Impact of COVID-19 Infection on the Outcome of Patients With Ischemic Stroke

Joan Martí-Fàbregas, MD, PhD; Daniel Guisado-Alonso, MD; Raquel Delgado-Mederos, MD, PhD; Alejandro Martínez-Domeño, MD; Luis Prats-Sánchez, MD, PhD; Marina Guasch-Jiménez, MD; Pere Cardona, MD; Ana Núñez-Guillén, MD; Manuel Requena, MD; Marta Rubiera, MD, PhD; Marta Olivé, MD; Alejandro Bustamante, MD; Meritxell Gomis, MD, PhD; Sergio Amaro, MD, PhD; Laura Llull, MD, PhD; Xavier Ustrell, MD; Gislaine Castilho de Oliveira, RN; Laia Seró, MD; Manuel Gomez-Choco, MD, PhD; Luis Mena, MD; Joaquín Serena, MD, PhD; Saima Bashir Viturro, MD; Francisco Purroy, MD, PhD; Mikel Vicente, MD; Ana Rodríguez-Campello, MD, PhD; Angel Ois, MD, PhD; Esther Catena, MD; Maria Carmen Garcia-Carreira, MD; Oriol Barrachina, MD; Ernest Palomeras, MD, PhD; Jerzky Krupinski, MD, PhD; Marta Almeria, MD; Josep Zaragoza, MD; Patricia Esteve, MD; Dolores Cocho, MD, PhD; Antia Moreira, MD; Cecile van Eendenburg, MD; Javier Emilio Codas, MD; Natalia Pérez de la Ossa, MD, PhD; Mercè Salvat, RN; Pol Camps-Renom, MD, PhD


Stroke. 2021;52(12):3908-3917. 

In This Article

Abstract and Introduction


Background and Purpose: We evaluated whether stroke severity, functional outcome, and mortality are different in patients with ischemic stroke with or without coronavirus disease 2019 (COVID-19) infection.

Methods: A prospective, observational, multicentre cohort study in Catalonia, Spain. Recruitment was consecutive from mid-March to mid-May 2020. Patients had an acute ischemic stroke within 48 hours and a previous modified Rankin Scale (mRS) score of 0 to 3. We collected demographic data, vascular risk factors, prior mRS score, National Institutes of Health Stroke Scale score, rate of reperfusion therapies, logistics, and metrics. Primary end point was functional outcome at 3 months. Favourable outcome was defined depending on the previous mRS score. Secondary outcome was mortality at 3 months. We performed mRS shift and multivariable analyses.

Results: We evaluated 701 patients (mean age 72.3±13.3 years, 60.5% men) and 91 (13%) had COVID-19 infection. Median baseline National Institutes of Health Stroke Scale score was higher in patients with COVID-19 compared with patients without COVID-19 (8 [3–18] versus 6 [2–14], P=0.049). Proportion of patients with a favourable functional outcome was 33.7% in the COVID-19 and 47% in the non-COVID-19 group. However, after a multivariable logistic regression analysis, COVID-19 infection did not increase the probability of unfavourable functional outcome. Mortality rate was 39.3% among patients with COVID-19 and 16.1% in the non-COVID-19 group. In the multivariable logistic regression analysis, COVID-19 infection was a risk factor for mortality (hazard ratio, 3.14 [95% CI, 2.10–4.71]; P<0.001).

Conclusions: Patients with ischemic stroke and COVID-19 infection have more severe strokes and a higher mortality than patients with stroke without COVID-19 infection. However, functional outcome is comparable in both groups.

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


The first patients with coronavirus disease 2019 (COVID-19) infection were identified in December 2019 in China[1] and the World Health Organization declared the pandemic on 11 March 2020. Starting in March 2020, the infection has affected about 1 500 000 individuals and caused >43 000 deaths in Spain as of November 2020. COVID-19 infection is associated with a global mortality of 2.3%,[1] but in critically ill patients the mortality rate may raise up to 21% to 49%,[1–3] mainly due to pulmonary complications and multiorgan failure.

Neurological complications, including stroke, occur frequently in patients with COVID-19, affecting up to 57% of them.[4,5] In 4 retrospective registries of hospitalized patients with COVID-19, the frequency of stroke ranged from 0.9% to 5%.[4–7] On the contrary, the pandemic has seriously compromised the application of well-established therapies and the ability of the health systems to continue caring for patients with stroke.[8,9]

Moreover, patients with vascular risk factors associated with stroke, such as aging, diabetes, hypertension, obesity, and previous cardiac or cerebrovascular disease are at increased risk of mortality and morbidity by the COVID-19.[3,10] It is unknown if patients with stroke and COVID-19 present worse functional and vital outcome than patients without the infection.

In the present study, we describe the clinical characteristics of ischemic stroke from a multicentre prospective cohort of consecutive patients in Catalonia (Spain) during the COVID-19 outbreak, and we focus on vital and functional outcome. Our hypothesis is that COVID-19 worsens the prognosis of patients with ischemic stroke compared with patients with stroke without the infection. We aim also to study whether this worse prognosis would be attributable to the harmful effects of the virus, to the logistical difficulties in extra and intrahospital care caused by the pandemic,[8,9,11] or to both factors. We hope that our contribution will help to improve the care of patients with ischemic stroke and concomitant COVID-19 infection.