Effect of Asymptomatic and Symptomatic COVID-19 on Acute Ischemic Stroke Revascularization Outcomes.

Background: The association of COVID-19 with higher bleeding risk and worse outcomes in acute ischemic stroke (AIS) undergoing revascularization may be related to the presence of infection symptoms. We aimed to assess the safety and outcomes of revascularization treatments in patients with AIS with asymptomatic COVID-19 (AS-COVID) or symptomatic COVID-19 (S-COVID).
Methods: We conducted an international multicenter retrospective cohort study of consecutive AIS tested for SARS-CoV-2, receiving intravenous thrombolysis and endovascular treatment between 2020 and 2021. We compared COVID-negative controls, AS-COVID, and S-COVID using multivariable regression. We assessed symptomatic intracranial hemorrhage (symptomatic intracerebral hemorrhage), mortality, and 3-month disability (modified Rankin Scale score).
Results: Among 15 124 patients from 105 centers (median age, 71 years; 49% men; 39% treated with intravenous thrombolysis only; and 61% with endovascular treatment±intravenous thrombolysis), 849 (5.6%) had COVID-19, of whom 395 (46%) were asymptomatic and 454 (54%) symptomatic. Compared with controls, both patients with AS-COVID and S-COVID had higher symptomatic intracerebral hemorrhage rates (COVID-controls, 5%; AS-COVID, 7.6%; S-COVID, 9.4%; adjusted odds ratio [aOR], 1.43 [95% CI, 1.03-1.99]; aOR, 1.63 [95% CI, 1.14-2.32], respectively). Only in patients with symptomatic infections, we observed a significant increase in mortality at 24 hours (COVID-controls, 1.3%; S-COVID, 4.8%; aOR, 2.97 [95% CI, 1.76-5.03]) and 3 months (COVID-controls, 19.5%; S-COVID, 40%; aOR, 2.64 [95% CI, 2.06-3.37]). Patients with COVID-19 had worse 3-month disability regardless of disease symptoms although disability was affected to a greater extent in symptomatic patients (aOR for worse modified Rankin Scale score shift: AS-COVID, 1.25 [95% CI, 1.03-1.51]; S-COVID, 2.10 [95% CI, 1.75-2.53]). S-COVID had lower successful recanalization (74.9% versus 85.6%; P <0.001), first pass recanalization (20.3% versus 28.3%; P =0.005), and a higher number of passes.
Conclusions: In AIS undergoing revascularization treatments, both AS-COVID and S-COVID influence the risk of intracranial bleeding and worse clinical outcomes. The magnitude of this effect is more pronounced in symptomatic infections, which also present less favorable recanalization outcomes. These findings emphasize the impact of SARS-CoV-2 infection on the prognosis of revascularized AIS independent of symptom status.
Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04895462.
Competing Interests: Disclosures Dr Nguyen is on the Advisory Board of Idorsia. Dr Michel received research grants from the Swiss National Science Foundation, the Swiss Heart Foundation, and the University of Lausanne. The other authors report no conflicts. Global COVID-19 Stroke Registry: R. Herzig received research grants from the Ministry of Health of the Czech Republic (Grant number DRO – UHHK 00179906) and Charles University, Czech Republic (Cooperatio Program). C. Nolte received research grants from the German Ministry of Research and Education, the German Center for Neurodegenerative Diseases, and the German Center for Cardiovascular Research and is a speaker and advisory for Abbott, Alexion, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Daiichi Sankyo, and Pfizer Pharma. S. Tjoumakaris is on Advisory Medtronic and MicroVention. J. Min is on Advisory Medtronic and Abbott. M.-A. Khan received research grants from National Institutes of Health, Spectrum Health-Michigan State University Research Alliance, and Genentech. A. Zini received consultation and travel expenses from Alexion-AstraZeneca, CSL Behring, and Boehringer Ingelheim and is on the steering committee of the OCEANIC-STROKE trial (A Study to Test Asundexian to Prevent a Clot-Related Stroke in Participants After an Acute Ischemic Stroke or High-Risk TIA/Mini-Stroke). A. Slowik and P. Wrona received research grant from European Research Area Network (ERA-NET) - Network of European Funding for Neuroscience Research (NEURON)/21/2020 Identification and clinical validation of biomarkers for long-term outcome after cerebral ischaemia (iBioStroke).