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SARS2-CoV-2 and Stroke in a New York Healthcare System

Our take —

Coagulopathy has been identified as an important manifestation of COVID-19. This fairly small study of ischemic stroke patients showed greater stroke severity and higher mortality among those who were infected with SARS-CoV-2 relative to those who were not. More than half of stroke patients with COVID-19 had strokes that were diagnosed after hospitalization, indicating the need for further study of anticoagulation treatment for stroke prevention in COVID-19 patients.

Study design

Retrospective Cohort

Study population and setting

This study included all patients with ischemic stroke who were hospitalized in one of three stroke centers in New York City between March 15 and April 19, 2020. All stroke patients discharged from two of the centers between March 15 and April 19, 2019 were used as historical controls. Patients with both stroke and laboratory-confirmed SARS-CoV-2 infection (n=32, median age 63 years, 72% male) were compared to contemporaneous stroke patients without SARS-CoV-2 infection (n=70, median age 70 years, 52% male) and to historical controls (n=80, median age 69 years, 45% male). Patient characteristics were extracted from medical records.

Summary of Main Findings

During the study period, 0.9% (32/3556) of hospitalized COVID-19 patients had an imaging-confirmed ischemic stroke. Of these 32 stroke patients with SARS-CoV-2 infection, stroke was the reason for admission in 14 (44%), while the 18 (56%) had stroke diagnosed after admission for COVID-19. The median duration from COVID-19 symptom onset to stroke diagnosis was 10 days (interquartile range: 5 – 16.5 days). 14 (44%) of these patients died, 8 (25%) were discharged home or to rehabilitation, and 10 (31%) remained critically ill at the end of follow-up. Compared to both contemporaneous and historical controls, patients with COVID-19 had a higher risk of mortality (among those with outcomes, mortality was 64% in the COVID-19 group vs. 9.3% in contemporaneous controls and 6.3% in historical controls), higher National Institutes of Health Stroke Scale (NIHSS) scores, and a higher likelihood of cryptogenic stroke (i.e unknown cause).

Study Strengths

The use of historical controls helps address the possibility of misclassification of SARS-CoV-2 infection status.

Limitations

Stroke was likely under-diagnosed in COVID-19 patients, particularly those with critical illness whose symptoms may be difficult to detect. Strokes diagnosed after hospital admission may have occurred earlier, as screening was likely impractical during acute COVID-19 treatment. 30% (14/46) of contemporaneous controls were screened but not tested for SARS-CoV-2 infection; some of these patients may have had mild or asymptomatic infection, and the resulting misclassification may have diluted observed differences between the groups. Limited availability of broad imaging likely resulted in an artificially high prevalence of cryptogenic stroke type. Findings were limited to ischemic stroke and did not include other manifestations of severe coagulopathy.

Value added

This study shows dramatically higher mortality among ischemic stroke patients with COVID-19 relative to stroke patients without COVID-19, adding to the emerging literature on coagulopathy as an important non-respiratory symptom of SARS-CoV-2 infection.

This review was posted on: 17 June 2020