Characteristics and Outcomes in Patients With COVID-19 and Acute Ischemic Stroke

Abstract

Recent case-series of small size implied a pathophysiological association between coronavirus disease 2019 (COVID-19) and severe large-vessel acute ischemic stroke. Given that severe strokes are typically associated with poor prognosis and can be very efficiently treated with recanalization techniques, confirmation of this putative association is urgently warranted in a large representative patient cohort to alert stroke clinicians, and inform pre- and in-hospital acute stroke patient pathways. We pooled all consecutive patients hospitalized with laboratory-confirmed COVID-19 and acute ischemic stroke in 28 sites from 16 countries. To assess whether stroke severity and outcomes (assessed at discharge or at the latest assessment for those patients still hospitalized) in patients with acute ischemic stroke are different between patients with COVID-19 and non-COVID-19, we performed 1:1 propensity score matching analyses of our COVID-19 patients with non-COVID-19 patients registered in the Acute Stroke Registry and Analysis of Lausanne Registry between 2003 and 2019. Between January 27, 2020, and May 19, 2020, 174 patients (median age 71.2 years; 37.9% females) with COVID-19 and acute ischemic stroke were hospitalized (median of 12 patients per site). The median National Institutes of Health Stroke Scale was 10 (interquartile range [IQR], 4–18). In the 1:1 matched sample of 336 patients with COVID-19 and non-COVID-19, the median National Institutes of Health Stroke Scale was higher in patients with COVID-19 (10 [IQR, 4–18] versus 6 [IQR, 3–14]), P =0.03; (odds ratio, 1.69 [95% CI, 1.08–2.65] for higher National Institutes of Health Stroke Scale score). There were 48 (27.6%) deaths, of which 22 were attributed to COVID-19 and 26 to stroke. Among 96 survivors with available information about disability status, 49 (51%) had severe disability at discharge. In the propensity score-matched population (n=330), patients with COVID-19 had higher risk for severe disability (median mRS 4 [IQR, 2–6] versus 2 [IQR, 1–4], P <0.001) and death (odds ratio, 4.3 [95% CI, 2.22–8.30]) compared with patients without COVID-19. Our findings suggest that COVID-19 associated ischemic strokes are more severe with worse functional outcome and higher mortality than non-COVID-19 ischemic strokes.

Stroke risk, phenotypes, and death in COVID-19

“…In-hospital mortality in this cohort of COVID-19 patients, which was mainly comprised of cases with ischemic stroke, was higher than recently reported in a cohort of COVID-19 patients with acute ischemic stroke (27.6%). 20 It was also higher than reported 30-day case fatality rates for ischemic stroke, ranging from 9 to 19% 21 or in-hospital mortality of stroke patients admitted to intensive care units, ranging between 14.7 to 21.9%. 22,23 It must be noted that the limited testing in several countries may have led to inflation of death rates.…”

Insights Into Neuroimaging Findings of Patients With Coronavirus Disease 2019 Presenting With Neurological Manifestations

“…Results of another study revealed that patients with COVID-19-related ischemic stroke had worse functional outcome and higher mortality than patients with ischemic stroke and without COVID-19 (48). However, no study has compared the frequency or outcome of neuroimaging findings other than stroke between COVID-19 and non-COVID-19 patients.…”

Characteristics and outcomes of COVID-19 associated stroke: a UK multicentre case-control study

“…Howeverthe virus responsible for this illness, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), mayinfluence the presentation of ischaemic stroke 2 , although this conclusion is controversial 3 because of a l a c k o f h i g h quality evidence. In particular, the largest studies havecompared patients with COVID-19-associated stroke with historical controls 4,5 , whose strokes tend to be milder than those seen in contemporaneous controls 6,7 , resulting in a bias towards overestimating the influence of COVID-19 on stroke severity and any other parameters correlated with severity.…”

“…Ourobjectives were to determine whether COVID-19 is associated with:a different demographic group; a higher proportion of ischaemic strokes; higher D-dimer values 7 in ischaemic strokes, as may be expec t e d o f a SARS-CoV-2-related hypercoagulable state 8 ; a different distribution of stroke mechanisms, possibly with a predominance of large vessel occlusions 9,10 ; more severe strokes with worse outcomes, including a higher inpatient mortality 4,7 ; a higher rate of early recurrence of stroke; and a delay between the onset of symptoms of infection and of stroke 7 . To address these objectives we analyseddata from a multicentre case-control study of strokes in patients admitted to 13 stroke services in England and Scotland during the 2020 COVID-19 pandemic.…”