In-hospital and out-of-hospital stroke in patients with COVID-19: two different diseases?

Abstract

Background Ischemic stroke is a known complication of COVID-19. It may have a different pathogenesis and worse outcome compared to stroke in patients without COVID-19. Furthermore, patients with COVID-19 and out-of-hospital stroke onset might have different characteristics compared to patients with COVID-19 and in-hospital stroke onset. The aim of our study was to analyze the characteristics of patients with stroke with and without COVID-19 and of patients with COVID-19 with in-hospital and out-of-hospital stroke. Methods We performed a retrospective study of all consecutive patients admitted to our hospital with ischemic stroke between October 2020 and February 2021. We compared functional outcome, lab test, demographic, and clinical characteristics between patients with or without COVID-19. We performed a sub-analysis comparing patients with COVID-19 and in-hospital and out-of-hospital stroke onset. Results We included in the final analysis 137 patients of whom 26 with COVID-19. Half (13) had out-of-hospital stroke and half in-hospital stroke onset. Overall, patients with COVID-19 had higher mortality compared to the control group (27% vs 9%, p : 0.02), and non-significantly lower rate of good functional outcome (50% vs 63%, p : 0.22). Patients with COVID-19 and out-of-hospital stroke had higher rate of good functional outcome (69% vs 39%, p : 0.05), higher lymphocyte count, and lower D-dimer compared with patients with in-hospital stroke onset. Conclusions Patients with stroke and COVID-19 had higher mortality compared to patients without COVID-19. Among patients with COVID-19 those with out-of-hospital stroke had better outcome and fewer blood test abnormalities compared to patients with in-hospital stroke. Supplementary Information The online version contains supplementary material available at 10.1007/s10072-021-05807-w.

Association between SARS-CoV-2 Seropositivity and Severity of Out-of-Hospital Acute Ischemic Stroke Following Asymptomatic/Mild COVID-19 in Children

“…Most pediatric studies investigating COVID-19-related AIS have focused on the acute infectious phase, 23 25 with delayed AIS during the postinfectious phase being less commonly described. 10 11 Our study showed that AIS is associated with prior SARS-CoV-2 infection, which adds to the growing evidence of delayed post-COVID AIS. Similarly, several reports described children developing AIS 3 to 8 weeks after resolution of SARS-CoV-2 infection.…”

“…Indeed, several studies showed an increased risk of AIS in patients with higher COVID-19 severity. 26 In the same vein, Ciolli et al 10 and Katz et al 11 reported that patients with in-hospital AIS related to severe COVID-19 had worse clinical outcomes and higher levels of inflammatory and procoagulant markers than patients with out-of-hospital AIS and asymptomatic or mild COVID-19. However, several studies have shown that AIS may occur even in patients with no or minimal symptoms of SARS-CoV-2 infection.…”

“…3 High D-dimer level is an independent risk factor for the occurrence, severity, and outcome of AIS in both adults and children with COVID-19. 1,3,10,12,29 Importantly, D-dimer as well as von Willebrand factor antigen and factor VIII, may remain elevated for > 6 months following SARS-CoV-2 infection. 33 From a clinical perspective, monitoring Ddimer levels could help predict the risk of AIS and guide thromboprophylaxis in patients with COVID-19.…”

“…However, our findings are commensurate with numerous adult studies, showing that COVID-19 is associated with higher severity and worse outcome measures of AIS. 10,35,36 Notably, many of these studies on the severity of COVID-19associated stroke report on the early COVID-19 pandemic time when the stroke care resources and access were markedly disrupted 10,27 ; this might confound the results of studies that compared COVID-19-related AIS patients with historical AIS control from the pre-COVID-19 pandemic era. Furthermore, most prior studies involved AIS in critically ill patients with COVID-19; these patients may have a higher NIHSS since the associated encephalopathy, intubation, and sedation may impede patients' interaction with the exam.…”

“…9 Moreover, most studies on COVID-19-related AIS have focused on adults with coexistent predisposing factors for stroke who were hospitalized during the acute infectious phase. 10,11 Since most children with SARS-CoV-2 infection have no or mild symptoms and do not require hospitalization, investigating the association between SARS-CoV-2 infection and AIS among severely ill hospitalized children may overestimate the relationship. 1,4 Additionally, the presence of other risk factors for stroke may confound the association between COVID-19 and AIS.…”