Patients with COVID-19 and stroke had significantly higher mortality than historical and contemporary controls. Conclusions: We observed a low rate of imaging-confirmed ischemic stroke in hospitalized patients with COVID-19. Most strokes were cryptogenic, possibly related to an acquired hypercoagulability, and mortality was increased. Studies are needed to determine the utility of therapeutic anticoagulation for stroke and other thrombotic event prevention in patients with COVID-19.
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                Author and article information

                Contributors
                Journal
                J Stroke Cerebrovasc Dis
                J Stroke Cerebrovasc Dis
                Journal of Stroke and Cerebrovascular Diseases
                Published by Elsevier Inc.
                1052-3057
                1532-8511
                22 July 2020
                22 July 2020
                : 105181
                Affiliations
                [a ]Central Stroke Unit, Ministry of Health of Oman, Khoula Hospital, Muscat, Oman Sr Consultant Neurologist, Head Central Stroke Unit
                [b ]Division of Neurology, Neurocritical Care, Eskisehir Osmangazi University, Turkey
                [c ]Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
                [d ]Department of Neurosurgery, Interventional Neuroradiology &Critical Care Medicine, King Fahad Hospital of the university, Imam Abdulrahman, AL Khobar Saudi Arabia
                [e ]Alexandria Faculty of Medicine Department of Neurology
                [f ]Neurology Unit, Medicine Department, College of Medicine, King Saud University Riyadh, Saudi Arabia
                [g ]Specialty Hospital, Amman, Jordan
                [h ]Neuroscience Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
                [i ]Neurology and Neurointerventional Surgery at Cleveland Clinic Abu Dhabi, UAE
                [j ]Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
                [k ]Trillium Hospital, University of Toronto at Mississauga, Mississauga ON Canada
                Author notes
                [* ]Corresponding author. 2E3 WC Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada T6G 2R7 Fax: 780-407-6020 msaqqur@ 123456ualberta.ca
                Article
                S1052-3057(20)30599-1 105181
                10.1016/j.jstrokecerebrovasdis.2020.105181
                7375312
                2b3c7cdc-1e6c-42fb-bf1a-215f3e174bf8
                © 2020 Published by Elsevier Inc.

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

                History
                : 26 May 2020
                : 9 July 2020
                : 18 July 2020
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