Reperfusion Therapies for Acute Ischemic Stroke in COVID-19 Patients: A Nationwide Multi-Center Study

Abstract

(1) Background: Acute ischemic stroke (AIS) is a possible complication of the coronavirus disease 2019 (COVID-19). Safety and efficacy data on reperfusion therapies (RT)—intravenous thrombolysis and endovascular treatment (EVT)—in stroke patients with COVID-19 is lacking. (2) Methods: We performed a retrospective nationwide multi-center pair-matched analysis of COVID-19 patients with AIS who underwent RT. We included adult COVID-19 patients with AIS who were treated with RT between 16 March 2020 and 30 June 2021. All subjects were paired with non-infected controls, matched for age, sex, stroke arterial vascular territory, and RT modality. The primary outcome measure was a favorable functional outcome defined by the modified Rankin scale (mRS 0–2). (3) Results: Thirty-one subjects and thirty-one matched controls were included. The median baseline National Institutes of Health Stroke Scale (NIHSS) score was higher in the COVID-19 group (16 vs. 12, p = 0.028). Rates of ischemic changes and symptomatic intracerebral hemorrhages did not differ significantly between the two groups at 24 h after RT. The median NIHSS 24 h after reperfusion remained significantly higher in the COVID-19 group (16 vs. 5, p = 0.003). MRS 0–2 at discharge was significantly less common in COVID-19 patients (22.6% vs. 51.8%, p = 0.018). Three-month mortality was 54.8% in the COVID-19 group versus 12.9% in controls (p = 0.001). (4) Conclusion: Reperfusion therapies on AIS in COVID-19 patients appear to be safe; however, functional outcomes are significantly worse, and 3-month mortality is higher.

Sex-specific Impact of the first COVID-19 Lockdown on Age Structure and Case Acuity at Admission in a Patient Population in southwestern Germany: a retrospective comparative Study in Neuroradiology

“… 35 Alternatively, delayed hospitalisation may have contributed to the lower clinical outcomes. Jurkevičienė et al 36 found a significant difference in stroke severity, as measured by the NIHSS (National Institutes of Health Stroke Scale), between COVID-19-positive patients and the uninfected population (NIHSS with 16 vs 12 points). 36 They observed that higher NIHSS values in COVID-19-positive patients seemed to be unaffected by a timely and/or successful reperfusion result.…”

“…Jurkevičienė et al 36 found a significant difference in stroke severity, as measured by the NIHSS (National Institutes of Health Stroke Scale), between COVID-19-positive patients and the uninfected population (NIHSS with 16 vs 12 points). 36 They observed that higher NIHSS values in COVID-19-positive patients seemed to be unaffected by a timely and/or successful reperfusion result. Concorantly for this, Ntaios et al 37 demonstrated a positive relationship between worse functional outcomes after ischaemic stroke in COVID-19positive patients, which could be attributable to a delayed admission.…”

Intravenous thrombolysis and endovascular therapy for acute ischemic stroke in COVID-19: a systematic review and meta-analysis

“…Previous studies have consistently identified COVID-19 as a significant predictor of mortality in acute ischemic stroke patients, regardless of the treatment method ( 33 ). Moreover, in COVID-19 positive ischemic stroke patients who underwent reperfusion therapy, there is a higher likelihood of experiencing acute respiratory and kidney failure, septic shock, cardiac arrest, and requiring mechanical ventilation compared to COVID-19 negative patients ( 19 , 34 ). Consistently, our pooled analysis of three studies showed an increased risk of ventilation dependency in COVID-19 positive ischemic stroke patients compared to COVID-19 negative patients.…”

COVID-19 and Cerebrovascular Disease

“…Despite similar rates of ischemic injury and symptomatic intracranial hemorrhage between COVID-19-infected and -uninfected patients treated with thrombolysis, the median 24-hour NIH Stroke Scale, 3-month mortality, and good functional outcome at discharge (mRS score: 0–2) are significantly lower in COVID-19-infected patients. 53 In the SVIN COVID-19 case series, in-hospital mortality was 38.1% for ischemic stroke and 58.3% for hemorrhagic stroke, with in-hospital mortality associated with cryptogenic stroke mechanism (adjusted odds ratio [aOR]: 5.01), older age (aOR: 1.78), and lower lymphocyte count at admission (aOR: 0.58). 13 In the VIRUS study, patients with stroke during admission for COVID-19 had worse outcomes with increased ICU admission, increased requirement for ECMO or renal replacement therapy, longer hospital and ICU length of stay, and increased hospital, ICU, and 30-day mortality.…”