Acute ischemic stroke in COVID-19 pandemic

Acute ischemic stroke in COVID-19 pandemic

Patients infected with SARS-CoV-2 develop arterial thrombosis including strokemyocardial infarction and peripheral arterial thrombosis, all of which result in poor outcomes despite maximal medical, endovascular, and microsurgical treatment compared with non-COVID-19-infected patients 1).

Evidence now suggests that 1-6% of hospitalized COVID-19 patients develop stroke. According to some reports, stroke risk is more than sevenfold greater in patients with COVID-19 than influenza. Concerningly, outcomes of COVID-19-related stroke are often worse than in stroke patients without COVID-19 from the same cohorts. In a review, Stein et al. highlight the emerging association between COVID-19 and stroke and discuss putative pathogenetic mechanisms. The etiology of stroke in COVID-19 patients is likely multifactorial, related to coagulopathyinflammationplatelet activation, and alterations to the vascular endothelium. Significant work remains to be done to better understand the pathogenesis of COVID-19-related stroke and for designing optimal primary and secondary prevention strategies 2).

The risk of discharge to destination other than home or death increased 2-fold with occurrence of acute ischemic stroke in patients with COVID-19 3).

Large Vessel Occlusion was predominant in patients with acute ischemic stroke and COVID-19 across 2 continents, occurring at a significantly younger age and affecting African Americans disproportionately in the USA 4).

The goal of a study of Shahjouei et al. was to better depict the short-term risk of stroke and its associated factors among SARS-CoV-2 hospitalized patients.

This multicentre, multinational observational study includes hospitalized SARS-CoV-2 patients from North and South America (United States, Canada, and Brazil), Europe (Greece, Italy, Finland, and Turkey), Asia (Lebanon, Iran, and India), and Oceania (New Zealand). The outcome was the risk of subsequent stroke. Centres were included by non-probability sampling. The counts and clinical characteristics including laboratory findings and imaging of the patients with and without a subsequent stroke were recorded according to a predefined protocol. Quality, risk of bias, and heterogeneity assessments were conducted according to ROBINS-E and Cochrane Q-test. The risk of subsequent stroke was estimated through meta-analyses with random effect models. Bivariate logistic regression was used to determine the parameters with predictive outcome value. The study was reported according to the STROBE, MOOSE, and EQUATOR guidelines.

Shahjouei et al. received data from 26,175 hospitalized SARS-CoV-2 patients from 99 tertiary centres in 65 regions of 11 countries until May 1st, 2020. A total of 17,799 patients were included in meta-analyses. Among them, 156(0.9%) patients had a stroke-123(79%) ischaemic stroke, 27(17%) intracerebral/subarachnoid hemorrhage, and 6(4%) cerebral sinus thrombosis. Subsequent stroke risks calculated with meta-analyses, under low to moderate heterogeneity, were 0.5% among all centres in all countries, and 0.7% among countries with higher health expenditures. The need for mechanical ventilation (OR: 1.9, 95% CI:1.1-3.5, p = 0.03) and the presence of ischaemic heart disease (OR: 2.5, 95% CI:1.4-4.7, p = 0.006) were predictive of stroke.

Interpretation: The results of this multi-national study on hospitalized patients with SARS-CoV-2 infection indicated an overall stroke risk of 0.5%(pooled risk: 0.9%). The need for mechanical ventilation and the history of ischaemic heart disease are the independent predictors of stroke among SARS-CoV-2 patients 5).

Based on a literature review, a series of consensus recommendations were established by the Madrid Stroke multidisciplinary group and its neurology committee.

These recommendations address 5 main objectives: 1) coordination of action protocols to ensure access to hospital care for stroke patients; 2) recognition of potentially COVID-19-positive stroke patients; 3) organisation of patient management to prevent SARS-CoV-2 infection among healthcare professionals; 4) avoidance of unnecessary neuroimaging studies and other procedures that may increase the risk of infection; and 5) safe, early discharge and follow-up to ensure bed availability. This management protocol has been called CORONA (Coordinate, Recognise, Organise, Neuroimaging, At home).

The recommendations presented may assist in the organisation of acute stroke care and the optimisation of healthcare resources, while ensuring the safety of healthcare professionals 6).

A series of 10 ischemic stroke patients with concomitant COVID-19 disease. Out of 10, 8 had large infarcts (3 massive middle cerebral artery, 2 basilar artery, 2 posterior cerebral artery, and 1 internal carotid artery infarct territory). Two had cardiogenic embolic stroke due to atrial fibrillation. Almost half of our patients did not have a vascular risk factor. Nine did not have fever and were diagnosed with COVID-19 upon admission for stroke. Stroke occurred in the first week of respiratory symptoms with moderate pulmonary involvement. Most Patients did not have hypoxia and did not establish respiratory failure or acute respiratory distress syndrome. The blood pressures were low and hemorrhagic transformation did not occur even after antiplatelet or anticoagulant therapy. Patients had markedly increased levels of lactate dehydrogenase, C-reactive protein, and D-dimer. Three patients died. It seems that ischemic strokes in COVID-19 patients tend to occur as large infarct and can be seen in patients with mild to moderate pulmonary involvement 7).


Zakeri A, Jadhav AP, Sullenger BA, Nimjee SM. Ischemic stroke in COVID-19-positive patients: an overview of SARS-CoV-2 and thrombotic mechanisms for the neurointerventionalist. J Neurointerv Surg. 2021 Mar;13(3):202-206. doi: 10.1136/neurintsurg-2020-016794. Epub 2020 Dec 9. PMID: 33298508.

Stein LK, Mayman NA, Dhamoon MS, Fifi JT. The emerging association between COVID-19 and acute stroke. Trends Neurosci. 2021 Apr 8:S0166-2236(21)00071-0. doi: 10.1016/j.tins.2021.03.005. Epub ahead of print. PMID: 33879319.

Qureshi AI, Baskett WI, Huang W, Shyu D, Myers D, Raju M, Lobanova I, Suri MFK, Naqvi SH, French BR, Siddiq F, Gomez CR, Shyu CR. Acute Ischemic Stroke and COVID-19: An Analysis of 27 676 Patients. Stroke. 2021 Mar;52(3):905-912. doi: 10.1161/STROKEAHA.120.031786. Epub 2021 Feb 4. PMID: 33535779; PMCID: PMC7903982.

Khandelwal P, Al-Mufti F, Tiwari A, Singla A, Dmytriw AA, Piano M, Quilici L, Pero G, Renieri L, Limbucci N, Martínez-Galdámez M, Schüller-Arteaga M, Galván J, Arenillas-Lara JF, Hashim Z, Nayak S, Desousa K, Sun H, Agarwalla PK, Nanda A, Roychowdhury JS, Nourollahzadeh E, Prakash T, Gandhi CD, Xavier AR, Lozano JD, Gupta G, Yavagal DR. Incidence, Characteristics and Outcomes of Large Vessel Stroke in COVID-19 Cohort: An International Multicenter Study. Neurosurgery. 2021 Mar 18:nyab111. doi: 10.1093/neuros/nyab111. Epub ahead of print. PMID: 33734404.

Shahjouei S, Naderi S, Li J, et al. Risk of stroke in hospitalized SARS-CoV-2 infected patients: A multinational study [published online ahead of print, 2020 Aug 17]. EBioMedicine. 2020;59:102939. doi:10.1016/j.ebiom.2020.102939

Rodríguez-Pardo J, Fuentes B, Alonso de Leciñana M, Campollo J, Calleja Castaño P, Carneado Ruiz J, Egido Herrero J, García Leal R, Gil Núñez A, Gómez Cerezo JF, Martín Martínez A, Masjuán Vallejo J, Palomino Aguado B, Riera López N, Simón de Las Heras R, Vivancos Mora J, Díez Tejedor E; en nombre del Grupo Multidisciplinar del Plan Ictus Madrid. Acute stroke care during the COVID-19 pandemic. Ictus Madrid Program recommendations. Neurologia. 2020 May;35(4):258-263. English, Spanish. doi: 10.1016/j.nrl.2020.04.008. Epub 2020 Apr 24. PMID: 32364127; PMCID: PMC7180371.

Ahmadi Karvigh S, Vahabizad F, Banihashemi G, Sahraian MA, Gheini MR, Eslami M, Marhamati H, Mirhadi MS. Ischemic Stroke in Patients with COVID-19 Disease: A Report of 10 Cases from Iran. Cerebrovasc Dis. 2020 Dec 15:1-6. doi: 10.1159/000513279. Epub ahead of print. PMID: 33321492; PMCID: PMC7801957.

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