Etiologic Subtypes of Ischemic Stroke in SARS-CoV-2 Patients in a Cohort of New York City Hospitals

Abstract

Objective: To describe the ischemic stroke subtypes related to coronavirus disease 2019 (COVID-19) in a cohort of New York City hospitals and explore their etiopathogenesis. Background: Most neurological manifestations are non-focal, but few have reported the characteristics of ischemic strokes or investigated its pathophysiology. Methods: Data were collected prospectively April 1-April 15, 2020 from two centers in New York City to review possible ischemic stroke types seen in COVID-19-positive patients. Patient presentation, demographics, related vascular risk factors, associated laboratory markers, as well as imaging and outcomes were collected. Results: The age of patients ranged between 27 and 82 years. Approximately 81% of patients had known vascular risk factors, the commonest being hypertension (75%) followed by diabetes (50%) coronary disease or atrial fibrillation. Eight patients presented with large vessel occlusion (LVO) with median age 55 years (27-82) and all were male. Eight patients presented with non-LVO syndromes, with median age 65.5 years (59-82) and most were female (62.5%). Both groups were 50% African Americans and 37.5% South Asian. Both groups had similar D-dimer levels although other acute phase reactants/disease severity markers (Ferritin, CRP, procalcitonin) were higher in the LVO group. The LVO group also had a significantly higher mortality compared to the non-LVO group. The most common etiology was cryptogenic (6 patients) followed by small vessel occlusion (3 patients) and undetermined-unclassified (3 patients). For the remaining 4 patients, 2 were identified as cardioembolic and 2 with large artery atherosclerosis. Conclusion: COVID-19-related ischemic events can present as small vessel occlusions, branch emboli or large vessel occlusions. The most common etiology is cryptogenic. Patients with LVO syndromes tend to be younger, male and may have elevated acute inflammatory markers.

Clinical and Radiological Characteristics of Acute Cerebrovascular Diseases Among Egyptian Patients With COVID-19 in Upper Egypt

“…In total, 76.2% of COVID-19 ischemic stroke patients had preexisting risk factors. Consistent with our findings, Tiwari et al (20) also reported that 81% of COVID-19 patients presenting with ischemic stroke had previous known vascular risk factors. COVID-19 cases are also more commonly associated with diabetes mellitus (DM), arterial hypertension (AH), and atrial fibrillation (AF) (16).…”

Incidence, Characteristics and Outcomes of Large Vessel Stroke in COVID-19 Cohort: An International Multicenter Study

“…These LVOs occur in a much younger age group than would otherwise be expected, and in the USA, they also seem to affect African Americans disproportionately as compared to historical controls. 4 , 12-14 We believe that the pathophysiology of COVID-19 likely leads to this higher incidence of LVO in AIS. Another possibility is that those with non-LVO strokes are not presenting to hospitals for evaluation.…”

Three-month functional outcomes following endovascular thrombectomy during the first wave of the COVID-19 pandemic: a Canadian single-center cohort study

“… 14 15 We also did not document a decrease in acute stroke evaluation and treatment volumes. 15–18 These differences likely highlight the local heterogeneity of COVID-19 epidemiology and that the impact of the pandemic is likely to differ accordingly.…”