Acute ischaemic strokes (AIS) associated with COVID-19 are more severe, lead to worse functional outcomes and are associated with higher mortality, according to researchers who analysed data on patients with COVID-19 and AIS treated at 28 health care centres in 16 countries this year and compared them to patients without COVID-19 from the Acute Stroke Registry and Analysis of Lausanne (ASTRAL) Registry, from 2003 to 2019. Researchers sought to determine the clinical characteristics and outcomes of patients with COVID-19 and AIS.
Between 27 January, 2020 to 19 May, 2020, there were 174 patients hospitalised with COVID-19 and AIS. Each COVID-19 patient with AIS was matched and compared to a non-COVID-19 AIS patient based on a set of pre-specified factors including age, gender and stroke risk factors (hypertension, diabetes, atrial fibrillation, coronary artery disease, heart failure, cancer, previous stroke, smoking, obesity and dyslipidemia). The final analysis included 330 patients total.
In both patient groups, stroke severity was estimated with the National Institute of Health Stroke Scale (NIHSS), and stroke outcome was assessed by the modified Rankin score (mRS). When AIS patients with COVID-19 were compared to non-COVID-19 patients:
COVID-19 patients had more severe strokes (median NIHSS score of 10 vs. 6, respectively);
COVID-19 patients had higher risk for severe disability following stroke (median mRS score 4 vs. 2, respectively); and
COVID-19 patients were more likely to die of AIS.
The researchers noted there are several potential explanations for the relationship between COVID-19-associated strokes and increased stroke severity: “The increased stroke severity at admission in COVID-19-associated stroke patients compared to the non-COVID-19 cohort may explain the worse outcomes. The broad, multi-system complications of COVID-19, including acute respiratory distress syndrome, cardiac arrhythmias, acute cardiac injury, shock, pulmonary embolism, cytokine release syndrome and secondary infection, probably contribute further to the worse outcomes including higher mortality in these patients. … The association highlights the urgent need for studies aiming to uncover the underlying mechanisms and is relevant for pre-hospital stroke awareness and in-hospital acute stroke pathways during the current and future pandemics.”
Abstract
Recent case-series of small size implied a pathophysiological association between coronavirus disease 2019 (COVID-19) and severe large-vessel acute ischemic stroke. Given that severe strokes are typically associated with poor prognosis and can be very efficiently treated with recanalization techniques, confirmation of this putative association is urgently warranted in a large representative patient cohort to alert stroke clinicians, and inform pre- and in-hospital acute stroke patient pathways. We pooled all consecutive patients hospitalized with laboratory-confirmed COVID-19 and acute ischemic stroke in 28 sites from 16 countries. To assess whether stroke severity and outcomes (assessed at discharge or at the latest assessment for those patients still hospitalized) in patients with acute ischemic stroke are different between patients with COVID-19 and non-COVID-19, we performed 1:1 propensity score matching analyses of our COVID-19 patients with non-COVID-19 patients registered in the Acute Stroke Registry and Analysis of Lausanne Registry between 2003 and 2019. Between January 27, 2020, and May 19, 2020, 174 patients (median age 71.2 years; 37.9% females) with COVID-19 and acute ischemic stroke were hospitalized (median of 12 patients per site). The median National Institute of Health Stroke Scale was 10 (interquartile range [IQR], 4–18). In the 1:1 matched sample of 336 patients with COVID-19 and non-COVID-19, the median National Institute of Health Stroke Scale was higher in patients with COVID-19 (10 [IQR, 4–18] versus 6 [IQR, 3–14]), P=0.03; (odds ratio, 1.69 [95% CI, 1.08–2.65] for higher National Institute of Health Stroke Scale score). There were 48 (27.6%) deaths, of which 22 were attributed to COVID-19 and 26 to stroke. Among 96 survivors with available information about disability status, 49 (51%) had severe disability at discharge. In the propensity score-matched population (n=330), patients with COVID-19 had higher risk for severe disability (median mRS 4 [IQR, 2–6] versus 2 [IQR, 1–4], P<0.001) and death (odds ratio, 4.3 [95% CI, 2.22–8.30]) compared with patients without COVID-19. Our findings suggest that COVID-19 associated ischemic strokes are more severe with worse functional outcome and higher mortality than non-COVID-19 ischemic strokes.
Authors
George Ntaios; Patrik Michel; Georgios Georgiopoulos; Yutao Guo; Wencheng Li; Jing Xiong; Patricia Calleja; Fernando Ostos; Guillermo González-Ortega; Blanca Fuentes,; María Alonso de Leciñana; Exuperio Díez-Tejedor; Sebastian García-Madrona; Jaime Masjuan; Alicia DeFelipe; Guillaume Turc; Bruno Gonçalves; Valerie Domigo; Gheorghe-Andrei Dan; Roxana Vezeteu; Hanne Christensen; Louisa Marguerite Christensen; Per Meden; Lejla Hajdarevic; Angela Rodriguez-Lopez; Fernando Díaz-Otero; Andrés García-Pastor; Antonio Gil-Nuñez; Errikos Maslias; Davide Strambo; David J Werring; Arvind Chandratheva; Laura Benjamin; Robert Simister; Richard Perry; Rahma Beyrouti; Pascal Jabbour; Ahmad Sweid; Stavropoula Tjoumakaris; Elisa Cuadrado-Godia; Ana Rodríguez Campello; Jaume Roquer; Tiago Moreira; Michael V Mazya; Fabio Bandini; Karl Matz; Helle K Iversen; Alejandra González-Duarte; Cristina Tiu; Julia Ferrari; Milan R Vosko; Helmut JF Salzer; Bernd Lamprecht; Martin W Dünser; Carlo W Cereda; Ángel Basilio Corredor Quintero; Eleni Korompoki; Eduardo Soriano-Navarro; Luis Enrique Soto-Ramírez; Paulo F Castañeda-Méndez; Daniela Bay-Sansores; Antonio Arauz; Vanessa Cano-Nigenda; Espen Saxhaug Kristoffersen; Marjaana Tiainen; Daniel Strbian; Jukka Putaala: Gregory YH Lip
[link url="https://newsroom.heart.org/news/global-covid-19-registry-finds-strokes-associated-with-covid-19-are-more-severe-have-worse-outcomes-and-higher-mortality"]American Heart Organisation material[/link]
[link url="https://www.ahajournals.org/doi/10.1161/STROKEAHA.120.031208"]Stroke abstract[/link]