Impact of SARS-CoV-2 on reperfusion therapies for acute ischemic stroke in Lombardy, Italy: the STROKOVID network

Abstract

Whether and how SARS-CoV-2 outbreak affected in-hospital acute stroke care system is still matter of debate. In the setting of the STROKOVID network, a collaborative project between the ten centers designed as hubs for the treatment of acute stroke during SARS-CoV-2 outbreak in Lombardy, Italy, we retrospectively compared clinical features and process measures of patients with confirmed infection (COVID-19) and non-infected patients (non-COVID-19) who underwent reperfusion therapies for acute ischemic stroke. Between March 8 and April 30, 2020, 296 consecutive patients [median age, 74 years (interquartile range (IQR), 62–80.75); males, 154 (52.0%); 34 (11.5%) COVID-19] qualified for the analysis. Time from symptoms onset to treatment was longer in the COVID-19 group [230 (IQR 200.5–270) minutes vs. 190 (IQR 150–245) minutes; p = 0.007], especially in the first half of the study period. Patients with COVID-19 who underwent endovascular thrombectomy had more frequently absent collaterals or collaterals filling ≤ 50% of the occluded territory (50.0% vs. 16.6%; OR 5.05; 95% CI 1.82–13.80) and a lower rate of good/complete recanalization of the primary arterial occlusive lesion (55.6% vs. 81.0%; OR 0.29; 95% CI 0.10–0.80). Post-procedural intracranial hemorrhages were more frequent (35.3% vs. 19.5%; OR 2.24; 95% CI 1.04–4.83) and outcome was worse among COVID-19 patients (in-hospital death, 38.2% vs. 8.8%; OR 6.43; 95% CI 2.85–14.50). Our findings showed longer delays in the intra-hospital management of acute ischemic stroke in COVID-19 patients, especially in the early phase of the outbreak, that likely impacted patients outcome and should be the target of future interventions. Supplementary Information The online version contains supplementary material available at 10.1007/s00415-021-10497-7.

Safety and Outcome of Revascularization Treatment in Patients With Acute Ischemic Stroke and COVID-19

“…In line with our results, 2 previous small studies indicated an increased risk of bleeding complications after IVT and EVT in patients with COVID-19. 13,15 Given the increased risk of SICH in the IVT group, we also investigated whether bridging was associated with a higher risk of intracranial hemorrhage than DMT. In this subgroup analysis, patients undergoing DMT had a nonsignificant lower risk of hemorrhagic complications in comparison with bridging, despite a numerically lower risk.…”

“…Regarding larger arteries and their recanalization, previous studies have reported inconsistent data concerning EVT revascularization results in patients with COVID-19, with successful recanalization ranging from 56% to 100% 9,[12][13][14]17,19 and first pass effect from 0% to 35.6%. 12,18 The procoagulant and proinflammatory states associated with COVID-19-related endothelial dysfunction 2 likely contribute to a higher clot burden and more difficult recanalization.…”

“…Case series and cohort studies have shown the feasibility of revascularization treatments in patients with AIS and COVID-19. Some of these studies documented lower recanalization rates 12,13 and higher rates of intracerebral hemorrhage 13 in patients with COVID-19 receiving EVT, but these studies were limited by the absence of a contemporary control group of non-COVID-19 patients, small sample size, or lack of 3-month outcome assessment. For these reasons, the question of the safety and efficacy of revascularization treatments in acute stroke patients with COVID-19 remains unanswered.…”

“…For these reasons, the question of the safety and efficacy of revascularization treatments in acute stroke patients with COVID-19 remains unanswered. [12][13][14][15][16][17][18] In this context, our aim was to assess the safety and outcome of revascularization treatment in patients with AIS and COVID-19 in a large, multicenter, international cohort by comparison with a contemporary control group of non-COVID-19 patients with AIS from the same centers.…”

Efficacy and safety of recanalization therapy for acute ischemic stroke with COVID-19: A systematic review and meta-analysis

“…Moreover, the time from door to treatment showed no significant difference. According to some studies, the time to treatment was significantly prolonged in COVID-19 positive patients with AIS ( 25 , 28 ). Such a delay may be due to: the shortage of stroke team members, deceleration of evaluations, adherence to traffic restriction, and practice of preventive measures ( 33 ).…”