Risk, clinical course and outcome of ischemic stroke in patients hospitalized with COVID-19: a multicenter cohort study

  1. Wouter M. Sluis
  2. Marijke Linschoten
  3. Julie E. Buijs
  4. J. Matthijs Biesbroek
  5. Heleen M. den Hertog
  6. Tessa Ribbers
  7. Dennis Nieuwkamp
  8. Reinier C. van Houwelingen
  9. Andreas Dias
  10. Ingeborg W.M. van Uden
  11. Joost P. Kerklaan
  12. H. Paul Bienfait
  13. Sarah E. Vermeer
  14. Sonja W. de Jong
  15. Mariam Ali
  16. Marieke J.H. Wermer
  17. Marieke T. de Graaf
  18. Paul J.A.M. Brouwers
  19. Folkert W. Asselbergs
  20. L. Jaap Kappelle
  21. H. Bart van der Worp
  22. Annemijn M. Algra
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Abstract

Background and purpose

The frequency of ischemic stroke in patients with COVID-19 varies in the current literature, and risk factors are unknown. We assessed the incidence, risk factors, and outcomes of acute ischemic stroke in hospitalized patients with COVID-19.

Methods

We included patients with a laboratory confirmed SARS-CoV-2 infection admitted in 16 hospitals participating in the international CAPACITY-COVID registry between March 1st and August 1st, 2020. Patients were screened for the occurrence of acute ischemic stroke. We calculated the cumulative incidence of ischemic stroke and compared risk factors, cardiovascular complications, and in-hospital mortality in patients with and without ischemic stroke.

Results

We included 2147 patients with COVID-19, of whom 586 (27.3%) needed treatment at an intensive care unit (ICU). Thirty-eight patients (1.8%) had an ischemic stroke. Patients with stroke were older, but did not differ in sex or cardiovascular risk factors. Median time between onset of COVID-19 symptoms and diagnosis of stroke was two weeks. The incidence of ischemic stroke was higher among patients who were treated at an ICU (16/586; 2.7% versus 22/1561; 1.4%; p=0.039). Pulmonary embolism was more common in patients with (8/38; 21.1%) than in those without stroke (160/2109; 7.6%; adjusted RR: 2.08; 95%CI:1.52-2.84). Twenty-seven patients with ischemic stroke (71.1%) died during admission or were functional dependent at discharge and in-hospital mortality. Patients with ischemic stroke were at a higher risk of in-hospital mortality (adjusted RR 1.56; 95%CI:1.13-2.15) than patients without stroke.

Conclusions

In this multicenter cohort study, the cumulative incidence of acute ischemic stroke in hospitalized patients with COVID-19 was approximately 2%, with a higher risk in patients treated at an ICU. The majority of stroke patients had a poor outcome. The association between ischemic stroke and pulmonary embolism warrants further investigation.

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