Cerebrovascular events and outcomes in hospitalized patients with COVID-19: The SVIN COVID-19 Multinational Registry

Siegler, James E; Cardona, Pere; Arenillas, Juan F; Talavera, Blanca; Guillen, Ana N; Chavarría-Miranda, Alba; de Lera, Mercedes; Khandelwal, Priyank; Bach, Ivo; Patel, Pratit; Singla, Amit; Requena, Manuel; Ribo, Marc; Jillella, Dinesh V; Rangaraju, Srikant; Nogueira, Raul G; Haussen, Diogo C; Vazquez, Alejandro R; Urra, Xabier; Chamorro, Ángel; Román, Luis S; Thon, Jesse M; Then, Ryna; Sanborn, Emma; de la Ossa, Natalia P; Millà n, Mònica; Ruiz, Isaac N; Mansour, Ossama Y; Megahed, Mohammed; Tiu, Cristina; Terecoasa, Elena O; Radu, Răzvan A; Nguyen, Thanh N; Curiale, Gioacchino; Kaliaev, Artem; Czap, Alexandra L; Sebaugh, Jacob; Zha, Alicia M; Liebeskind, David S; Ortega-Gutierrez, Santiago; Farooqui, Mudassir; Hassan, Ameer E; Preston, Laurie; Patterson, Mary S; Bushnaq, Saif; Zaidat, Osama; Jovin, Tudor G

BACKGROUND: Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) has been associated with a significant risk of thrombotic events in critically ill patients. AIM: To summarize the findings of a multinational observational cohort of patients with SARS-CoV-2 and cerebrovascular disease. METHODS: Retrospective observational cohort of consecutive adults evaluated in the emergency department and/or admitted with coronavirus disease 2019 (COVID-19) across 31 hospitals in four countries (1 February 2020–16 June 2020). The primary outcome was the incidence rate of cerebrovascular events, inclusive of acute ischemic stroke, intracranial hemorrhages (ICH), and cortical vein and/or sinus thrombosis (CVST). RESULTS: Of the 14,483 patients with laboratory-confirmed SARS-CoV-2, 172 were diagnosed with an acute cerebrovascular event (1.13% of cohort; 1130/100,000 patients, 95%CI 970–1320/100,000), 68/171 (40.5%) were female and 96/172 (55.8%) were between the ages 60 and 79 years. Of these, 156 had acute ischemic stroke (1.08%; 1080/100,000 95%CI 920–1260/100,000), 28 ICH (0.19%; 190/100,000 95%CI 130–280/100,000), and 3 with CVST (0.02%; 20/100,000, 95%CI 4–60/100,000). The in-hospital mortality rate for SARS-CoV-2-associated stroke was 38.1% and for ICH 58.3%. After adjusting for clustering by site and age, baseline stroke severity, and all predictors of in-hospital mortality found in univariate regression (p < 0.1: male sex, tobacco use, arrival by emergency medical services, lower platelet and lymphocyte counts, and intracranial occlusion), cryptogenic stroke mechanism (aOR 5.01, 95%CI 1.63–15.44, p < 0.01), older age (aOR 1.78, 95%CI 1.07–2.94, p = 0.03), and lower lymphocyte count on admission (aOR 0.58, 95%CI 0.34–0.98, p = 0.04) were the only independent predictors of mortality among patients with stroke and COVID-19. CONCLUSIONS: COVID-19 is associated with a small but significant risk of clinically relevant cerebrovascular events, particularly ischemic stroke. The mortality rate is high for COVID-19-associated cerebrovascular complications; therefore, aggressive monitoring and early intervention should be pursued to mitigate poor outcomes.