Impact of COVID-19 on Future Ischemic Stroke Incidence

Elfasi, Aisha; Echevarria, Franklin D.; Rodríguez, Robert; Casul, Yoram A. Roman; Khanna, Anna; Mankowski, Robert T.; Simpkins, Alexis N

doi:10.1016/j.ensci.2021.100325

Cited by 7 publications

(6 citation statements)

References 31 publications

(52 reference statements)

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“…Some consensus is emerging that the impact of COVID-19 is destined to influence stroke research and epidemiology even beyond the first impetuous waves of the ongoing pandemic ( 29 , 30 ). So, additional data on stroke occurrence in COVID-19 and on the patients at risk of cerebrovascular complications are extremely important.…”

Section: Introductionmentioning

confidence: 99%

Ischemic strokes in COVID-19: risk factors, obesity paradox, and distinction between trigger and causal association

Janes,

Sozio,

Gigli

et al. 2023

Front. Neurol.

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Background and purposeStroke has been described as a COVID-19 complication. However, its occurrence rate, risk factors, and causal relationships are still not well established.MethodsWe describe the characteristics of confirmed COVID-19-related strokes among all cases of COVID-19 hospitalized in our health network, from November 1, 2020 to April 30, 2021. Risk factor analysis has been conducted for ischemic stroke (IS), which represents 92% of all confirmed cases of Covid-19-related strokes, and a “causal attribution to infection” classification is provided.ResultsIn all, 62/4105 hospitalized COVID-19 patients had an acute stroke (1.51%). Severe COVID-19 (OR 2.27—CI 1.06–4.77; p = 0.032), atrial fibrillation (OR 3.65—CI 1.63–7.98; p = 0.001), and ischemic heart disease (OR 4.590—CI 1.714–12.137; p = 0.002) proved to be independent risk factors for IS, while obesity was a protective factor (OR 0.90—CI 0.82–0.97; p = 0.012). COVID-19 had a causal role in 32.1% of IS cases, was a relevant cofactor in 28.6% of cases of IS, and was a possible trigger in 39.3% of events.ConclusionOur stroke occurrence rate is consistent with other population-based reports (range 0.34–2.7%). Prespecified peculiar clinical and radiological features allow the distinction between “IS caused by COVID-19” and “IS triggered by COVID-19.” Clinical history of vascular diseases and risk factors is crucial in determining the risk of IS in patients with COVID-19. However, the protective effect of a BMI > 30 kg/m2 seems to suggest an obesity paradox.

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Section: Introductionmentioning

confidence: 99%

Ischemic strokes in COVID-19: risk factors, obesity paradox, and distinction between trigger and causal association

Janes,

Sozio,

Gigli

et al. 2023

Front. Neurol.

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“…[1][2][3][4][5] Hypercoagulability, inflammation, cardiac dysfunction, and endothelial inflammation that occur during the infectious phase can lead to thrombotic events and thus cerebral ischemia. 6 Reported risks of stroke in COVID-19 have varied substantially across studies. 7 Most studies have focused on AIS incidence in patients diagnosed during or upon hospitalization.…”

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confidence: 99%

Risk of Acute Ischemic Stroke in Patients 65 and Older Is Early After COVID-19 Diagnosis

Simpkins

Lekoubou

2022

Neurology

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Associated acute and long-term medical complications of COVID-19 beyond respiratory illness include acute ischemic stroke (AIS). [1][2][3][4][5] Hypercoagulability, inflammation, cardiac dysfunction, and endothelial inflammation that occur during the infectious phase can lead to thrombotic events and thus cerebral ischemia. 6 Reported risks of stroke in COVID-19 have varied substantially across studies. 7 Most studies have focused on AIS incidence in patients diagnosed during or upon hospitalization. Unlike any other infectious disease in modern times and as a result of the need to trace and monitor for outbreaks to prevent the spread of COVID-19, a very large number of patients have been screened for COVID-19 at the time of hospital admission. This screening has identified both asymptomatic and symptomatic individuals with COVID-19, thus making it more difficult to determine whether and in whom COVID-19 may increase the risk of AIS and whether the association is true or incidental. In this issue of Neurology ® , Yang et al. 8 evaluated the estimated incidence rate ratio of AIS after COVID-19 infection in a known high-risk group-patients older than 65-and determined the time frame of highest risk of AIS associated with COVID-19 within this population. 8 The authors used inpatient and outpatient fee-for-service Medicare claims to identify 37,379 patients with COVID-19 and AIS between January 2019 and February 2021. 8 A pre-COVID diagnosis phase was used to account for unknown possible inoculation times and the time frame from COVID-19 billing diagnosis to stroke billing diagnosis code of up to 28 days was evaluated. 8 Applying the self-controlled case series method, the authors found that the incidence rate ratios (IRRs) were highest within 3 days of diagnosis of COVID-19, with an odds ratio of 10.3 (95% confidence interval 9.86-10.8), and that the estimated IRR was higher in those between ages 65 and 74 without a prior history of stroke. 8 By contrast, the association between stroke and COVID-19 was weaker 15-28 days after the initial diagnosis, suggesting that AIS rarely manifests as a long-term COVID-19 sequela in elderly patients. 8 Major strengths of the study are the inclusion of COVID-19 cases diagnosed both in outpatient and inpatient settings, the inclusion of a large number of patients from minority groups, and the use of robust statistical methods, such as the self-case-controlled case study, which has the advantage of implicit control for all fixed confounding effects. The authors made a great effort to verify that all assumptions were not violated, albeit with some modifications. They solidified the findings of their study by performing a number of sensitivity analyses.Interpretation of the study results should consider potential limitations, which were described by Yang et al. 8 These limitations stem primarily from the retrospective nature of the analysis and the use of administrative claims to identify cases of COVID-19 and AIS. As the Medicare data are updated monthly, cases of COVID-19 and death...

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“…What we do know is that patients at the highest risk of severe COVID-19 and stroke are those who already have cardiovascular risk factors. Therefore, despite the many challenges of managing primary and secondary stroke prevention during the pandemic, 3 the imperative to prioritize stroke prevention for those at risk has never been greater. 9,10 Fortunately, the meta-analysis results reported by Stefano et al offer reassurance that the frequency of postvaccine AIS is generally lower than the frequency of post-COVID AIS.…”

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confidence: 99%

“…2 Patients with COVID-19, particularly severe respiratory manifestations of the disease, were found early on to have evidence of a prothrombotic and proinflammatory state along with a propensity for cardiac dysfunction and stroke. 3 Stroke incidence in patients with COVID-19 was particularly higher in those with cardiovascular risk factors but could also occur in younger patients and those without preexisting traditional cardiovascular risk factors. 2 After the advent of COVID-19 vaccines, there emerged similarly concerning case reports of thrombotic events such as acute ischemic stroke (AIS) and cerebral venous thrombosis post–COVID-19 vaccine exposure, potentially resulting from thrombotic thrombocytopenia syndrome (TTS), cardiac dysfunction, or an excess of the vaccine-induced immune response.…”

mentioning

confidence: 99%