COVID-19 Infection Linked to Ischemic, Hemorrhagic Spinal Strokes

COVID-19 infection may be associated with both ischemic and hemorrhagic spinal strokes, with distinct clinical characteristics, underlying mechanisms, and outcomes, according to findings published in the Journal of Clinical Neuroscience.

Although neurologic complications of SARS-CoV-2 infection, such as cerebral stroke, encephalitis, and myelitis, are well documented, the relationship between COVID-19 and spinal vascular events remains less understood. Researchers conducted a systematic review to evaluate published data describing hemorrhagic and ischemic spinal strokes linked to COVID-19 infection, focusing on their clinical presentations, neuroimaging features, management strategies, and outcomes.

The investigators performed a comprehensive search of PubMed, Scopus, Embase, Web of Science, and Google Scholar for all relevant articles published through May 2024. Eligible studies included interventional or observational designs (including case series and case reports) that reported COVID-19-related spinal ischemia or hemorrhage.

Any new neurological manifestation should be thoroughly investigated by neurological examination and neuroaxis imaging, simultaneously to prevent ongoing neural damage.

A total of 8 datasets describing spinal cord ischemia and 11 describing spinal hemorrhage were included. Mean patient age was 47 years for ischemic and 52 years for hemorrhagic events. Among those with ischemia, 62% had severe COVID-19 pneumonia, and 75% demonstrated coagulation abnormalities, suggesting a hypercoagulable state. In contrast, patients with hemorrhagic spinal stroke typically presented with mild to moderate COVID-19 infection and had normal coagulation profiles.

Magnetic resonance imaging revealed that the anterior spinal artery and central ischemia patterns were most commonly affected in ischemic lesions, while epidural (54%) and intramedullary hematomas (36%) predominated in hemorrhagic cases, most frequently in the cervical and thoracic regions. The median interval between COVID-19 onset and neurological symptoms ranged from approximately 13 days (ischemia) to 17 days (hemorrhage).

Treatment approaches differed by stroke type. All patients with spinal cord ischemia received conservative management, including anticoagulation, corticosteroids, and supportive care. In contrast, among those with hemorrhagic lesions, 4 underwent surgical decompression via laminectomy, 6 received conservative therapy, and 1 required combined medical and surgical treatment.

Post-intervention outcomes were generally poor in ischemic cases but more favorable following hemorrhage, particularly among those undergoing early decompression. No mortality was reported in either group during follow-up, which ranged from 2 weeks to 1 year.

The authors proposed that coagulopathy and endothelial dysfunction may underlie ischemic lesions, whereas direct viral neurotoxicity, vascular inflammation, or blood-spine barrier disruption may contribute to hemorrhagic presentations. Although the mechanisms may overlap, the different ways coagulation pathways are involved highlight the complexity of COVID-19’s neurological effects.

Study limitations include reliance on case reports with small sample sizes due to the rarity of the disease.

“Any new neurological manifestation should be thoroughly investigated by neurological examination and neuroaxis imaging, simultaneously to prevent ongoing neural damage,” the study authors concluded. “Early medical and neurosurgical intervention is the key to achieving the best clinical outcome.”