COVID May Complicate Ischemic Stroke Revascularization

Megan Brooks

November 11, 2022

New data from the Global COVID-19 Stroke Registry suggest higher rates of intracranial bleeding complications and worse outcomes of stroke revascularization in acute ischemic stroke (AIS) complicated by COVID-19.

However, study investigator João Pedro Marto, MD, with Hospital de Egas Moniz, Lisbon, Portugal, cautioned that the number of patients who experienced complications was small.

"We believe treatments to restore blood flow remain beneficial to people with ischemic stroke and COVID-19 and suggest they continue to be given as quickly as possible using current treatment," Marto said in a statement.

“Clinicians should be aware that patients with stroke and COVID-19 have more severe strokes at admission and higher rate of intracerebral bleeding after treatment with either intravenous thrombolysis or mechanical thrombectomy. Endovascular procedures seem to be more challenging, with lower recanalization rates and higher number of passes,” Marto told Medscape Medical News.

The study was published online November 9 in Neurology.

Recognized COVID Complication 

AIS is a recognized complication of SARS-CoV-2 infection, believed to be due to virus-related inflammation, endothelial dysfunction and coagulopathy.

Earlier data from the Global COVID-19 Stroke Registry show patients with AIS and COVID-19 may have worse functional outcome than those without SARS-CoV-2 infection — an observation later confirmed in other studies.

Yet, the safety and efficacy of revascularization treatments in AIS patients with COVID-19 remains unclear.

To investigate, Marto and colleagues looked back at 15,128 patients with AIS (mean age, 72 years, 51% male). A total of 853 patients (6%) were diagnosed with COVID-19 and the remainder were COVID-negative controls.

SARS-CoV-2 infection was most frequently diagnosed at stroke onset (46%), followed by diagnosis before stroke (38%) and then diagnosis during hospital admission (16%).

All patients had treatments to restore blood flow — 39% received intravenous thrombolysis (IVT) only and 61% received endovascular treatment (EVT) with or without IVT.

Rates of intracerebral hemorrhage (ICH) were higher in patients with than without COVID-19 (9% vs 5%). The same was true for SAH (4% vs 2%) and both outcomes combined (10% vs 6%).

In "doubly robust adjusted outcome analysis on multiple imputed datasets," patients with COVID-19 had a higher rate of symptomatic ICH (adjusted odds ratio [aOR] 1.53; 95% CI, 1.16-2.01), symptomatic SAH (aOR 1.80; 95% CI, 1.20-2.69), and both combined (OR 1.56; 95% CI, 1.23-1.99), the researchers report.

Revascularization Still Beneficial

In the treatment subgroup analysis, both IVT-only and EVT patients had an increased risk for ICH, while only EVT patients showed an increased risk for symptomatic SAH.

In a further subgroup analysis, patients undergoing direct mechanical thrombectomy had a nonsignificant lower risk of hemorrhagic complications in comparison to bridging therapy.

COVID-19 patients with AIS also had an unfavorable shift in the distribution of the Modified Rankin Score at 3 months.

They were more than twice as likely to die within 24 hours of stroke treatment (OR 2.47; 95% CI, 1.58-3.86) and 88% more likely to die 3 months after treatment (aOR 1.88; 95% CI, 1.52-2.33).

"In our study, we did not find delays to revascularization treatment previously described in patients with AIS and COVID-19 and proposed as a factor contributing to the worse clinical outcomes," the researchers write.

They caution that the study design did not allow for direct conclusions to be made on the effectiveness of revascularization treatments in COVID-19 patients.

Importantly, they note, the "relatively large margin of benefit of revascularization treatments, in particular of EVT, and the rather small absolute numbers of symptomatic hemorrhage in patients with AIS and COVID-19 make it likely that revascularization treatments remain beneficial for these patients."

Therefore, they suggest that these treatments continue to be given "as rapidly as possible to COVID-19 patients using the current treatment recommendations."

Interpret Cautiously

Commenting on the study for Medscape Medical News, James Meschia, MD, neurologist and stroke expert at Mayo Clinic in Jacksonville, Florida, noted that this is a "large, well-done, case-control study and, obviously, it doesn't lack for statistical power."

Meschia said he would "tend to agree that mechanical thrombectomy is worth pursuing in large vessel occlusion; the small vessel patients, the ones that don't go to the cath lab, it's not as clear."

"What you don't want to say is patients with COVID should avoid the hospital if they have ischemic stroke to avoid brain hemorrhage. That would be the wrong message because there's overwhelming benefit of treatment and the absolute risk is low," Meschia said.

The study had no commercial funding. Marto and Meschia reported no relevant disclosures.

Neurology. Published online November 9, 2022. Abstract.

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