Incidence, characteristics and clinical relevance of acute stroke in old patients hospitalized with COVID-19

Abstract

Background: Stroke in the course of coronavirus disease (COVID-19) has been shown to be associated with more severe respiratory symptoms and higher mortality, but little knowledge in this regard exists on older populations. We aimed to investigate the incidence, characteristics, and prognosis of acute stroke in geriatric patients hospitalized with COVID-19.

Methods: A monocentric cross-sectional retrospective study of 265 older patients hospitalized with COVID-19 on acute geriatric wards. 11/265 presented a stroke episode during hospitalization. Mortality rates and two-group comparisons (stroke vs non-stroke patients) were calculated and significant variables added in logistic regression models to investigate stroke risk factors.

Results: Combined ischemic and hemorrhagic stroke incidence was 4.15%. 72.7% of events occurred during acute care. Strokes presented with altered state of consciousness and/or delirium in 81.8%, followed by a focal neurological deficit in 45.5%. Ischemic stroke was more frequently unilateral (88.8%) and localized in the middle cerebral artery territory (55.5%). Smoking and a history of previous stroke increased by more than seven (OR 7.44; 95% CI 1.75-31.64; p = 0.007) and five times (OR 5.19; 95% CI 1.50-17.92; p = 0.009), respectively, the risk of stroke. Each additional point in body mass index (BMI) reduced the risk of stroke by 14% (OR 0.86; 95% CI 0.74-0.98; p = 0.03). In-hospital mortality (32.1% vs. 27.3%; p > 0.999) and institutionalization at discharge (36.4% vs. 21.1%; p = 0.258) were similar between patients with and without stroke.

Conclusion: Incident stroke complicating COVID-19 in old patients was associated with active smoking, previous history of stroke, and low BMI. Acute stroke did not influence early mortality or institutionalization rate at discharge.

Keywords: COVID-19; Cerebrovascular; Hemorrhagic stroke; Ischemic stroke; Stroke.

Fig. 1

Illustrative images of neurologic complications in older patients hospitalized with COVID-19 pneumonia. a, b, c, d, and e, CT and MRI images of an 89-year-old woman with left-sided hemiplegia. a, Non-contrast head CT did not show early CT signs of ischemia. b, CT angiogram showed occlusion of the right middle cerebral artery (arrow). c, Perfusion CT mean transit time (MTT) images showed prolonged MTT in the entire right middle cerebral artery territory (arrows), whereas perfusion CT derived cerebral blood volume (d) remained symmetric between both hemispheres. e, Diffusion-weighted image of MRI study obtained one day later and after intravenous thrombolysis showed a small area of infarction in the right corona radiata (arrow). f, Non-contrast head CT image of an 84-year-old woman with obnubilation showed an isolated focus of intraparenchymal hemorrhage in the left lentiform nucleus (arrow). No evidence of underlying vascular or tumoral pathology was found on subsequent MRI (not shown)

Fig. 2

Distribution of body mass index (kg × m⁻²) categories in patients with and without stroke. *p-value corresponds to trend analysis of stroke incidence across body mass index categories [21]