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Global COVID-19 registry finds strokes associated with COVID-19 are more severe, have worse outcomes and higher mortality

July 10, 2020

DALLAS, July 10, 2020 -- Acute ischemic strokes (AIS) associated with COVID-19 are more severe, lead to worse functional outcomes and are associated with higher mortality , according to new research published yesterday in Stroke, a journal of the American Stroke Association, a division of the American Heart Association.

In "Characteristics and Outcomes in Patients with COVID-19 and Acute Ischemic Stroke: The Global COVID-19 Stroke Registry," researchers analyzed data on patients with COVID-19 and AIS treated at 28 health care centers in 16 countries this year and compared them to patients without COVID-19 from the Acute Stroke Registry and Analysis of Lausanne (ASTRAL) Registry, from 2003 to 2019. Researchers sought to determine the clinical characteristics and outcomes of patients with COVID-19 and AIS.

Between January 27, 2020 to May 19, 2020, there were 174 patients hospitalized with COVID-19 and AIS. Each COVID-19 patient with AIS was matched and compared to a non-COVID-19 AIS patient based on a set of pre-specified factors including age, gender and stroke risk factors (hypertension, diabetes, atrial fibrillation, coronary artery disease, heart failure, cancer, previous stroke, smoking, obesity and dyslipidemia). The final analysis included 330 patients total.

In both patient groups, stroke severity was estimated with the National Institute of Health Stroke Scale (NIHSS), and stroke outcome was assessed by the modified Rankin score (mRS). When AIS patients with COVID-19 were compared to non-COVID-19 patients:

COVID-19 patients had more severe strokes (median NIHSS score of 10 vs. 6, respectively);

COVID-19 patients had higher risk for severe disability following stroke (median mRS score 4 vs. 2, respectively); and

COVID-19 patients were more likely to die of AIS.

The researchers noted there are several potential explanations for the relationship between COVID-19-associated strokes and increased stroke severity: "The increased stroke severity at admission in COVID-19-associated stroke patients compared to the non-COVID-19 cohort may explain the worse outcomes. The broad, multi-system complications of COVID-19, including acute respiratory distress syndrome, cardiac arrhythmias, acute cardiac injury, shock, pulmonary embolism, cytokine release syndrome and secondary infection, probably contribute further to the worse outcomes including higher mortality in these patients. ... The association highlights the urgent need for studies aiming to uncover the underlying mechanisms and is relevant for prehospital stroke awareness and in-hospital acute stroke pathways during the current and future pandemics."
Co-authors are George Ntaios, M.D., M.Sc., Ph.D.; Patrik Michel, M.D.; Georgios Georgiopoulos, M.D.; Yutao Guo, M.D.; Wencheng Li, M.D.; Jing Xiong, M.D.; Patricia Calleja, M.D.; Fernando Ostos, M.D.; Guillermo González-Ortega, M.D.; Blanca Fuentes, M.D., Ph.D.; María Alonso de Leciñana, M.D., Ph.D.; Exuperio Díez-Tejedor, M.D., Ph.D.; Sebastian García-Madrona, M.D.; Jaime Masjuan, M.D., Ph.D.; Alicia DeFelipe, M.D.; Guillaume Turc, M.D.; Bruno Gonçalves, M.D.; Valerie Domigo, M.D.; Gheorghe-Andrei Dan, M.D.; Roxana Vezeteu, M.D.; Hanne Christensen, M.D.; Louisa Marguerite Christensen, M.D., Ph.D.; Per Meden, M.D.; Lejla Hajdarevic, M.D.; Angela Rodriguez-Lopez, M.D.; Fernando Díaz-Otero, M.D.; Andrés García-Pastor, M.D., Ph.D.; Antonio Gil-Nuñez, M.D., Ph.D.; Errikos Maslias, M.D.; Davide Strambo, M.D.; David J. Werring, M.D., Ph.D.; Arvind Chandratheva, M.D.; Laura Benjamin, M.D.; Robert Simister, M.D., Ph.D.; Richard Perry, M.D.; Rahma Beyrouti M.D.; Pascal Jabbour, M.D., Ph.D.; Ahmad Sweid, M.D.; Stavropoula Tjoumakaris, M.D.; Elisa Cuadrado-Godia, M.D.; Ana Rodríguez Campello, M.D.; Jaume Roquer, M.D.; Tiago Moreira, M.D.; Michael V. Mazya, M.D.; Fabio Bandini, M.D.; Karl Matz, M.D.; Helle K. Iversen, M.D.; Alejandra González-Duarte, M.D.; Cristina Tiu, M.D., Ph.D.; Julia Ferrari, M.D.; Milan R. Vosko, M.D.; Helmut J.F. Salzer, M.D.; Bernd Lamprecht, M.D.; Martin W. Dünser, M.D.; Carlo W. Cereda, M.D.; Ángel Basilio Corredor Quintero, M.D.; Eleni Korompoki, M.D., Ph.D.; Eduardo Soriano-Navarro, M.D.; Luis Enrique Soto-Ramírez, M.D.; Paulo F. Castañeda-Méndez, M.D.; Daniela Bay-Sansores, M.D.; Antonio Arauz, M.D.; Vanessa Cano-Nigenda, M.D.; Espen Saxhaug Kristoffersen, M.D., Ph.D.; Marjaana Tiainen, M.D.; Daniel Strbian, M.D.; Jukka Putaala, M.D.; and Gregory Y.H. Lip, M.D. Author disclosures are detailed in the manuscript.

No funding sources were reported for this study.

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About the American Stroke Association

The American Stroke Association is devoted to saving people from stroke -- the No. 2 cause of death in the world and a leading cause of serious disability. We team with millions of volunteers to fund innovative research, fight for stronger public health policies and provide lifesaving tools and information to prevent and treat stroke. The Dallas-based association officially launched in 1998 as a division of the American Heart Association. To learn more or to get involved, call 1-888-4STROKE or visit Follow us on Facebook and Twitter.

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