Mona Al Banna, MB BCh, Msc(Res)
Martí-Fàbregas J, Guisado-Alonso D, Delgado-Mederos R, Martínez-Domeño A, Prats-Sánchez L, Guasch-Jiménez M, Cardona P, Núñez-Guillén A, Requena M, Rubiera M, et al. Impact of COVID-19 Infection on the Outcome of Patients With Ischemic Stroke. Stroke. 2021.
Various studies are showing that neurologic complications, including stroke, occur frequently in COVID-19 patients. In addition, the COVID-19 pandemic has compromised the delivery of well-established time-sensitive therapies and system delivery in stroke care. The authors of this study set out to determine whether patients with stroke and COVID-19 had worse functional outcomes compared to patients without COVID-19 and, if so, evaluate whether this was attributable to direct effects of the virus itself or due to logistical difficulties of providing care during a global pandemic.
The authors conduced a prospective multicentered cohort study of 19 hospitals in Catalonia, Spain, from mid-March to May 15, 2020. Patients were eligible if they had an acute ischemic stroke with a previous modified Rankin Scale (mRS) of 0-3. Patients were then classified according to their SARS-CoV-2 PCR status. The authors then collected various data variables, including demographic data, vascular risk factor profiles, pre-admission medications, NIHSS on admission and at 72 hours, imaging data, reperfusion therapies (and, if applicable, TICI scores), time metrics (e.g., door to needle, door to groin), stroke etiology and functional outcome at 3 months.
A total of 701 patients were studied, of which 13% were diagnosed with COVID-19. In those 13%, the infection was diagnosed before the stroke in 6%, and in the remainder, COVID-19 was detected after hospitalization. In the COVID-19 positive group, 29% were admitted to the ICU, and 22% required mechanical ventilation. Both the COVID-19 and non-COVID-19 groups were similar in most variables except for median baseline NIHSS score. It was two points higher in the COVID-19 group compared to the non-COVID-19 group (8 [3-18] vs 6 [2-14], p=0.049). In addition, more of the COVID-19 population was admitted to the ICU. There were 43% of the patients with an LVO in the COVID-19 group and 33% in the non-COVID-19 group (p=0.059). For this group, baseline NIHSS, proportion of patients who received fibrinolysis, proportion of patients treated with mechanical thrombectomy and rates of successful recanalization were similar regardless of COVID-19 status.
The median mRS score at 3 months was 4 (IQR 2-6) in the COVID-19 group and 3 (IQR 1-4) in the non-COVID-19 group (p<0.001). However, with regression analysis and adjustment for age and baseline NIHSS, the odds radio (indicating odds of worsening by 1 point on the mRS) was not statistically significant (2.03 [95% CI, 1.31 to 3.13; p=0.001]). COVID-19 was found to be a risk factor for mortality (HR 3.14 [95% CI, 2.10-4.71; p<0.001]). The study authors concluded that patients with ischemic stroke and concomitant COVID-19 infection had a more severe neurological deficit at admission and at 72 hours, and higher mortality (3.1-fold). They indicate that despite presenting with similar demographics, risk factor profile and time from the onset of symptoms, stroke severity measured by the NIHSS score was higher in the COVID-19 patients. It is important to note, however, that this was an increase of only 2 points on the NIHSS and barely reached the statistically significant threshold. In addition, it was not specified what the 2-point increase was most commonly.. I do not think these results are robust enough to conclude that patients with COVID-19 and stroke will have a worse functional outcome at 3 months or that they are worse neurologically at baseline presentation. However, this is a key study in noting that the cohort of patients with stroke and COVID-19 is a vulnerable population group prone to worsening neurologic status while hospitalized and has a greater admission rate to the ICU and a higher mortality rate. It is also commendable that in the hospital systems studied, there did not seem to be delays in provision of care and time-sensitive therapies to COVID-19 patients compared to non-COVID-19 patients.