Stroke occurs frequently in COVID-19, leads to ‘devastating consequences’ for patients

Respiratory symptom severity served as the most significant indicator of in-hospital mortality among patients with COVID-19 who had a stroke, according to a systematic review published in Neurology.

Older age and a greater number of cardiovascular comorbidities also correlated with in-hospital mortality in this patient population, study findings demonstrated.

“To date, relatively little is known about the frequency, clinical characteristics and outcomes of acute cerebrovascular events in patients with COVID-19,” the researchers wrote. “We hypothesized that stroke is a frequent complication among COVID-19 patients, that in-hospital mortality is higher in patients with stroke and COVID-19 compared to historical non-COVID-19 cohorts, and that young patients would show a higher mortality due to a higher incidence of large vessel occlusion (LVO).”

The researchers added that the burden on the health care system and other factors related to the pandemic have led the frequency of stroke events to be underestimated.

Sebastian Fridman, MD, MPH, of the department of clinical neurological sciences at Schulich School of Medicine and Dentistry, Western University, in Ontario, and colleagues’ systematic review analyzed studies published between November 1, 2019, and May 29, 2020, with a random-effects meta-analysis. The review included studies that addressed the proportion of patients with COVID-19 who experience a stroke event, the type of cerebrovascular event and the mortality rate.

The intended outcomes of the review were to estimate the proportion of COVID-19 patients who experience stroke; analyze their comorbidities, clinical characteristics and outcomes; determine clinical phenotypes; and compare in-hospital mortality between those clinical phenotypes.

Fridman and colleagues analyzed data from 10 published studies that were pooled with one unpublished series from Canada. They applied random-effects meta-analyses to determine the number of strokes that occurred among patients with COVID-19. They also conducted an additional systematic search for case series of strokes in patients with COVID-19 (n = 125) and pooled that data with 35 unpublished studies from Canada, the United States and Iran.

The researchers assessed in-hospital mortality rates for patients who experienced a stroke between 14 days before and 60 days after a COVID-19 diagnosis and compared results between patients under age 50, those aged 51-70 and those over age 70. They applied cluster analyses to determine different clinical phenotypes and their relationships with mortality.

Fridman and colleagues found that 1.8% of patients with COVID-19 experienced a stroke (95% CI, 0.9%-3.7%), including 1.5% who had an ischemic stroke (95% CI, 0.8%-2.8%). They also reported an in-hospital mortality rate of 34.4% (95% CI, 27.2%-42.2%). Both the rates of stroke and in-hospital mortality were “exceedingly high,” according to the researchers.

Patients aged less than 50 years experienced a mortality rate that was 67% lower relative to those aged more than 70 years (OR = 0.33; 95% CI, 0.12-0.94). Large vessel occlusion occurred at twice the frequency reported in previous studies (46.9%) and was high across all age groups, “even in the absence of risk factors or comorbidities.” Fridman and colleagues found that a clinical phenotype characterized by older age, increased comorbidity burden and severe COVID-19-related respiratory symptoms correlated with the highest rates of in-hospital mortality (58.6%) and a risk for death three times greater than the rest of the cohort (OR = 3.52; 95% CI, 1.53-8.09).

“Interestingly, 50% of patients <50 years old experienced their strokes before the onset of COVID-19 respiratory symptoms, and this was significantly more frequent than in other age groups,” the researchers wrote. “This finding may imply that, in the COVID-19 era, younger patients presenting to the [ED] with acute stroke would need to be tested for SARS-COV-2 even in the absence of specific symptoms or regardless of having passed a COVID-19 screen.”

The researchers found that stroke is “relatively frequent” among patients with COVID-19, with “devastating consequences” for patients of all ages.

“Our findings should serve as information for guiding prognostication, resource allocation, and counseling of patients and their families,” Fridman and colleagues wrote.