SARS-CoV-2 and Stroke in a New York Healthcare System

Abstract

Background and purpose: With the spread of coronavirus disease 2019 (COVID-19) during the current worldwide pandemic, there is mounting evidence that patients affected by the illness may develop clinically significant coagulopathy with thromboembolic complications including ischemic stroke. However, there is limited data on the clinical characteristics, stroke mechanism, and outcomes of patients who have a stroke and COVID-19.

Methods: We conducted a retrospective cohort study of consecutive patients with ischemic stroke who were hospitalized between March 15, 2020, and April 19, 2020, within a major health system in New York, the current global epicenter of the pandemic. We compared the clinical characteristics of stroke patients with a concurrent diagnosis of COVID-19 to stroke patients without COVID-19 (contemporary controls). In addition, we compared patients to a historical cohort of patients with ischemic stroke discharged from our hospital system between March 15, 2019, and April 15, 2019 (historical controls).

Results: During the study period in 2020, out of 3556 hospitalized patients with diagnosis of COVID-19 infection, 32 patients (0.9%) had imaging proven ischemic stroke. Cryptogenic stroke was more common in patients with COVID-19 (65.6%) as compared to contemporary controls (30.4%, P=0.003) and historical controls (25.0%, P<0.001). When compared with contemporary controls, COVID-19 positive patients had higher admission National Institutes of Health Stroke Scale score and higher peak D-dimer levels. When compared with historical controls, COVID-19 positive patients were more likely to be younger men with elevated troponin, higher admission National Institutes of Health Stroke Scale score, and higher erythrocyte sedimentation rate. Patients with COVID-19 and stroke had significantly higher mortality than historical and contemporary controls.

Conclusions: We observed a low rate of imaging-confirmed ischemic stroke in hospitalized patients with COVID-19. Most strokes were cryptogenic, possibly related to an acquired hypercoagulability, and mortality was increased. Studies are needed to determine the utility of therapeutic anticoagulation for stroke and other thrombotic event prevention in patients with COVID-19.

Keywords: COVID-19; coronavirus; diagnosis; pandemic; troponin.

Figure 1.

A, COVID-19 hospitalizations (gray bars) and COVID-19 related deaths (black bars) in New York City over the study period. B, All COVID-19 admissions to New York University Langone Health (NYULH) during the study period. C, Number of in-house COVID-19 positive patients per day. D, COVID-19 hospitalizations with imaging proven ischemic stroke. Arrows indicate when the stay at home order was issued (March 22, 2020 at 8 pm).

Figure 2.

These images are from 2 patients with ischemic stroke in the setting of coronavirus disease 2019 (COVID-19). The left shows chest imaging (CT or x-ray) and the right shows brain imaging of 2 patients with cryptogenic stroke and COVID-19 infection in our patient cohort.