Higher Mortality of Ischaemic Stroke Patients Hospitalized with COVID-19 Compared to Historical Controls

Acute ischemic stroke outcomes in patients with COVID-19: a systematic review and meta-analysis

BACKGROUND

Although patients with COVID-19 have a higher risk of acute ischemic stroke (AIS), the impact on stroke outcomes remains uncertain.

AIMS

To determine the clinical outcomes of patients with AIS and COVID-19 (AIS-COVID+).

METHODS

We performed a systematic review and meta-analysis following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Our protocol was registered with the International Prospective Register of Systematic Reviews (CRD42020211977). Systematic searches were last performed on June 3, 2021 in EMBASE, PubMed, Web-of-Science, Scopus, and CINAHL Databases.

INCLUSION CRITERIA

(1) studies reporting outcomes on AIS-COVID+; (2) original articles published in 2020 or later; (3) study participants aged ≥18 years.

EXCLUSION CRITERIA

(1) case reports with <5 patients, abstracts, review articles; (2) studies analyzing novel interventions. Risk of bias was assessed using the Mixed Methods Appraisal Tool. Random-effects models estimated the pooled OR and 95% confidence intervals (95% CI) for mortality, modified Rankin Scale (mRS) score, length of stay (LOS), and discharge disposition.

RESULTS

Of the 43 selected studies, 46.5% (20/43) reported patients with AIS without COVID-19 (AIS-COVID-) for comparison. Random-effects model included 7294 AIS-COVID+ and 158 401 AIS-COVID-. Compared with AIS-COVID-, AIS-COVID+ patients had higher in-hospital mortality (OR=3.87 (95% CI 2.75 to 5.45), P<0.001), less mRS scores 0-2 (OR=0.53 (95% CI 0.46 to 0.62), P<0.001), longer LOS (mean difference=4.21 days (95% CI 1.96 to 6.47), P<0.001), and less home discharge (OR=0.31 (95% CI 0.21 to 0.47), P<0.001).

CONCLUSIONS

Patients with AIS-COVID had worse outcomes, with almost fourfold increased mortality, half the odds of mRS scores 0-2, and one-third the odds of home discharge. These findings confirm the significant impact of COVID-19 on early stroke outcomes.

Depression during the COVID-19 pandemic among older adults with stroke history: Findings from the Canadian Longitudinal Study on Aging

OBJECTIVES

The COVID-19 pandemic and accompanying public health measures exacerbated many known risk factors for depression, while also increasing numerous health-related stressors for people with stroke history. Using a large longitudinal sample of older adults, the current study examined the prevalence of incident and recurrent depression among participants with stroke history, and also identified factors that were associated with depression during the pandemic among this population.

METHODS

Data came from four waves of the Canadian Longitudinal Study on Aging's (CLSA) comprehensive cohort (n = 577 with stroke history; 46.1% female; 20.8% immigrants; mean age = 74.56 SD = 9.19). The outcome of interest was a positive screen for depression, based on the CES-D-10, collected during the 2020 CLSA COVID autumn questionnaire. Bivariate and multivariate logistic regression analyses were conducted to identify factors that were associated with depression.

RESULTS

Approximately 1 in 2 (49.5%) participants with stroke history and a history of depression experienced a recurrence of depression early in the pandemic. Among those without a history of depression, approximately 1 in 7 (15.0%) developed depression for the first time during this period. The risk of depression was higher among immigrants, those who were lonely, those with functional limitations, and those who experienced COVID-19 related stressors, such as increased family issues, difficulty accessing healthcare, and becoming ill or having a loved one become ill or die during the pandemic.

CONCLUSIONS

Interventions that target those with stroke history, both with and without a history of depression, are needed to buffer against the stressors of the COVID-19 pandemic and support the mental health of this population.

COVID-19 induced ischemic stroke and mechanisms of viral entry in brain and clot formation: a systematic review and current update

Background: Coronavirus disease 2019, caused by SARS-CoV-2 (SCV-2) was stated as a pandemic on March 11 2020 by World Health Organization (WHO), and since then, it has become a major health issue worldwide. It mainly attacks the respiratory system with various accompanying complications, including cardiac injury, renal failure, encephalitis and Stroke.Materials and Methods: The current systematic review has been compiled to summarize the available literature on SCV-2 induced ischemic Stroke and its subtypes. Further, the mechanisms by which the virus crosses the blood-brain barrier (BBB) to enter the brain have also been explored. The role of CRP and D-dimer as potent prognostic markers was also explored. The literature search was carried out comprehensively on Google scholar, PubMed, SCOP US, Embase and Cochrane databases by following guidelines.Results: All the studies were reviewed thoroughly by authors and disagreements were resolved by consensus and help of the senior authors. The most common subtype of the IS was found to be large artery atherosclerosis in SCV-2 induced IS. Hypertension emerged as the most significant risk factor. The mechanism resulting in elevated levels of CRP and D-dimer have also been discussed. However, there is a scarcity of definitive evidence on how SCV-2 enters the human brain. The available literature based on various studies demonstrated that SCV-2 enters through the nasopharyngeal tract via olfactory cells to olfactory neurons, astrocytes and via choroid plexus through endothelial cells. Further, disruption of gut-brain axis has been also discussed.Conclusion: Data available in the literature is not adequate to come to a conclusion. Therefore, there is a need to carry out further studies to delineate the possible association between SCV-2 induced IS.

The Potential Role of Gender in the Incidence, Management, and Outcomes of Stroke in Patients Suffering From COVID-19: A Brief Review

Gender-disaggregated data are continuously needed in all aspects of the coronavirus disease 2019 (COVID-19) pandemic, including cerebrovascular disease in patients infected with SARS-CoV-2. This brief review was conducted to summarize available evidence and highlight potential sex differences regarding the incidence, applied therapies, and outcomes of stroke in patients with COVID-19. Local and global registries of such patients were included, where comparisons with historical (pre-pandemic era) and contemporary (stroke patients negative for SARS-CoV-2) cohorts formed the basis of the analysis. According to the herein reported evidence, the frequency of stroke under COVID-19 does not seem to vary according to gender, although a tendency toward male predominance cannot be excluded. In terms of management and outcomes, more advanced therapies are used in men. Follow-up data on gender differences are needed, as the pandemic is evolving (no lockdowns; new strains; vaccinated or naturally immune populations).

The effect of COVID-19 on treatment and outcomes following ischemic stroke: A national assessment

INTRODUCTION

COVID-19 has had innumerable impacts on the healthcare system, both by worsening patient illness and impeding effective and efficient care. Further, COVID-19 has been tied to increased rates of ischemic stroke, particularly among young patients. We utilized a national database to assess associations of COVID-19 with thrombectomy rates, mortality, and discharge disposition among stroke patients.

METHODS

Patients were identified from the National Inpatient Sample (NIS, 2020). Inclusion criteria selected for adult ischemic stroke patients; those with venous thrombosis or unspecified cerebral infarction were excluded. Patients were stratified by presence or absence of COVID-19 diagnosis. Outcome variables included mechanical thrombectomy, in-hospital mortality, and discharge disposition. Additional patient demographics, hospital characteristics, and disease severity metrics were collected. Statistical analysis was performed via multivariable logistic regression and log-binary regression.

RESULTS

54,368 patients were included in the study; 2116 (3.89%) were diagnosed with COVID-19. COVID-19 was associated with lower rates of mechanical thrombectomy (OR 0.94, p < 0.0001), higher rates of in-hospital mortality (OR 1.14, p < 0.0001), and unfavorable discharge disposition (OR 1.08, p < 0.0001), even when controlling for illness severity. Other relationships, such as a male predominance among stroke patients with COVID-19, were also identified.

CONCLUSION

This study identified a relationship between COVID-19 diagnosis and worse outcomes for each metric assessed, including mechanical thrombectomy rates, in-hospital mortality, and discharge disposition. Several factors might underly this, ranging from systemic/multisystem inflammation and worsened disease severity to logistical barriers to treatment caused by COVID-19. Further research is needed to determine causality of these findings.

A global federated real-world data and analytics platform for research

Objective

This article describes a scalable, performant, sustainable global network of electronic health record data for biomedical and clinical research.

Materials and Methods

TriNetX has created a technology platform characterized by a conservative security and governance model that facilitates collaboration and cooperation between industry participants, such as pharmaceutical companies and contract research organizations, and academic and community-based healthcare organizations (HCOs). HCOs participate on the network in return for access to a suite of analytics capabilities, large networks of de-identified data, and more sponsored trial opportunities. Industry participants provide the financial resources to support, expand, and improve the technology platform in return for access to network data, which provides increased efficiencies in clinical trial design and deployment.

Results

TriNetX is a growing global network, expanding from 55 HCOs and 7 countries in 2017 to over 220 HCOs and 30 countries in 2022. Over 19 000 sponsored clinical trial opportunities have been initiated through the TriNetX network. There have been over 350 peer-reviewed scientific publications based on the network's data.

Conclusions

The continued growth of the TriNetX network and its yield of clinical trial collaborations and published studies indicates that this academic-industry structure is a safe, proven, sustainable path for building and maintaining research-centric data networks.

COVID-19 and Cerebrovascular Disease

COVID-19 has been associated with numerous neurological complications, with acute cerebrovascular disease being one of the most devastating complications. Ischemic stroke is the most common cerebrovascular complication of COVID-19, affecting between 1 and 6% of all patients. Underlying mechanisms for COVID-related ischemic strokes are thought to be due to vasculopathy, endotheliopathy, direct invasion of the arterial wall, and platelet activation. Other COVID-19-associated cerebrovascular complications include hemorrhagic stroke, cerebral microbleeds, posterior reversible encephalopathy syndrome, reversible cerebral vasoconstriction syndrome, cerebral venous sinus thrombosis, and subarachnoid hemorrhage. This article discusses the incidence of these cerebrovascular complications, risk factors, management strategies, prognosis and future research directions, as well as considerations in pregnancy-related cerebrovascular events in the setting of COVID-19.

The impact of SARS-CoV-2 infection on the outcome of acute ischemic stroke-A retrospective cohort study

BACKGROUND

Acute ischemic stroke (AIS) is a common complication of severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2) infection (COVID-19), but the prognosis of these patients is poorly understood.

PURPOSE

To explore the impact of COVID-19 on neurological outcomes in AIS patients.

METHODS

A comparative retrospective cohort study was conducted in 32 consecutive AIS patients with and 51 without COVID-19 between the 1st of March 2020 and 1st of May 2021. The evaluation was based on a detailed chart review for demographic data, medical history, stroke severity, cranial and vessel imaging results, laboratory parameters, COVID-19 severity, hospitalization time, in-hospital mortality, and functional deficits at discharge (modified Rankin Scale, mRS).

RESULTS

COVID-19 AIS patients showed tendency to worse initial neurological deficit (NIHSS 9 (3-13) vs. 4 (2-10); p = 0.06), higher rate of large vessel occlusion (LVO; 13/32 vs. 14/51; p = 0.21), had prolonged hospitalization (19.4 ± 17.7 vs. 9.7 ± 7 days; p = 0.003), had lower chance of functional independence (mRS≤2) (12/32 vs. 32/51; p = 0.02) and showed higher in-hospital mortality (10/32 vs. 6/51; p = 0.02). In COVID-19 AIS patients, LVO was more common with COVID-19 pneumonia than without (55.6% vs. 23.1%; p = 0.139).

CONCLUSION

COVID-19-related AIS carries a worse prognosis. COVID-19 with pneumonia seems to be associated with a higher rate of LVO.

What is the impact of previous cerebrovascular disease on critical COVID-19 patients' mortality? A prospective cohort study

OBJECTIVES

We aimed to evaluate the effect of previous cerebrovascular disease (CVD) on mortality rates of critically ill COVID-19 patients.

MATERIALS & METHODS

A prospective cohort study was performed between May/2020 and May/2021, at a tertiary-care-center. We consecutively included adult patients admitted to intensive care units (ICU) having as primary diagnosis Acute Respiratory Distress Syndrome due to SARS-CoV-2, requiring invasive mechanical ventilation for >48 h. We considered as exposure the diagnosis of previous CVD and as main outcome the in-ICU mortality.

RESULTS

The study sample included 178 patients: 74.2% were males, with a mean age of 63 ± 12.4 years-old(yo). Previous CVD was documented in 17 patients (9.6%). During the study period, the mortality rate at ICU was of 33.1% (n = 59). The proportion of mortality at ICU was higher in patients with prior CVD (58.8% vs 30.4%; p = 0.02). Also, older patients (66 ± 11.4 yo vs. 62 ± 12.7 yo, p = 0.04) and those with higher score at SAPSII at ICU admission (47.8 ± 15.4 vs. 40.7 ± 15.9; p = 0.01) had a higher ICU deathrate. Patients with previous CVD had a 2.70 (95%CI = 1.36-5.39) higher likelihood of dying compared to those who had no previous CVD. After adjustment (for gender, age, SAPSII and total length of stay), multivariate Cox analysis revealed that previous CVD remained a strong predictor for in-ICU death in critically ill COVID-19 patients (HR = 2.51; 95%CI = 1.15-5.51).

CONCLUSIONS

Previous CVD was significantly associated to higher mortality in critical COVID-19 patients. We suggest that, in patients with previous CVD, prioritization of vaccination strategies should be implemented alongst with higher surveillance when infected with SARS-CoV-2.

Impact of the First COVID-19 Wave on French Hospitalizations for Myocardial Infarction and Stroke: A Retrospective Cohort Study

The COVID-19 pandemic modified the management of myocardial infarction (MI) and stroke. We aimed to evaluate the effect of the COVID-19 pandemic on the volume and spatial distribution of hospitalizations for MI and stroke, before, during and after the first nationwide lockdown in France in 2020, compared with 2019. Hospitalization data were extracted from the French National Discharge database. Patient’s characteristics were compared according to COVID-19 status. Changes in hospitalization rates over time were measured using interrupted time series analysis. Possible spatial patterns of over or under-hospitalization rates were investigated using Moran’s indices. We observed a rapid and significant drop in hospitalizations just before the beginning of the lockdown with a nadir at 36.5% for MI and 31.2% for stroke. Hospitalization volumes returned to those seen in 2019 four weeks after the end of the lockdown, except for MI, which rebounded excessively. Older age, male sex, elevated rate of hypertension, diabetes, obesity and mortality characterized COVID-19 patients. There was no evidence of a change in the spatial pattern of over- or under-hospitalization clusters over the three periods. After a steep drop, only MI showed a significant rebound after the first lockdown with no change in the spatial distribution of hospitalizations.

Hospital Outcomes among COVID-19 Hospitalizations with Acute Ischemic Stroke: Cross-Sectional Study Results from California State Inpatient Database

Coronavirus disease 2019 (COVID-19) could be a risk factor for acute ischemic stroke (AIS) due to the altered coagulation process and hyperinflammation. This study examined the risk factors, clinical profile, and hospital outcomes of COVID-19 hospitalizations with AIS. This study was a retrospective analysis of data from California State Inpatient Database (SID) during 2019 and 2020. COVID-19 hospitalizations with age ≥ 18 years during 2020 and a historical cohort without COVID-19 from 2019 were included in the analysis. The primary outcomes studied were in-hospital mortality and discharge to destinations other than home. There were 91,420 COVID-19 hospitalizations, of which, 1027 (1.1%) had AIS. The historical control cohort included 58,083 AIS hospitalizations without COVID-19. Conditional logistic regression analysis showed that the odds of in-hospital mortality, discharge to destinations other than home, DVT, pulmonary embolism, septic shock, and mechanical ventilation were significantly higher among COVID-19 hospitalizations with AIS, compared to those without AIS. The odds of in-hospital mortality, DVT, pulmonary embolism, septic shock, mechanical ventilation, and respiratory failure were significantly higher among COVID-19 hospitalizations with AIS, compared to AIS hospitalizations without COVID-19. Although the prevalence of AIS was low among COVID-19 hospitalizations, it was associated with higher mortality and greater rates of discharges to destinations other than home.

Telestroke’s Role Through the COVID-19 Pandemic and Beyond

Purpose of review

The goal of this paper is to discuss the role and utilization of telestroke services through the COVID-19 pandemic and to suggest future directions to sustain and increase patients’ access to stroke expertise.

Recent findings

Telestroke is an innovative and effective tool that has been shown to improve access, quality of care, and outcomes of patients with acute stroke syndromes in resource-limited areas for the last two decades. The COVID-19 pandemic posed a significant challenge and strained healthcare systems worldwide, but it created novel and unique opportunities to expand and increase the utilization of telehealth and telestroke services to deliver personalized healthcare across the continuum of stroke care outside of traditional settings. This rapid and widespread increase in telestroke use was facilitated by the removal of many legislative and regulatory barriers which have limited patients’ access to stroke expertise for many years.

Summary

As the public health emergency ends, there exists a unique opportunity to optimize and expand upon the pandemic-related rapid growth of telestroke care. Optimal utilization of telehealth and telestroke services will depend on maintaining and improving required infrastructure, laws, and regulations, particularly those governing reimbursement and licensing.

Ischemic stroke in COVID-19 patients: a cross-sectional study from an Indonesian COVID-19 referral hospital

Background

COVID-19 increases the risk of acute ischemic stroke. The objective of this study is to identify the risk factors, comorbidities, and outcomes in COVID-19 patients with acute ischemic stroke at University of Indonesia Hospital.

Results

The clinical condition of COVID-19 patients with ischemic stroke is more severe for patients older than 55 years (p < 0.05), patients at the critical COVID-19 clinical stage, and patients with atrial fibrillation (p < 0.05). The level of C-reactive protein (CRP) more than 60 mg/L correlated with the outcome of the patient as well.

Conclusion

The study concluded that, age, COVID-19 clinical degree, and atrial fibrillation significantly affect the outcome in COVID-19 patients with stroke.

Severe Acute Respiratory Syndrome Coronavirus 2 Infection is Associated with Homocysteine Level and Clinical Outcomes in Ischemic Stroke Patients

BACKGROUND: Since its emergence in December 2019 and declared as pandemic in March 2020, the drastic increase in cases of coronavirus disease 2019 (COVID-19) is alarming the importance of disease monitoring in order to prevent further complication, like ischemic stroke. One of the efforts is utilizing biomarker. For instance, elevated homocysteine level, already known risk factor of ischemic stroke, is currently identified in COVID-19 patients. AIM: To assess factor associated with homocysteine level and clinical outcomes of ischemic stroke patients. Methods: A cross-sectional study was conducted at Dr. Zainoel Abidin Hospital di Indonesia between March and August 2021. Ischemic stroke patients who had physical and neurology examinations, SARS-CoV-2 RT-PCR swab, chest x-ray, electrocardiography, head CT-scan and the total homocysteine level were included. To assess the factors associated with homocysteine level and the outcomes of ischemic stroke patients, the independent Student t-test or Anova and chi-squared were used, respectively. RESULTS: We included 62 ischemic stroke patients of which 32 (51.6%) were male and the age ranged between 30 and 80 years. Out of total, 60 patients (96.8%) were survived after the hospital admission. There was a significant association between gender and having COVID-19 with homocysteine level (p=0.012 and p=0.020, respectively). Having COVID-19 was the only variable significantly associated with the outcome of the ischemic stroke patient (p=0.035). CONCLUSION: COVID-19 is associated with homocysteine level and the clinical outcome in ischemic stroke patients. Therefore, SARS-CoV-2 infection in ischemic stroke or vice versa need to be monitored closely in hospital settings.

The management of type 2 diabetes before, during and after Covid-19 infection: what is the evidence?

Patients with Covid-19 place new challenges on the management of type 2 diabetes, including the questions of whether glucose-lowering therapy should be adjusted during infection and how to manage a return to normal care after resolution of Covid-19 symptoms. Due to the sudden onset of the pandemic, physicians have by necessity made such important clinical decisions in the absence of robust evidence or consistent guidelines. The risk to patients is compounded by the prevalence of cardiovascular disease in this population, which alongside diabetes is a major risk factor for severe disease and mortality in Covid-19. We convened as experts from the Central and Eastern European region to consider what advice we can provide in the setting of type 2 diabetes and Covid-19, considering the evidence before, during and after infection. We review recommendations that have been published to date, and consider the best available—but currently limited—evidence from large observational studies and the DARE-19 randomized control trial. Notably, we find a lack of guidance on restarting patients on optimal antidiabetic therapy after recovering from Covid-19, and suggest that this may provide an opportunity to optimize treatment and counter clinical inertia that predates the pandemic. Furthermore, we emphasize that optimization applies not only to glycaemic control, but other factors such as cardiorenal protection. While we look forward to the emergence of new evidence that we hope will address these gaps, in the interim we provide a perspective, based on our collective clinical experience, on how best to manage glucose-lowering therapy as patients with Covid-19 recover from their disease and return to normal care.

Racial disparities in COVID-19 pandemic cases, hospitalisations, and deaths: A systematic review and meta-analysis

Background

People from racial minority groups in western countries experience disproportionate socioeconomic and structural determinants of health disadvantages. These disadvantages have led to inequalities and inequities in health care access and poorer health outcomes. We report disproportionate disparities in prevalence, hospitalisation, and deaths from COVID-19 by racial minority populations.

Methods

We conducted a systematic literature search of relevant databases to identify studies reporting on prevalence, hospitalisations, and deaths from COVID-19 by race groups between 01 January 2020 – 15 April 2021. We grouped race categories into Blacks, Hispanics, Whites and Others. Random effects model using the method of DerSimonian and Laird were fitted, and forest plot with respective ratio estimates and 95% confidence interval (CI) for each race category, and subgroup meta-regression analyses and the overall pooled ratio estimates for prevalence, hospitalisation and mortality rate were presented.

Results

Blacks experienced significantly higher burden of COVID-19: prevalence ratio 1.79 (95% confidence interval (CI) = 1.59-1.99), hospitalisation ratio 1.87 (95% CI = 1.69-2.04), mortality ratio 1.68 (95% CI = 1.52-1.83), compared to Whites: prevalence ratio 0.70 (95% CI = 0.0.64-0.77), hospitalisation ratio 0.74 (95% CI = 0.65-0.82), mortality ratio 0.82 (95% CI = 0.78-0.87). Also, Hispanics experienced a higher burden: prevalence ratio 1.78 (95% CI = 1.63-1.94), hospitalisation ratio 1.32 (95% CI = 1.08-1.55), mortality ratio 0.94 (95% CI = 0.84-1.04) compared to Whites. A higher burden was also observed for Other race groups: prevalence ratio 1.43 (95% CI = 1.19-1.67), hospitalisation ratio 1.12 (95% CI = 0.89-1.35), mortality ratio 1.06 (95% CI = 0.89-1.23) compared to Whites. The disproportionate burden among Blacks and Hispanics remained following correction for publication bias.

Conclusions

Blacks and Hispanics have been disproportionately affected by COVID-19. This is deeply concerning and highlights the systemically entrenched disadvantages (social, economic, and political) experienced by racial minorities in western countries; and this study underscores the need to address inequities in these communities to improve overall health outcomes.

The COVID-19 Pandemic and the Need for an Integrated and Equitable Approach: An International Expert Consensus Paper

BACKGROUND

 One year after the declaration of the coronavirus disease 2019 (COVID-19) pandemic by the World Health Organization (WHO) and despite the implementation of mandatory physical barriers and social distancing, humanity remains challenged by a long-lasting and devastating public health crisis.

MANAGEMENT

 Non-pharmacological interventions (NPIs) are efficient mitigation strategies. The success of these NPIs is dependent on the approval and commitment of the population. The launch of a mass vaccination program in many countries in late December 2020 with mRNA vaccines, adenovirus-based vaccines, and inactivated virus vaccines has generated hope for the end of the pandemic.

CURRENT ISSUES

 The continuous appearance of new pathogenic viral strains and the ability of vaccines to prevent infection and transmission raise important concerns as we try to achieve community immunity against severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) and its variants. The need of a second and even third generation of vaccines has already been acknowledged by the WHO and governments.

PERSPECTIVES

 There is a critical and urgent need for a balanced and integrated strategy for the management of the COVID-19 outbreaks organized on three axes: (1) Prevention of the SARS-CoV-2 infection, (2) Detection and early diagnosis of patients at risk of disease worsening, and (3) Anticipation of medical care (PDA).

CONCLUSION

 The "PDA strategy" integrated into state policy for the support and expansion of health systems and introduction of digital organizations (i.e., telemedicine, e-Health, artificial intelligence, and machine-learning technology) is of major importance for the preservation of citizens' health and life world-wide.