Thrombolysis and bridging therapy in patients with acute ischaemic stroke and Covid‐19

Abstract

Background and purpose Comorbidity of acute ischaemic stroke with Covid‐19 is a challenging condition, potentially influencing the decision of whether to administer intravenous thrombolysis (IVT). We aimed to assess the 1‐month outcome in ischaemic stroke patients with Covid‐19 infection who received IVT alone or before thrombectomy (bridging therapy). Methods As a collaboration initiative promoted by the Italian Stroke Organization, all Italian stroke units (n = 190) were contacted and invited to participate in data collection on stroke patients with Covid‐19 who received IVT. Results Seventy‐five invited centers agreed to participate. Thirty patients received IVT alone and 17 received bridging therapy between 21 February 2020 and 30 April 2020 in 20 centers (n = 18, Northern Italy; n = 2, Central Italy). At 1 month, 14 (30.4%) patients died and 20 (62.5%) survivors had a modified Rankin Scale (mRS) score of 3 to 5. At 24 to 36 hours, asymptomatic intracerebral hemorrhage (ICH) was reported in eight (17.4%) patients and symptomatic ICH (sICH) in two (4.3%) patients. Causes of death were severe ischaemic stroke (n = 8), a new ischaemic stroke (n = 2), acute respiratory failure (n = 1), acute renal failure (n = 1), acute myocardial infarction (n = 1), and endocarditis (n = 1). In survivors with a 1‐month mRS score of 3 to 5, baseline glucose level was higher, whereas endovascular procedure time in cases of bridging therapy was longer. Baseline National Institutes of Health Stroke Scale glucose and creatinine levels were higher in patients who died. Conclusions Intravenous thrombolysis for patients with stroke and Covid‐19 was not a rare event in the most affected areas by pandemic, and rates of 1‐month unfavorable outcomes were high compared to previous data from the pre–Covid‐19 literature. However, risk of sICH was not increased.

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

“…For cerebrovascular disease, some of the predictors of poor outcome were in line with the experience in non-COVID stroke cases, such as older age, higher NIHSS at admission, baseline glucose, and creatinine levels, while others appear to be more specific to this particular population (e.g. thrombocytopenia, lymphocytopenia, and elevated levels of D-dimer and LDH) [ 7 , 11 , 13 , 19 , 60 , 62 ].…”

“…Importantly, the outcome of COVID-19-related stroke cases was significantly worse than that of non-COVID stroke cases in 2 different studies performed in Italy and USA, respectively [ 59 , 60 ]. The mortality rate was particularly high in cases with stroke ensuing in association with severe respiratory disease requiring ICU admission [ 7 ].…”

Large Vessel Occlusion Causing Cerebral Ischemic Stroke in Previously Healthy Middle-Aged Recently Recovered from Severe COVID-19 Infection

“…This is true for both patients who received intravenous thrombolysis alone and those who received it as a bridging therapy before undergoing thrombectomy. 18 Additionally, a study has shown that having a poor outcome after receiving reperfusion therapies was independently associated with SARS-CoV-2 infection. 19 This finding is in agreement with another study done by Escalard et al, describing that poor outcome could be related to the prothrombotic state due to SARS-CoV-2 infection causing re-occlusions after receiving reperfusion therapies.…”

Utilization and Outcomes of Acute Revascularization Treatments in Ischemic Stroke Patients with SARS-CoV-2 Infection

“…There may be reluctance in using acute revascularization treatments due to presence of elevated concentration of inflammation and hypercoagulability markers 4,6,7 and reports of high mortality in patients with SARS-CoV-2 infection who were treated with acute revascularization treatments. [1][2][3] Patients with SARS-CoV-2 infection may be excluded due to hepatic dysfunction 5 and coagulopathy (elevated prothrombin time, international normalized ratio, activated partial thromboplastin time, or reduced platelet count). The relatively high rate of renal insufficiency with subsequent acute kidney injury in patients with SARS-CoV-2 infection 26 may delay or preclude administration of contrast for computed tomography angiography and/or perfusion to identify appropriate candidates.…”

“…Our understanding of outcomes in acute ischemic stroke patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection following acute revascularization treatments (as intravenous thrombolysis and/or thrombectomy) is based on small case series. [1][2][3] . An international panel 4 cautioned regarding the potential for high rate of death or disability and post thrombolytic intracerebral hemorrhage (ICH)s in acute ischemic stroke patients with SARS-CoV-2 infection due to elevated concentrations of inflammation and hypercoagulability markers such as leukocytosis, and C reactive protein and D dimers and multisystem dysfunction.…”