Acute Ischemic Stroke and COVID-19: An Analysis of 27 676 Patients

Adnan I. Qureshi, MD; William I. Baskett, BS; Wei Huang, MA; Daniel Shyu, BS; Danny Myers, PhD; Murugesan Raju, PhD; Iryna Lobanova, MD; M. Fareed K. Suri, MD; S. Hasan Naqvi, MD; Brandi R. French, MD; Farhan Siddiq, MD; Camilo R. Gomez, MD; Chi-Ren Shyu, PhD

Disclosures

Stroke. 2021;52(3):905-912. 

In This Article

Abstract and Introduction

Abstract

Background and Purpose: Acute ischemic stroke may occur in patients with coronavirus disease 2019 (COVID-19), but risk factors, in-hospital events, and outcomes are not well studied in large cohorts. We identified risk factors, comorbidities, and outcomes in patients with COVID-19 with or without acute ischemic stroke and compared with patients without COVID-19 and acute ischemic stroke.

Methods: We analyzed the data from 54 health care facilities using the Cerner deidentified COVID-19 dataset. The dataset included patients with an emergency department or inpatient encounter with discharge diagnoses codes that could be associated to suspicion of or exposure to COVID-19 or confirmed COVID-19.

Results: A total of 103 (1.3%) patients developed acute ischemic stroke among 8163 patients with COVID-19. Among all patients with COVID-19, the proportion of patients with hypertension, diabetes, hyperlipidemia, atrial fibrillation, and congestive heart failure was significantly higher among those with acute ischemic stroke. Acute ischemic stroke was associated with discharge to destination other than home or death (relative risk, 2.1 [95% CI, 1.6–2.4]; P<0.0001) after adjusting for potential confounders. A total of 199 (1.0%) patients developed acute ischemic stroke among 19 513 patients without COVID-19. Among all ischemic stroke patients, COVID-19 was associated with discharge to destination other than home or death (relative risk, 1.2 [95% CI, 1.0–1.3]; P=0.03) after adjusting for potential confounders.

Conclusions: Acute ischemic stroke was infrequent in patients with COVID-19 and usually occurs in the presence of other cardiovascular risk factors. 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.

Graphic Abstract: An online graphic abstract is available for this article.

Introduction

Coronavirus disease 2019 (COVID-19) may increase the risk of acute ischemic stroke[1] similar to the increased risk of 3.2-fold to 7.8-fold seen within the first 3 days after other respiratory tract infections.[2,3] In a review of literature in April 2020,[4] the proportion of patients with COVID-19 who have acute ischemic stroke was estimated to be 4.9% (95% CI, no continuity correction, 2.8%–8.7%)[5] during initial hospitalization. Using similar assumptions, an estimated 182 485 and 269 383 patients who have COVID-19 will also have ischemic stroke considering 9 988 254 patients had COVID-19 in the world on June 27, 2020,[4] and an estimated 21% to 31% of patients with COVID-19 required hospitalization.[6] Subsequently, several small case series have reported the occurrence of ischemic stroke in patients with COVID-19.[7–12] The increased risk of ischemic stroke is probably multifactorial, with activation of coagulation and inflammatory pathways as reflected in increased fibrin D-dimer levels, erythrocyte sedimentation rate, lactic acid dehydrogenase, and lymphopenia.[8,13–16] An international panel of stroke experts from 18 countries recommended further studies to understand whether there are differences in risk factors, manifestations, response to treatment strategies, and outcomes in acute ischemic stroke patients with COVID-19.[4] We performed this study to identify risk factors, comorbidities, treatment strategies, and outcomes in patients with ischemic stroke derived from a large cohort of COVID-19 patients.

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