Juan Carlos Martinez Gutierrez, MD

Shahjouei S, Tsivgoulis G, Farahmand G, Koza E, Mowla A, Vafaei Sadr A, Kia A, Vaghefi Far A, Mondello S, Cernigliaro A, et al. SARS-CoV-2 and Stroke Characteristics: A Report From the Multinational COVID-19 Stroke Study Group. Stroke. 2021;52:e117-e130.

A large 32-country multinational group published an observational study of ischemic and hemorrhagic stroke characteristics in patients with coexisting SARS-CoV-2.

There was a total of 432 patients with ischemic strokes (75%), hemorrhagic strokes (21%) and venous thrombosis (4%). A surprising 38% of patients has asymptomatic infection on admission, 24% were less than 55 years old, and 24% had no vascular risk factors supporting concerns of COVID-19 induced thrombotic/hemorrhagic complications.

AIS patients (n=323) were generally young (46% <65 years, 36% <55 years), had an embolic etiology (81%) and an LVO (45%) with moderate severity NIHSS 5-15 (44%). 36% were asymptomatic on admission with a median COVID-19 to stroke interval of 3 days (0-9 IQR), but ultimately high rates of mechanical ventilation (74%) and in-hospital mortality (28%). Thrombolysis rate was only 14% and thrombectomy rate 7% despite high rates of LVOs. This low rate of thrombectomy was further highlighted in low health expenditure countries where access is already limited. Sadly, these findings were similar to other regional and national studies.

ICH patients (n=68) generally had severe bleeds with median ICH score 3, despite most not being on antithrombotics (Antiplatelet 28%, Anticoagulation 11%). Similarly, most were asymptomatic from COVID-19 at onset (53%) with median diagnosis to onset of 0 days (0-10 IQR) with only 50% mechanically ventilated but a significant in-hospital mortality (63%), not too dissimilar to mortality of patients with ICH scores of 3 (70%). In the small subset of 23 SAH, a shocking 70% had no detectable aneurysm.

CVST patients (n=18) were quite younger (mean 49 yo) females (61%) with a paucity of risk factors, yet some with prior anticoagulation (24%). Interestingly, they were rarely asymptomatic (22%), with a 56% rate of mechanical ventilation but an overall good outcome (67% discharged home, 17% mortality). Laboratory data showed mean D-Dimer was highest in ICH compared to AIS and even CVST (8668 vs 2654 vs 1080 ng/mL). While this seems counterintuitive, it highlights how we should be cautious of using lab values to guide empiric anticoagulation.

This was an interesting confirmatory study of trends observed in COVID-19 and neurovascular disease. It is clear that more severe strokes were observed overall relative to pre-pandemic times. The reasons are likely two-fold from a healthcare utilization hesitation by mild stroke patients and a likely underdiagnosis of mild stroke in severe COVID-19 infection. This study serves as a great example of collegial collaboration that is needed in times of hardship.