Large studies reported at American Stroke Association virtual International Stroke Conference (ISC) homed in on more accurate estimates of the stroke implications of COVID-19.
Ischemic stroke incidence among COVID-19 patients in the American Heart Association (AHA) COVID-19 Registry was 0.75% overall, reported Saate Shakil, MD, of the University of Washington in Seattle.
That rate was lower than the 0.9% to 2% reported in other studies of stroke in COVID-19 patients, she noted during an ISC late-breaking trial session.
However, the series was much larger than those prior studies, which topped out at about 8,000 patients, she pointed out.
Another factor was that the registry data extended from March through November 2020, and the data showed a trend for higher stroke numbers in the spring pandemic peak than in the later period, Shakil told MedPage Today at a press conference.
The study included 21,073 hospitalized patients with SARS-CoV-2 during the study period who had race or ethnicity information recorded, among the total of more than 31,000 in the AHA COVID-19 CVD Registry as part of the “Get With the Guidelines” database.
A separate international study of 6,698 COVID-19 patients admitted to nine stroke centers showed a 1.3% incidence of stroke. Of those 88 cases, 60% (53) were large vessel occlusions (LVOs).
While the predominance of large vessel strokes has been reported before, this large series affirmed it, Dileep R. Yavagal, MD, MBBS, of the University of Miami, told MedPage Today. His group reported the findings at ISC and online in Neurosurgery.
The retrospective study included consecutive patients admitted with acute ischemic stroke and COVID-19 from March 1 to May 1, 2020, at 12 stroke centers from four countries, although three of the centers were excluded from the stroke incidence calculation as they only accepted LVO transfer patients.
Large vessel occlusion was also more prominent in a separate analysis of the “Get With The Guidelines-Stroke” database, accounting for 30.4% of acute ischemic strokes in COVID-19 patients versus 23.6% among non-COVID stroke patients.
The analysis of 41,971 acute ischemic stroke patients (1,143 with COVID-19) hospitalized between Feb. 4 and June 29, 2020, at 458 participating hospitals was reported by Gregg Fonarow, MD, of the University of California Los Angeles, and colleagues at ISC and online in Stroke.
Notable among the findings were the significantly longer delays in treatment, despite the similar rates of thrombolysis and thrombectomy:
- Door to CT: median 55 vs 35 min
- Door to needle: 59 vs 46 min
- Door to endovascular therapy: 114 vs 90 min
Yavagal said this fit with his experience. “Looking at our own center data, the COVID-positive patients do get delayed because of PPE [personal protective equipment] issues,” he said. “In the range of about a 10- to 20-minute delay is, thankfully, not huge but does matter in stroke because those neurons are dying.”
Outcomes were also worse for the COVID-19 patients, as has been seen previously in smaller studies. Discharge with modified Rankin Scale score of ≤2 was 35% less likely, and in-hospital mortality was more than four-fold elevated compared with other stroke patients.
In Shakil’s study, the COVID-19 patients were twice as likely to need ICU care or die, and had twice the hospital length of stay as other ischemic stroke patients.
All three studies showed a disproportionate burden of stroke or LVO in COVID-19 among non-Hispanic Black patients.
Fonarow’s analysis showed elevated risk for Hispanic and Asian patients as well, but Shakil’s study found actually a lower risk for Hispanic patients. She said it wasn’t clear why that might have been, although co-author and AHA President Mitchell Elkind, MD, suggested that the timing of the studies could have played a role as different areas of the country with different demographics were more severely impacted early versus late in the pandemic.
These studies show the strength of large numbers, commented ISC chair Louise McCullough, MD, PhD, of the University of Texas Health Science Center at Houston.
She also pointed to the bigger picture of how infections more generally affect stroke risk.
“We’re looking at the immediate effects of COVID,” she noted. The question though is for the millions who have recovered from it, what are the long-term implications for repeat events, dementia, and other neurological issues over the next decades. Datasets like this will help answer those questions, she said. “Even if COVID completely disappears next year, it’s never going to disappear because of the sheer number of people it has touched and affected.”
While it took some effort to get the data forms updated, Elkind noted that there will be data in the AHA registries on COVID-19 vaccination to be mined to find out more about impact on stroke and other clinical questions.
Shakil disclosed no relevant relationships with industry.
The study by Fonarow’s group was supported by Genentech. Fonarow disclosed relevant relationships with Abbott, Amgen, CHF Solutions, Janssen, Medtronic, Merck, and Novartis.
Yavagal disclosed relevant relationships with Medtronic, Cerenovus, Rapid Medical, Neuralanalytics, Vascular Dynamics, Inneuroco, Poseydon Medical, and Deck Therapeutics.