Cerebrovascular events and outcomes in hospitalized patients with COVID-19: The SVIN COVID-19 Multinational Registry

Abstract

Background Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) has been associated with a significant risk of thrombotic events in critically ill patients. Aim To summarize the findings of a multinational observational cohort of patients with SARS-CoV-2 and cerebrovascular disease. Methods Retrospective observational cohort of consecutive adults evaluated in the emergency department and/or admitted with coronavirus disease 2019 (COVID-19) across 31 hospitals in four countries (1 February 2020–16 June 2020). The primary outcome was the incidence rate of cerebrovascular events, inclusive of acute ischemic stroke, intracranial hemorrhages (ICH), and cortical vein and/or sinus thrombosis (CVST). Results Of the 14,483 patients with laboratory-confirmed SARS-CoV-2, 172 were diagnosed with an acute cerebrovascular event (1.13% of cohort; 1130/100,000 patients, 95%CI 970–1320/100,000), 68/171 (40.5%) were female and 96/172 (55.8%) were between the ages 60 and 79 years. Of these, 156 had acute ischemic stroke (1.08%; 1080/100,000 95%CI 920–1260/100,000), 28 ICH (0.19%; 190/100,000 95%CI 130–280/100,000), and 3 with CVST (0.02%; 20/100,000, 95%CI 4–60/100,000). The in-hospital mortality rate for SARS-CoV-2-associated stroke was 38.1% and for ICH 58.3%. After adjusting for clustering by site and age, baseline stroke severity, and all predictors of in-hospital mortality found in univariate regression (p < 0.1: male sex, tobacco use, arrival by emergency medical services, lower platelet and lymphocyte counts, and intracranial occlusion), cryptogenic stroke mechanism (aOR 5.01, 95%CI 1.63–15.44, p < 0.01), older age (aOR 1.78, 95%CI 1.07–2.94, p = 0.03), and lower lymphocyte count on admission (aOR 0.58, 95%CI 0.34–0.98, p = 0.04) were the only independent predictors of mortality among patients with stroke and COVID-19. Conclusions COVID-19 is associated with a small but significant risk of clinically relevant cerebrovascular events, particularly ischemic stroke. The mortality rate is high for COVID-19-associated cerebrovascular complications; therefore, aggressive monitoring and early intervention should be pursued to mitigate poor outcomes.

The Impact of SARS‐CoV‐2 on Stroke Epidemiology and Care: A Meta‐Analysis

“…Finally, we identified 18 observational cohort studies including a total of 67,845 patients who qualified our predefined inclusion and exclusion criteria (Supplementary Table S3). 18–35 Nine of the included studies reported imaging confirmation of reported cerebrovascular events 21–24,26,27,33–35 …”

Ischemic stroke in COVID-19-positive patients: an overview of SARS-CoV-2 and thrombotic mechanisms for the neurointerventionalist

“…4 Reported rates of cerebrovascular events ranged from 0.19% to 5.4% in one population study, with the rate of cerebrovascular events and acute ischemic stroke decreasing as the number of patients treated for COVID-19 increased. 26 Other reports from Wuhan, China described a higher risk of poor outcomes associated with a history of stroke among infected patients, with increased rates of in-hospital mortality. 27 In the USA, Yaghi et al provided the first study examining the rate of stroke among COVID-19-infected patients in New York and found that 0.9% of all patients hospitalized with COVID-19 experienced ischemic stroke, with 63.6% of these patients dying during their hospitalization.…”

“…1 This increase in proportion of cryptogenic stroke as a mechanism of acute ischemic stroke was also noted by the largest population study performed to date, where cryptogenic stroke was also found to be the only independent predictor of mortality. 26 It was proposed that COVID-19-associated cryptogenic stroke represented a unique stroke mechanism associated with a higher probability of early mortality. 26 Other initial studies from New York, Italy, and Barcelona have described patients with COVID-19 experiencing both stroke and large vessel occlusion (LVO) at a younger age than is usually seen.…”

“…26 It was proposed that COVID-19-associated cryptogenic stroke represented a unique stroke mechanism associated with a higher probability of early mortality. 26 Other initial studies from New York, Italy, and Barcelona have described patients with COVID-19 experiencing both stroke and large vessel occlusion (LVO) at a younger age than is usually seen. 3 28-30 Furthermore, three studies have found COVID-19 infection to be an independent risk factor for both acute ischemic stroke and LVO.…”

COVID-19 and cerebrovascular diseases: a comprehensive overview

“…47 Regarding the IS subtype according to Trial of ORG 10172 in Acute Stroke Treatment classification, COVID-19 was reported to be associated with a higher incidence of cryptogenic stroke. 47,48,56,60 According to a retrospective cohort study performed in a major health system in New York, cryptogenic stroke was twice more prevalent in COVID-19 positive patients compared with both a contemporary control group consisting of COVID-19 negative patients and a historical control group derived from patients treated in the same period in 2019. 48 The presented high rates of cryptogenic stroke could further alarm clinicians regarding hypercoagulability state, in situ arterial thrombosis from endothelitis and occult cardioembolism or paradoxical embolism, both of which require deeper investigation and consideration of therapeutic anticoagulation.…”