SARS-CoV-2 and Stroke in a New York Healthcare System

Abstract

Background and Purpose: With the spread of coronavirus disease 2019 (COVID-19) during the current worldwide pandemic, there is mounting evidence that patients affected by the illness may develop clinically significant coagulopathy with thromboembolic complications including ischemic stroke. However, there is limited data on the clinical characteristics, stroke mechanism, and outcomes of patients who have a stroke and COVID-19. Methods: We conducted a retrospective cohort study of consecutive patients with ischemic stroke who were hospitalized between March 15, 2020, and April 19, 2020, within a major health system in New York, the current global epicenter of the pandemic. We compared the clinical characteristics of stroke patients with a concurrent diagnosis of COVID-19 to stroke patients without COVID-19 (contemporary controls). In addition, we compared patients to a historical cohort of patients with ischemic stroke discharged from our hospital system between March 15, 2019, and April 15, 2019 (historical controls). Results: During the study period in 2020, out of 3556 hospitalized patients with diagnosis of COVID-19 infection, 32 patients (0.9%) had imaging proven ischemic stroke. Cryptogenic stroke was more common in patients with COVID-19 (65.6%) as compared to contemporary controls (30.4%, P =0.003) and historical controls (25.0%, P <0.001). When compared with contemporary controls, COVID-19 positive patients had higher admission National Institutes of Health Stroke Scale score and higher peak D-dimer levels. When compared with historical controls, COVID-19 positive patients were more likely to be younger men with elevated troponin, higher admission National Institutes of Health Stroke Scale score, and higher erythrocyte sedimentation rate. Patients with COVID-19 and stroke had significantly higher mortality than historical and contemporary controls. Conclusions: We observed a low rate of imaging-confirmed ischemic stroke in hospitalized patients with COVID-19. Most strokes were cryptogenic, possibly related to an acquired hypercoagulability, and mortality was increased. Studies are needed to determine the utility of therapeutic anticoagulation for stroke and other thrombotic event prevention in patients with COVID-19.

Mechanisms of Stroke in COVID-19

“…They recommended monitoring of prothrombin time, Ddimer, platelet count, and fibrinogen and prophylactic anticoagulation with low-molecular weight (LMW) heparin in all patients with COVID-19. Yaghi et al [6] reported that high levels of D-dimer were more common among patients with stroke and COVID-19 and suggested that hypercoagulability may underly much of stroke in this disease. They indicated that a randomized trial of therapeutic anticoagulation versus prophylactic anticoagulation is underway.…”

“…An early report from China and the previous report from Singapore on SARS-CoV-1 infection developing stroke during that 2002-2003 outbreak demonstrated cardioembolic mechanisms in 36 and 60% of their cases, respectively [43]. Yaghi et al [6] reported that stroke patients with COVID-19 were more likely to be young men with elevated troponin levels compared with historical controls.…”

“…COVID-19-related hemorrhagic strokes are far less common than ischemic strokes, but a few cases have been reported [2][3][4][5]. The median time from diagnosis to ischemic stroke in one small single-center study was 10 days (IQR: 1-19) [6]. Patients with COVID-19 who had strokes were more likely to be older and have hypertension and higher levels of D-dimer [1].…”

“…In a retrospective review of 32 patients with COVID-19, 65.6% had cryptogenic stroke compared with 30.4% of contemporary controls (p = 0.003) and 25% of historical controls (p < 0.001). The next most frequent stroke category was cardioembolism (22%) [6]. It should be noted that diagnostic investigations could not be completed in some patients with COVID-19 and this might have contributed to the high rate of cryptogenic strokes.…”

The Incidence of SARS-COV-2 Manifestations in the Central Nervous System: A Rapid Review and Meta-Analysis

“…The percentage of patients with previous arterial hypertension was similar in both studies. In regard to age, a case series of ve COVID-19 ischemic stroke patients with a lower age (ranged between 33 and 49 years) remains outstanding[38].In comparison to our meta-analysis, Yaghi et al described a lower rate of ischemic strokes in patients with COVID-19 infections in New York City with a follow-up of up to four weeks[39]. Referring to 3,556 hospitalized COVID-19 patients, the researchers reported 32 patients with COVID-19 that suffered from an ischemic stroke.…”