Safety and Outcome of Revascularization Treatment in Patients With Acute Ischemic Stroke and COVID-19: The Global COVID-19 Stroke Registry

João Pedro Marto 1Davide Strambo 2George Ntaios 2Thanh N Nguyen 2Roman Herzig 2Anna Czlonkowska 2Jelle Demeestere 2Ossama Yassin Mansour 2Alexander Salerno 2Susanne Wegener 2Philipp Baumgartner 2Carlo W Cereda 2Giovanni Bianco 2Morin Beyeler 2Marcel Arnold 2Emmanuel Carrera 2Paolo Machi 2Valerian Altersberger 2Leo Bonati 2Henrik Gensicke 2Manuel Bolognese 2Nils Peters 2Stephan Wetzel 2Marta Magriço 2João Nuno Ramos 2João Sargento-Freitas 2Rita Machado 2Carolina Maia 2Egídio Machado 2Ana Paiva Nunes 2Patricia Ferreira 2Teresa Pinho E Melo 2Mariana Carvalho Dias 2André Paula 2Manuel Alberto Correia 2Pedro Castro 2Elsa Azevedo 2Luís Albuquerque 2José Nuno Alves 2Joana Ferreira-Pinto 2Torcato Meira 2Liliana Pereira 2Miguel Rodrigues 2Andre Pinho Araujo 2Marta Rodrigues 2Mariana Rocha 2Ângelo Pereira-Fonseca 2Luís Ribeiro 2Ricardo Varela 2Sofia Malheiro 2Manuel Cappellari 2Cecilia Zivelonghi 2Giulia Sajeva 2Andrea Zini 2Mauro Gentile 2Stefano Forlivesi 2Ludovica Migliaccio 2Maria Sessa 2Sara La Gioia 2Alessandro Pezzini 2Davide Sangalli 2Marialuisa Zedde 2Rosario Pascarella 2Carlo Ferrarese 2Simone Beretta 2Susanna Diamanti 2Ghil Schwarz 2Giovanni Frisullo 2Simona Marcheselli 2Pierre Seners 2Candice Sabben 2Simon Escalard 2Michel Piotin 2Benjamin Maïer 2Guillaume Charbonnier 2Fabrice Vuillier 2Loïc Legris 2Pauline Cuisenier 2Francesca R Vodret 2Gaultier Marnat 2Jean-Sebastien Liegey 2Igor Sibon 2Fabian Flottmann 2Gabriel Broocks 2Nils-Ole Gloyer 2Ferdinand O Bohmann 2Jan Hendrik Schaefer 2Christian Nolte 2Heinrich J Audebert 2Eberhard Siebert 2Marek Sykora 2Wilfried Lang 2Julia Ferrari 2Lukas Mayer-Suess 2Michael Knoflach 2Elke Ruth Gizewski 2Jeffrey Stolp 2Lotte J Stolze 2Jonathan M Coutinho 2Paul Nederkoorn 2Ido van den Wijngaard 2Joke De Meris 2Robin Lemmens 2Sylvie De Raedt 2Fenne Vandervorst 2Matthieu Pierre Rutgers 2Antoine Guilmot 2Anne Dusart 2Flavio Bellante 2Patricia Calleja-Castaño 2Fernando Ostos 2Guillermo González-Ortega 2Paloma Martín-Jiménez 2Sebastian García-Madrona 2Antonio Cruz-Culebras 2Rocio Vera 2Maria Consuelo Matute 2Blanca Fuentes 2María Alonso-de-Leciñana 2Ricardo Rigual 2Exuperio Díez-Tejedor 2Soledad Perez-Sanchez 2Joan Montaner 2Fernando Díaz-Otero 2Natalia Pérez-de-la-Ossa 2Belén Flores-Pina 2Lucia Muñoz-Narbona 2Angel Chamorro 2Alejandro Rodríguez-Vázquez 2Arturo Renú 2Oscar Ayo-Martin 2Francisco Hernández-Fernández 2Tomas Segura 2Herbert Tejada-Meza 2Daniel Sagarra-Mur 2Marta Serrano-Ponz 2Thant Hlaing 2Isaiah See 2Robert Simister 2David Werring 2Espen Saxhaug Kristoffersen 2Annika Nordanstig 2Katarina Jood 2Alexandros Rentzos 2Libor Šimůnek 2Dagmar Krajíčková 2Antonín Krajina 2Robert Mikulik 2Martina Cviková 2Jan Vinklárek 2David Školoudík 2Martin Roubec 2Eva Hurtikova 2Rostislav Hrubý 2Svatopluk Ostry 2Ondrej Skoda 2Marek Pernicka 2Lubomir Jurak 2Zuzana Eichlová 2Martin Jíra 2Martin Kovar 2Michal Panský 2Pavel Mencl 2Hana Palouskova 2Aleš Tomek 2Petr Janský 2Anna Olšerová 2Martin Sramek 2Roman Havlicek 2Petr Malý 2Lukáš Trakal 2Jan Fiksa 2Matěj Slovák 2Michal Adam Karlinski 2Maciej Nowak 2Halina Sienkiewicz-Jarosz 2Anna Bochynska 2Pawel Wrona 2Tomasz Homa 2Katarzyna Sawczynska 2Agnieszka Slowik 2Ewa Wlodarczyk 2Marcin Wiacek 2Izabella Tomaszewska-Lampart 2Bartosz Sieczkowski 2Halina Bartosik-Psujek 2Marta Bilik 2Anna Bandzarewicz 2Malgorzata Dorobek 2Justyna Zielinska-Turek 2Marta Nowakowska-Kotas 2Krystian Obara 2Paweł Urbanowski 2Slawomir Budrewicz 2Maciej Guziński 2Milena Świtońska 2Iwona Rutkowska 2Paulina Sobieszak-Skura 2Beata M Labuz-Roszak 2Aleksander Debiec 2Jacek Staszewski 2Adam Stępień 2Jacek Zwiernik 2Grzegorz Wasilewski 2Cristina Tiu 2Elena Oana Terecoasă 2Razvan Alexandru Radu 2Anca Negrila 2Bogdan Dorobat 2Cristina Panea 2Vlad Tiu 2Simona Petrescu 2Atilla Ozdemir 2Mostafa Mahmoud 2Hussam El-Samahy 2Hazem Abdelkhalek 2Jasem Al-Hashel 2Ismail Ibrahim Ismail 2Athari Salmeen 2Abdoreza Ghoreishi 2Sergiu Ionut Sabetay 2Hana Gross 2Piers Klein 2Mohamad Abdalkader 2Pascal Jabbour 2Kareem El Naamani 2Stavropoula Tjoumakaris 2Rawad Abbas 2Ghada A Mohamed 2Alex Chebl 2Jiangyong Min 2Majesta Hovingh 2Jenney P Tsai 2Muhib Khan 2Krishna Nalleballe 2Sanjeeva Onteddu 2Hesham Masoud 2Mina Michael 2Navreet Kaur 2Laith Maali 2Michael G Abraham 2Priyank Khandelwal 2Ivo Bach 2Melody Ong 2Denis Babici 2Ayaz M Khawaja 2Maryam Hakemi 2Kumar Rajamani 2Vanessa Cano-Nigenda 2Antonio Arauz 2Pablo Amaya 2Natalia Llanos 2Akemi Arango 2Miguel Ángel Vences 2Jose Dominguo Barrientos Guerra 2Rayllene Caetano 2Rodrigo Targa Martins 2Sergio Daniel Scollo 2Patrick Matic Yalung 2Shashank Nagendra 2Abhijit Gaikwad 2Kwon-Duk Seo 2Georgios Georgiopoulos 2Raul G Nogueira 2Patrik Michel 2Global COVID-19 Stroke Registry

Affiliations


Abstract

Background and objectives: COVID-19-related inflammation, endothelial dysfunction, and coagulopathy may increase the bleeding risk and lower the efficacy of revascularization treatments in patients with acute ischemic stroke (AIS). We aimed to evaluate the safety and outcomes of revascularization treatments in patients with AIS and COVID-19.

Methods: This was a retrospective multicenter cohort study of consecutive patients with AIS receiving intravenous thrombolysis (IVT) and/or endovascular treatment (EVT) between March 2020 and June 2021 tested for severe acute respiratory syndrome coronavirus 2 infection. With a doubly robust model combining propensity score weighting and multivariate regression, we studied the association of COVID-19 with intracranial bleeding complications and clinical outcomes. Subgroup analyses were performed according to treatment groups (IVT-only and EVT).

Results: Of a total of 15,128 included patients from 105 centers, 853 (5.6%) were diagnosed with COVID-19; of those, 5,848 (38.7%) patients received IVT-only and 9,280 (61.3%) EVT (with or without IVT). Patients with COVID-19 had a higher rate of symptomatic intracerebral hemorrhage (SICH) (adjusted OR 1.53; 95% CI 1.16-2.01), symptomatic subarachnoid hemorrhage (SSAH) (OR 1.80; 95% CI 1.20-2.69), SICH and/or SSAH combined (OR 1.56; 95% CI 1.23-1.99), 24-hour mortality (OR 2.47; 95% CI 1.58-3.86), and 3-month mortality (OR 1.88; 95% CI 1.52-2.33). Patients with COVID-19 also had an unfavorable shift in the distribution of the modified Rankin score at 3 months (OR 1.42; 95% CI 1.26-1.60).

Discussion: Patients with AIS and COVID-19 showed higher rates of intracranial bleeding complications and worse clinical outcomes after revascularization treatments than contemporaneous non-COVID-19 patients receiving treatment. Current available data do not allow direct conclusions to be drawn on the effectiveness of revascularization treatments in patients with COVID-19 or to establish different treatment recommendations in this subgroup of patients with ischemic stroke. Our findings can be taken into consideration for treatment decisions, patient monitoring, and establishing prognosis.

Trial registration information: The study was registered under ClinicalTrials.gov identifier NCT04895462.


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