Acute Cerebrovascular Events With COVID-19 Infection

Mandip S. Dhamoon, MD, DrPH; Alison Thaler, MD; Kapil Gururangan, MD; Amit Kohli, MD; Daniella Sisniega, MD; Danielle Wheelwright, RN; Connor Mensching, MS; Johanna T. Fifi, MD; Michael G. Fara, MD, PhD; Nathalie Jette, MD, MSc; Ella Cohen, BS; Priya Dave, BA; Aislyn C. DiRisio, BS; Jonathan Goldstein, BA; Emma M. Loebel, BA; Naomi A. Mayman, BS; Akarsh Sharma, MS, BS; Daniel S. Thomas, BBA; Ruben D. Vega Perez, MPH; Mark R. Weingarten, BA; Huei Hsun Wen, MD, MSCR; Stanley Tuhrim, MD; Laura K. Stein, MD


Stroke. 2021;52(1):48-56. 

In This Article


During the study period, 277 patients were diagnosed with stroke, of whom 38.0% (n=105) were COVID-19-positive. This represents 1.9% of the 5469 patients admitted to MSHS with COVID-19 during the study period. Table 1 lists baseline characteristics stratified by COVID-19 infection status. A total of 24.6% of the cohort did not receive SARS-CoV-2 testing, predominantly during the first 2 weeks of the study period, after which almost all admitted patients with stroke received testing. There were no significant differences in age, race-ethnicity, or major cardiovascular risk factors between patients with or without COVID-19. However, significantly more patients in the COVID-19-negative cohort had a history of smoking (47.1% versus 28.3%, P=0.014) and were taking a full-dose anticoagulant at stroke onset (90.7% versus 68.6%, P<0.0001).

Initial stroke severity was higher among those with COVID-19 (mean National Institutes of Health Stroke Scale of 15.5 versus 9.6 among those without COVID-19, Table 2). Although the distribution of stroke subtypes was similar between the COVID-19 and non-COVID-19 cohorts (P=0.45), IS cause differed between cohorts (Table 2). For 51.8% (n=43) of COVID-19-positive patients, etiologic subtype was cryptogenic, compared with only 22.3% (n=27) for the COVID-19-negative cohort (P<0.0001). Additionally, only 6.0% (n=5) of COVID-19 patients suffered small-vessel IS and 28.9% (n=24) cardioembolic IS, compared with 17.4% (n=21) and 42.2% (n=51) among non-COVID-19 patients, respectively. IS occurred more commonly in the temporal (P=0.04), parietal (P=0.002), occipital (P=0.002), and cerebellar (P=0.027) regions among COVID-19-positive patients compared with COVID-negative patients. ICH location did not differ between groups. Receipt of intravenous thrombolysis and mechanical thrombectomy were similar regardless of COVID-19 status. Prevalence of arterial stenosis and occlusion was similar between groups, and there was no difference in Thrombolysis in Cerebral Infarction score in patients treated with thrombectomy. Pulmonary ground-glass opacities were seen on computed tomography angiogram in 67.7% (n=44) of COVID-19-positive patients with stroke, compared with only 8.8% of COVID-negative patients (P<0.0001).

Table 3 summarizes laboratory test results comparing COVID-19-positive patients to COVID-19-negative patients and proportions of COVID-19 patients with abnormal values. At the time closest to stroke discovery, mean coagulation markers were mildly elevated compared with normal values (prothrombin time 15.4±3.7 seconds, partial thromboplastin time 38.9±24.8 seconds, and international normalized ratio 1.4±1.3). White blood cells, hemoglobin, and hematocrit were each abnormal in around half of the COVID-19 patients; white blood cells and platelets were higher among COVID-19-positive patients compared with COVID-negative, and hemoglobin and hematocrit were lower. Elevated peak troponin levels were seen in 62.9% of COVID-19 patients (mean 0.80±2.0 ng/mL), and 97.0% had elevated peak D-dimer levels (mean 8.6±7.5 ng/mL). Peak inflammatory markers were most frequently elevated in COVID-19 patients, including C-reactive protein, erythrocyte sedimentation rates, and interleukin-6 levels. Forty-five percent (n=48) of COVID-19-positive patients with stroke were treated with systemic anticoagulation, compared with only 1.2% (n=2) of COVID-19-negative patients with stroke (P<0.0001).

Outcomes were worse among COVID-19-positive patients with stroke compared with COVID-19-negative patients with stroke (Table 4). Mean length of stay for the COVID-19 cohort was 17.4±14.8 days compared with 8.0±6.4 days for the non-COVID-19 cohort (P<0.0001), and 58.7% (n=61) of the COVID-19 cohort required intensive care unit admission, compared with 44.7% of non-COVID-19 cohort (P=0.025). Half of COVID-19-positive patients with stroke experienced neurological worsening during admission, compared with only 21% of the COVID-19-negative cohort (P<0.0001). Additionally, 37.2% (n=35) of COVID-19-positive patients with stroke developed acute respiratory distress syndrome and 45.2% (n=47) required mechanical ventilation, compared with only 2.6% (n=4) and 19.4% (n=33) of COVID-19-negative patients with stroke, respectively (P<0.0001 for each). Only 29.8% (n=14) of intubated COVID-19-positive patients were extubated, compared with 75.8% (n=25) of COVID-19-negative patients. In-hospital death occurred in 33% (n=35) of COVID-19-positive patients with stroke, compared with 12.9% (n=22) among COVID-19-negative patients. Only 22.9% (n=24) of the COVID-19-positive patients were discharged home compared with 49.4% (n=84) in the COVID-19-negative cohort.

Finally, there was a higher proportion of IS and ICH and lower proportion of subarachnoid hemorrhage and transient ischemic attack among COVID-19-positive patients with stroke compared with COVID-19 negative patients admitted during the same period 1 year prior (Table 5). Among IS, cryptogenic cause was more than twice as common among COVID-19 positive patients as COVID-19 negative patients in all comparison groups. One-third of COVID-19 patients with stroke died in hospital, compared with much lower proportions in all comparison groups. There were fewer overall MSHS stroke admissions during the pandemic (277) compared with the same period 1 year prior (312) and to the expected number of admissions during a 61-day period based on a daily average of admissions in 2019 (332).