Risk, clinical course and outcome of ischemic stroke in patients hospitalized with COVID-19: a multicenter cohort study

Abstract

Background and purpose The frequency of ischemic stroke in patients with COVID-19 varies in the current literature, and risk factors are unknown. We assessed the incidence, risk factors, and outcomes of acute ischemic stroke in hospitalized patients with COVID-19. Methods We included patients with a laboratory confirmed SARS-CoV-2 infection admitted in 16 hospitals participating in the international CAPACITY-COVID registry between March 1st and August 1st, 2020. Patients were screened for the occurrence of acute ischemic stroke. We calculated the cumulative incidence of ischemic stroke and compared risk factors, cardiovascular complications, and in-hospital mortality in patients with and without ischemic stroke. Results We included 2147 patients with COVID-19, of whom 586 (27.3%) needed treatment at an intensive care unit (ICU). Thirty-eight patients (1.8%) had an ischemic stroke. Patients with stroke were older, but did not differ in sex or cardiovascular risk factors. Median time between onset of COVID-19 symptoms and diagnosis of stroke was two weeks. The incidence of ischemic stroke was higher among patients who were treated at an ICU (16/586; 2.7% versus 22/1561; 1.4%; p=0.039). Pulmonary embolism was more common in patients with (8/38; 21.1%) than in those without stroke (160/2109; 7.6%; adjusted RR: 2.08; 95%CI:1.52-2.84). Twenty-seven patients with ischemic stroke (71.1%) died during admission or were functional dependent at discharge and in-hospital mortality. Patients with ischemic stroke were at a higher risk of in-hospital mortality (adjusted RR 1.56; 95%CI:1.13-2.15) than patients without stroke. Conclusions In this multicenter cohort study, the cumulative incidence of acute ischemic stroke in hospitalized patients with COVID-19 was approximately 2%, with a higher risk in patients treated at an ICU. The majority of stroke patients had a poor outcome. The association between ischemic stroke and pulmonary embolism warrants further investigation.

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

“…Additionally, AIS patients with COVID-19 infection had a considerably longer length of hospital stay than those without COVID-19 infection. The previous report showed that ischemic stroke is more severe in patients with COVID-19, with a higher rate of patients who needed treatment in an ICU ( 31 ). In addition, patients with COVID-19 infection were more likely to have pneumonia, respiratory failure, acute kidney injury, septic shock, cardiac arrest, and require intubation or mechanical ventilation ( 26 ).…”

Ischemic strokes in COVID-19: risk factors, obesity paradox, and distinction between trigger and causal association

“…Acute ischemic stroke (AIS) is largely the most common and studied stroke subtype in COVID-19 patients. The most relevant features that have been highlighted in the literature are a higher proportion of large artery disease (LAD) (3) and multifocality (4,5), a younger age at onset (6), a higher rate of concurrent systemic thrombotic events (7), resistance to prophylactic and even therapeutic antithrombotic therapy (8-10), a higher NIHSS at onset, and a worse functional outcome (11). A lower number of reports described intracerebral hemorrhage (ICH) related to COVID-19 infection, pointing out the more inhomogeneous pattern of presentation at neuroimaging, the higher tendency to early hematoma expansion (12), the high mortality rate, COVID-19 severity as a risk factor, and the role of therapeutic anticoagulation as an independent risk factor for ICH (13,14).…”