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Cerebrovascular disease
Original research
Acute ischaemic stroke associated with SARS-CoV-2 infection in North America
  1. Adam A Dmytriw1,2,
  2. Mahmoud Dibas1,
  3. Kevin Phan1,
  4. Aslan Efendizade3,4,
  5. Johanna Ospel5,
  6. Clemens Schirmer6,
  7. Fabio Settecase7,
  8. Manraj K S Heran7,
  9. Anna Luisa Kühn8,
  10. Ajit S Puri8,
  11. Bijoy K Menon5,
  12. Sanjeev Sivakumar9,
  13. Askan Mowla10,
  14. Daniel Vela-Duarte11,
  15. Italo Linfante11,
  16. Guilherme C Dabus11,
  17. Robert W Regenhardt2,
  18. Salvatore D'Amato1,
  19. Joseph A Rosenthal1,
  20. Alicia Zha12,
  21. Nafee Talukder12,
  22. Sunil A Sheth12,
  23. Ameer E Hassan13,
  24. Daniel L Cooke14,
  25. Lester Y Leung15,
  26. Adel M Malek15,
  27. Barbara Voetsch16,
  28. Siddharth Sehgal16,
  29. Ajay K Wakhloo16,
  30. Mayank Goyal5,
  31. Hannah Wu17,18,19,
  32. Jake Cohen17,18,19,
  33. Sherief Ghozy1,
  34. David Turkel-Parella17,18,19,
  35. Zerwa Farooq3,4,
  36. Justin E Vranic2,
  37. James D Rabinov2,
  38. Christopher J Stapleton2,
  39. Ramandeep Minhas3,4,
  40. Vinodkumar Velayudhan3,4,
  41. Zeshan Ahmed Chaudhry3,4,
  42. Andrew Xavier20,21,
  43. Maria Bres Bullrich22,
  44. Sachin Pandey22,
  45. Luciano A Sposato22,
  46. Stephen A Johnson23,
  47. Gaurav Gupta23,
  48. Priyank Khandelwal23,
  49. Latisha Ali24,
  50. David S Liebeskind24,
  51. Mudassir Farooqui25,
  52. Santiago Ortega-Gutierrez25,
  53. Fadi Nahab26,
  54. Dinesh V Jillella26,
  55. Karen Chen1,
  56. Mohammad Ali Aziz-Sultan1,
  57. Mohamad Abdalkader27,
  58. Artem Kaliaev27,
  59. Thanh N Nguyen27,
  60. Diogo C Haussen28,
  61. Raul G Nogueira28,
  62. Israr Ul Haq29,
  63. Osama O Zaidat29,30,
  64. Emma Sanborn31,
  65. Thabele M Leslie-Mazwi2,
  66. Aman B Patel2,
  67. James E Siegler31,
  68. Ambooj Tiwari17,18,19
  69. on behalf of the North American Neurovascular COVID-19 (NAN-C) Consortium & Society of Vascular and Interventional Neurology (SVIN) Investigators
  1. 1 Neuroradiology, Neurosurgery & Neurology Services, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
  2. 2 Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
  3. 3 Department of Neuroradiology, University Hospital Brooklyn, SUNY Downstate School of Medicine, Brooklyn, New York, USA
  4. 4 Department of Neuroradiology, Kings County Hospital, NYC Health and Hospitals, Brooklyn, New York, USA
  5. 5 Calgary Stroke Program, Cumming School of Medicine, Calgary, AB, Canada
  6. 6 Department of Neurosurgery & Neuroscience Institute, Geisinger Health, Geisinger Health, PA, USA
  7. 7 Division of Neuroradiology, Vancouver General Hospital, Vancouver, BC, Canada
  8. 8 Division of Neurointerventional Radiology, Department of Radiology, UMass Memorial Medical Center, Worcester, Massachusetts, USA
  9. 9 Department of Medicine (Neurology), Prisma Health Upstate, USC, Greenville, SC, USA
  10. 10 Department of Neurological Surgery, USC Keck School of Medicine, Los Angeles, CA, USA
  11. 11 Neuroradiology & Neurology Services, Miami Baptist Medical Center, Miami, FL, USA
  12. 12 Department of Neurology, UT Health Science Center, Houston, TX, USA
  13. 13 Department of Neurology, University of Texas Rio Grande Valley, Valley Baptist Medical Center, Harlingen, TX, USA
  14. 14 Department of Neurointerventional Radiology, University California San Francisco, San Francisco, CA, USA
  15. 15 Departments of Neurology and Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA
  16. 16 Departments of Neurology & Neurointerventional Radiology, Lahey Hospital and Medical Center, Burlington, MA, USA
  17. 17 Department of Neurology, Brookdale University Hospital & Medical Center, Brooklyn, NY, USA
  18. 18 Department of Neurology & Neurosurgery, St. Francis Hospital, Roslyn, NY, USA
  19. 19 Department of Neurology, NYU Grossman School of Medicine, New York, NY, USA
  20. 20 Department of Neurology, St Joseph Mercy Health System, Ann Arbor, MI, USA
  21. 21 Department of Neurology, Sinai Grace Hospital, Detroit, MI, USA
  22. 22 Departments of Neurology & Neuroradiology, London Health Sciences Centre, London, Ontario, Canada
  23. 23 Departments of Neurology & Neurosurgery, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
  24. 24 Department of Neurology, UCLA Medical Center, University of California, Los Angeles, California, USA
  25. 25 Department of Neurology, The University of Iowa Hospitals and Clinics, Iowa City, IO, USA
  26. 26 Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
  27. 27 Departments of Neurology and Radiology, Boston University Medical Center, Boston, Massachusetts, USA
  28. 28 Department of Neurology, Grady Memorial Hospital, Atlanta, Georgia, USA
  29. 29 Neuroscience Institute, Bon Secours Mercy Health St Vincent Hospital, Toledo, OH, USA
  30. 30 Department of Neuroscience, St Vincent Mercy Hospital, Toledo, Ohio, USA
  31. 31 Cooper Neurological Institute, Cooper University Hospital, Camden, New Jersey, USA
  1. Correspondence to Dr Adam A Dmytriw, Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; admytriw{at}mgh.harvard.edu

Abstract

Background To analyse the clinical characteristics of COVID-19 with acute ischaemic stroke (AIS) and identify factors predicting functional outcome.

Methods Multicentre retrospective cohort study of COVID-19 patients with AIS who presented to 30 stroke centres in the USA and Canada between 14 March and 30 August 2020. The primary endpoint was poor functional outcome, defined as a modified Rankin Scale (mRS) of 5 or 6 at discharge. Secondary endpoints include favourable outcome (mRS ≤2) and mortality at discharge, ordinal mRS (shift analysis), symptomatic intracranial haemorrhage (sICH) and occurrence of in-hospital complications.

Results A total of 216 COVID-19 patients with AIS were included. 68.1% (147/216) were older than 60 years, while 31.9% (69/216) were younger. Median [IQR] National Institutes of Health Stroke Scale (NIHSS) at presentation was 12.5 (15.8), and 44.2% (87/197) presented with large vessel occlusion (LVO). Approximately 51.3% (98/191) of the patients had poor outcomes with an observed mortality rate of 39.1% (81/207). Age >60 years (aOR: 5.11, 95% CI 2.08 to 12.56, p<0.001), diabetes mellitus (aOR: 2.66, 95% CI 1.16 to 6.09, p=0.021), higher NIHSS at admission (aOR: 1.08, 95% CI 1.02 to 1.14, p=0.006), LVO (aOR: 2.45, 95% CI 1.04 to 5.78, p=0.042), and higher NLR level (aOR: 1.06, 95% CI 1.01 to 1.11, p=0.028) were significantly associated with poor functional outcome.

Conclusion There is relationship between COVID-19-associated AIS and severe disability or death. We identified several factors which predict worse outcomes, and these outcomes were more frequent compared to global averages. We found that elevated neutrophil-to-lymphocyte ratio, rather than D-Dimer, predicted both morbidity and mortality.

  • COVID-19
  • stroke
  • interventional

Data availability statement

Data are available on reasonable request.

This article is made freely available for personal use in accordance with BMJ’s website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.

https://bmj.com/coronavirus/usage

https://doi.org/10.1136/jnnp-2021-328354

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    Data availability statement

    Data are available on reasonable request.

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    Footnotes

    • Twitter @AdamDmytriw, @adelmalek, @nanconsortium, @dineshjillella, @NguyenThanhMD, @amboojtiwari

    • Correction notice This article has been corrected since it first published. Author name 'Ospel Johanna' has been transposed.

    • Contributors Conception or design of the work: AAD, MD, KP, AE, AT. Performing the procedures: AAD, MD, KP, AE, OJ, CS, FS, MKSH, ALK, ASP, BKM, SS, AM, DV-D, IL, GCD, RWR, SD'A, JAR, AZ, NT, SAS, AEH, DLC, LYL, AMM, BV, SS, AKW, MG, HW, JC, SG, DT-P, JV, JDR, CJS, RM, VV, ZAC, AX, MBB, SP, LAS, SAJ, GG, PK, LA, DSL, MF, SO-G, FN, DVJ, KC, MAA-S, MA, AK, TNN, DCH, RGN, IUH, OOZ, ES, TML-M, ABP, JES and AT. Data acquisition and analysis: AAD, MD, KP, AE, OJ, CS, FS, MKSH, ALK, ASP, BKM, SS, AM, DV-D, IL, GCD, RWR, SD'A, JAR, AZ, NT, SAS, AEH, DLC, LYL, AMM, BV, SS, AKW, MG, HW, JC, SG, DT-P, JV, JDR, CJS, RM, VV, ZAC, AX, MBB, SP, LAS, SAJ, GG, PK, LA, DSL, MF, SO-G, FN, DVJ, KC, MAA-S, MA, AK, TNN, DCH, RGN, IUH, OOZ, ES, TML-M, ABP, JES and AT. Interpretation of data: AAD, MD, KP, AE, AT. Drafting the work: AAD, MD, KP, AE, AT. Revising the work for valuable intellectual content: AAD, MD, KP, AE, OJ, CS, FS, MKSH, ALK, ASP, BKM, SS, AM, DV-D, IL, GCD, RWR, SD'A, JAR, AZ, NT, SAS, AEH, DLC, LYL, AMM, BV, SS, AKW, MG, HW, JC, SG, DT-P, JV, JDR, CJS, RM, VV, ZAC, AX, MBB, SP, LAS, SAJ, GG, PK, LA, DSL, MF, SO-G, FN, DVJ, KC, MAA-S, MA, AK, TNN, DCH, RGN, IUH, OOZ, ES, TML-M, ABP, JES and AT. Final approval of the version: AAD, MD, KP, AE, OJ, CS, FS, MKSH, ALK, ASP, BKM, SS, AM, DV-D, IL, GCD, RWR, SD'A, JAR, AZ, NT, SSS, AEH, DLC, LYL, AMM, BV, SS, AKW, MG, HW, JC, SG, DT-P, JV, JDR, CJS, RM, VV, ZAC, AX, MBB, SP, LAS, SAJ, GG, PK, LA, DSL, MF, SO-G, FN, DVJ, KC, MAA-S, MA, AK, TNN, DCH, RGN, IUH, OOZ, ES, TML-M, ABP, JES and AT. Authors responsible for the overall content as the guarantors: AAD and AT.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.