Overall Stroke Risk Appears Low With COVID-19 Infection

Ramin Zand, MD

A multinational study on patients hospitalized with SARS-CoV-2 infection (COVID-19) suggests that the overall risk of stroke was low, in light of increasing reports of connections between stroke and COVID-19 infections.¹

All told, the data revealed a risk of stroke of 0.5% (pooled risk, 0.9%) at all center included, rising to 0.7% among countries with higher health expenditures. Notably, the need for mechanical ventilation (OR, 1.9; 95% CI, 1.1–3.5; P = .03) and the presence of ischemic heart disease (OR, 2.5; 95% CI, 1.4–4.7; P = .006) were the most predictive indicators of stroke.

The study was led by Ramin Zand, MD, vascular neurologist and clinician-scientist, Geisinger, and colleagues, and their observational analyses included data from 17,799 hospitalized patients from 99 centers in North and South America (including the United States, Canada, and Brazil), Europe (including Greece, Italy, Finland, and Turkey), Asia (including Lebanon, Iran, and India), and Oceania (New Zealand). Data were collected until May 1, 2020.

“For clinicians, knowing the rate of stroke among COVID-19 patients is important when deciding to order confirmatory brain imaging for stroke diagnosis,” Zand said in a statement.² “Having a clear understanding of the rate of stroke among hospitalized patients with COVID-19 infection is the first step towards better patient management and risk mitigation.”

The risk of subsequent stroke was estimated through meta-analyses with random effect models. Bivariate logistic regression was used to determine the parameters with predictive outcome value. The study was reported according to the STROBE, MOOSE, and EQUATOR guidelines.

READ MORE: Neurological Deterioration May Play a Factor in Stroke Outcome​

Among the almost 18,000 patients included, 156 (0.9%) had a stroke. Of those, 123 (79%) had ischemic stroke, 27 (17%) had intracerebral/subarachnoid hemorrhage, and 6 (4%) had cerebral sinus thrombosis. The mean age of those with ischemic stroke was 68.6 years (standard deviation [SD], 13.9), among those with intracranial hemorrhage was 62.5 years (SD, 15.3), and among those with cerebral venous thrombosis was 50.3 years (SD, 12.9).

In total, 43 (27.6%) of the patients with stroke presented with stroke-related symptoms as their major complaint and without the prior diagnosis of SAR-CoV-2 infection. Those with an acute ischemic stroke had a median National Institutes of Health Stroke Scale (NIHSS) score of 9.5 (range, 6.0–19.0) on admission. Of those, 80 patients (65%) had MRI data available for assessment—ischemic strokes could be considered as lacunar in 6 (7.5%), embolic/large vessel athero-thromboembolism in 58 (72.5%), and other phenotypes (borderzone or equivocal: n = 16; 20.0%).

Those with intracerebral/subarachnoid hemorrhage presented with an NIHSS score of 13 (range, 8.0–17.0) and an intracerebral hemorrhage (ICH) score of 3.0 (range, 2.0–4.0). Those included 25 (93%) with an intracerebral hemorrhage and 2 (7%) with subarachnoid hemorrhage. Among the 6 patients with cerebral venous thrombosis, 2 (33%) patients had episodes of seizures prior to hospital admission.

Zand et al. noted that when conducting meta-analyses by continent, they reported a subsequent stroke risk ranging from 0.7% to 1.2% in North America, 0.5% in Europe, and 0.3% in Asia. “This difference might be due to many factors including policy variation among different healthcare systems for the hospitalization of SARS-CoV-2 infected patients,” they wrote, acknowledging variance in admission standards for infected patients as well as the availability of center resources and confirmation of infection.

"Our experience using machine learning and artificial intelligence has been very positive here at Geisinger, and we see huge potential to continue its use during these uncertain times," said coauthor Vida Abedi, PhD, scientist, department of molecular and functional genomics, Geisinger, in a statement."We are well equipped to break new ground in identifying potential venues to improve care for stroke patients, even as they are affected by COVID-19 infection and its related complications."

In July, data from a retrospective cohort study from 2 academic hospitals in New York City suggest that an estimated 1.6% of adults with COVID-19 who were hospitalized or presented to the emergency department experienced an ischemic stroke—a higher rate than that of a comparative cohort of patients with influenza. The study included a COVID-19 cohort of 1916 patients (data collected March 4, 2020, to May 2, 2020), of which 31 patients (1.6%; 95% CI, 1.1—2.3) had an acute ischemic stroke, and an influenza cohort of 1486 patients (data collected January 1, 2016, to May 31, 2018), of which 3 patients (0.2%; 95% CI, 0.0–0.6) had an acute ischemic stroke.³

REFERENCES
1. Shahjouei S, Naderi S, Li J, et al. Risk of stroke in hospitalized SARS-CoV-2 infected patients: A multinational study. EBioMed. 2020;59:102939.doi: 10.1016/j.ebiom.2020.102939
2. Geisinger scientists lead multinational study of COVID-19 and stroke. News release. Danville, PA. Geisinger Health System. Published September 11, 2020. Accessed October 9, 2020. prnewswire.com/news-releases/geisinger-scientists-lead-multinational-study-of-covid-19-and-stroke-301128495.html
3.Merkler AE, Parikh NS, Mir S, et al. Risk of Ischemic Stroke in Patients With Coronavirus Disease 2019 (COVID-19) vs Patients With Influenza. JAMA Neurol. Published online July 2, 2020. doi:10.1001/jamaneurol.2020.2730