Stroke risk, phenotypes, and death in COVID-19

Abstract

Objectives:To investigate the hypothesis that strokes occurring in patients with COVID-19 have distinctive features, we investigated stroke risk, clinical phenotypes, and outcomes in this population.Methods:We performed a systematic search resulting in 10 studies reporting stroke frequency among COVID-19 patients, which were pooled with one unpublished series from Canada. We applied random-effects meta-analyses to estimate the proportion of stroke among COVID-19. We performed an additional systematic search for cases series of stroke in COVID-19 patients (n=125) and we pooled these data with 35 unpublished cases from Canada, USA, and Iran. We analyzed clinical characteristics and in-hospital mortality stratified into age groups (<50, 50-70, >70 years). We applied cluster analyses to identify specific clinical phenotypes and their relationship with death.Results:The proportion of COVID-19 patients with stroke (1.8%, 95%CI 0.9-3.7%) and in-hospital mortality (34.4%, 95%CI 27.2-42.4%) were exceedingly high. Mortality was 67% lower in patients <50 years-old relative to those >70 years-old (OR 0.33, 95%CI 0.12-0.94, P=0.039). Large vessel occlusion was twice as frequent (46.9%) as previously reported and was high across all age groups, even in the absence of risk factors or comorbidities. A clinical phenotype characterized by older age, a higher burden of comorbidities, and severe COVID-19 respiratory symptoms, was associated with the highest in-hospital mortality (58.6%) and a 3x higher risk of death than the rest of the cohort (OR 3.52, 95%CI 1.53-8.09, P=0.003).Conclusions:Stroke is relatively frequent among COVID-19 patients and has devastating consequences across all ages. The interplay of older age, comorbidities, and severity of COVID-19 respiratory symptoms is associated with an extremely elevated mortality.

Diagnosis-wide analysis of COVID-19 complications: an exposure-crossover study

“…Although COVID-19 has been widely reported to increase the risk of stroke, 25 this was not seen in our study. For I63 ("cerebral infarction") in our overall population, we observed an OR of 0.58 and an overall risk of 1.5% (Appendix 1, eTable 3), suggesting that while patients with COVID-19 do experience stroke at significant frequencies, a causal association with COVID-19 was not supported in this population.…”

Stroke in patients with COVID-19: Clinical and neuroimaging characteristics

“…Since male patients are more likely to experience severe SARS-CoV-2 symptoms requiring ICU admission, it is not surprising that the majority of the patients developing stroke during COVID-19 are male (62%), with a median age of 63 years [ 18 ]. Importantly, most of the cases present already important vascular risk factors (in particular, hypertension and diabetes mellitus [ 7 , 17 , 18 , 20 ]) and, therefore, in this group the infection may simply represent more a trigger than an independent cause. Nevertheless, the importance of COVID-19 as a stroke trigger should not be underestimated, considering that it was observed a 7.6-fold increase in the odds of cerebrovascular complications with SARS-CoV-2 infection as compared to influenza [ 21 ].…”

RETRACTED: Clinical and Scientific Rationale for the “MATH+” Hospital Treatment Protocol for COVID-19

“…Further, in a recent systematic review examining the incidence of stroke in COVID-19, the proportion of COVID-19 patients with stroke (1.8%, 95%CI 0.9-3.7%) was 8x higher than that reported among hospitalized patients with influenza (0.2%). 94 More concerning was the suggestion that these estimates were almost certainly a gross underestimate due to; 1) missed stroke diagnoses in those not extubated and who died, 2) the restrictions on and therefore lack of autopsies, and 3) the well-recognized drop in the number of patients with acute cerebrovascular symptoms seeking medical attention in the COVID-19 era.…”