Ying Gue, PhD
In this article, Dhamoon et al. compared the differences in characteristics and outcomes of patients, with and without concurrent coronavirus disease 2019 (COVID-19) infection, who presented with stroke during the peak of the COVID-19 pandemic in New York City. The retrospective observational study identified a total of 277 patients, of which 105 (38%) were COVID-19 positive.
Interestingly, patients with COVID-19 who suffered an acute cerebrovascular event were more likely males (61.9% vs. 46.1% P=0.038) with no history of smoking (28.3% vs. 47.1%, P=0.014) and less likely to be taking full-dose anticoagulant at stroke onset (68.6% vs. 90.7%, P<0.0001). Many studies have shown that males with COVID-19 are associated with more adverse events and complications, and, hence, this finding was not surprising. Secondly, COVID-19 infection is associated with a pro-thrombotic state, and, therefore, the lack of traditional cardiovascular risk factor (such as smoking) is probable. As the authors pointed out, failure of data captured on admission due to a higher proportion of patients being more critically ill could also explain the lower proportion of smokers.
The lower proportion of patients on anticoagulants at the time of stroke can be attributed to the reduction in use of therapeutic dose anticoagulation in patients with COVID-19 from admission to stroke from 84.8% to 68.6%. There could be many underlying reasons for this phenomenon — bleeding events, severe sepsis with multiorgan failure resulting in contraindications or loss of oral route due to being critically ill. The higher rates of ischemic strokes and prevalence of intracranial hemorrhage highlight the derangement in haemostasis in patients with COVID-19 infection and the importance of maintaining this delicate balance to reduce adverse outcomes.
Patients with COVID-19 also had higher mean NIHSS score on presentation (15.5 vs. 9.6, P<0.0001) and had a higher proportion of cryptogenic stroke (51.8% vs. 22.3%). As previously reported, the role of ACE2 and COVID-19 infection cannot be undermined.1 This study further confirms that rather than a concurrent illness, COVID-19 is likely the underlying cause of stroke.
Lastly, outcomes were worse with longer mean length of stay (17.4 vs. 8 days) and higher in-hospital mortality (33.3% vs 12.9%), which highlights that apart from the respiratory support, the thrombotic phenomenon is also important to consider when managing these patients.
1. Kaneko N, Satta S, Komuro T, Muthukrishnan S D, Kakarla V, Guo L, An J, Elahi F, Kornblum H, Liebeskind D, Hsiai T, and Hinman J. Flow-mediated Susceptibility and Molecular Response of Cerebral Endothelia to Sars-CoV-2 Infection. Stroke.