How SARS-CoV-2 infection affects acute ischemic stroke outcomes

The ongoing coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), has affected millions of people around the world, with a high death rate and of morbidity. Importantly, SARS-CoV-2 infection has been associated with an increased risk of thromboembolic events. Acute ischemic stroke (AIS) is one of the common cerebrovascular complications related to COVID-19. A recent PLOS ONE log The study assessed the impact of COVID-19 on neurological outcomes in patients with AIS.

Study: The impact of SARS-CoV-2 infection on the outcome of acute ischemic stroke – A retrospective cohort study. Image Credit: April Stock / Shutterstock

Background

Several pathophysiological mechanisms, such as downregulation of angiotensin-converting enzyme-2 (ACE2) receptors and myocardial damage associated with COVID-19, have been shown to increase the risks of ischemic stroke. Several studies have indicated that the risk of AIS increases with higher SARS-CoV-2 disease severity.

Numerous studies have indicated that strokes related to COVID-19 occur in younger patients, with few or no risk factors. Moreover, the majority of AIS patients with concurrent SARS-CoV-2 infection were elderly and had several cardiovascular complications. Cardiovascular risk factors have also been found to increase the risk of AIS.

About the study

The current retrospective study analyzed data from thirty-two consecutive AIS patients with COVID-19 between March 1, 2020 and May 1, 2021. It compared the results with fifty-one consecutive non-COVID-19 AIS patients.

All AIS patients considered in this study had acute neurological signs of stroke and ischemia, confirmed by magnetic resonance imaging (MRI) and computed tomography (CT) of the head. For this study, the authors collected relevant demographic data, medical history, stroke characteristics, length of hospital stay, in-hospital mortality, number of patients transferred to an intensive care unit ( USI) and laboratory test reports.

Study results

The study cohort did not include any patients with mild symptoms; 50% had moderate symptoms, 37.5% had severe infections, and 12.5% ​​were severely infected with SARS-CoV-2. About 31% of the COVID-19 AIS group and 23.5% of the control group were treated with acute reperfusion therapy. Only severely critical patients required transfer to intensive care, and their length of hospitalization was slightly longer than that of the other groups. A moderately higher mortality rate was observed in severely critical COVID-19 AIS patients.

Consistent with previous studies, the current study observed no significant differences between the COVID-19 AIS and non-COVID-19 AIS groups based on age and gender. However, it should be noted that both groups were slightly male dominated.

In the context of medical history, the authors found no significant differences in history of malignancy, diabetes, ischemic heart disease, chronic kidney or lung disease, hyperlipemia, and peripheral arterial disease (PAD) between COVID -19 AIS and the control group. However, the prevalence of hypertension was significantly lower in the COVID-19 AIS group. The authors explained that in the non-COVID-19 group, the proportion of small vessel disease etiology, usually associated with hypertension, is higher than in the COVID-19 group. Additionally, all stroke risk factors were more common in COVID-19 patients.

Imagery data revealed that the territorial involvement of multiple vessels was similar in both COVID-19 and non-COVID-19 AIS groups. A higher rate of great vessel occlusion was found in the COVID-19 group, with greater LVO anterior circulation in the COVID-19 AIS group. Notably, in the COVID-19 AIS group, patients with pneumonia mainly had a higher prevalence of LVO, indicating a stronger association between COVID-19 pneumonia and LVO. In the future, further research is needed to validate this finding.

Interestingly, a significant difference in lymphocyte count (lower) and C-reactive protein (CRP) levels (higher) was found between COVID-19 and non-COVID-19 AIS patients. However, no other relevant differences were found in the other parameters tested.

In-hospital mortality was higher in the COVID-19 AIS group, along with an increased disability rate at discharge. Based on a subgroup analysis, the functional outcome of prior LVO patients in the COVID-19 AIS group was less favorable compared to the non-COVID-19 AIS group. The elderly group, with more cerebrovascular risk factors, was found to be at higher risk of contracting COVID-19 as well as AIS.

Study limitations

One of the main limitations of the current study is its small sample size, which resulted in results not reaching statistical significance. Another limitation is the retrospective design of the study, where the authors only assessed laboratory tests and other available medical data, but did not conduct patient interviews.

conclusion

Compared to non-COVID-19 AIS, AIS with SARS-CoV-2 infection resulted in poorer functional outcomes, more severe neurological deficits, and higher mortality. In addition, severe infection was associated with poorer outcomes. This study highlights the importance of providing personalized multidisciplinary care, such as expertise in neurology, pulmonology and critical care, for this vulnerable group to protect them from adverse outcomes.