SARS-CoV-2 and Stroke Characteristics: A Report from the Multinational COVID-19 Stroke Study Group
Authors: Shahjouei Shima , Tsivgoulis Georgios , Farahmand Ghasem , Koza Eric , Mowla Ashkan , Sadr Alireza Vafaei , Kia Arash , Far Alaleh Vaghefi , Mondello Stefania , Cernigliaro Achille , Ranta Annemarei , Punter Martin , Khodadadi Faezeh , Sabra Mirna , Ramezani Mahtab , Naderi Soheil , Olulana Oluwaseyi , Chaudhary Durgesh , Lyoubi Aicha , Campbell Bruce , Arenillas Juan F. , Bock Daniel , Montaner Joan , Neshin Saeideh Aghayari Sheikh , de Sousa Diana Aguiar , Tenser Matthew S. , Aires Ana , Alfonso Merccedes De Lera , Alizada Orkhan , Azevedo Elsa , Goyal Nitin , Babaeepour Zabihollah , Banihashemi Gelareh , Bonati Leo H. , Cereda Carlo , Chang Jason J. , Crnjakovic Miljenko , De Marchis GianMarco , Del Sette Massimo , Ebrahimzadeh Seyed Amir , Farhoudi Mehdi , Gandoglia Ilaria , Gonçalves Bruno , Griessenauer Christoph , Hancı Mehmet Murat , Katsanos Aristeidis H. , Krogias Christos , Leker Ronen , Lotman Lev , Mai Jeffrey , Male Shailesh , Malhotra Konark , Malojcic Branko , Mesquita Teresa , Mirghasemi Asadollah , Aref Hany Mohamed , Afshar Zeinab Mohseni , Moon Jusun , Niemelä Mika , Jahromi Behnam Rezaei , Nolan Lawrence , Pandhi Abhi , Park Jong-Ho , Marto João Pedro , Purroy Francisco , Ranji-Burachaloo Sakineh , Carreira Nuno Reis , Requena Manuel , Rubiera Marta , Sajedi Seyed Aidin , Sargento-Freitas João , Sharma Vijay , Steiner Thorsten , Tempro Kristi , Turc Guillaume , Ahmadzadeh Yassaman , Almasi-Dooghaee Mostafa , Assarzadegan Farhad , Babazadeh Arefeh , Baharvahdat Humain , Cardoso Fabricio , Dev Apoorva , Ghorbani Mohammad , Hamidi Ava , Hasheminejad Zeynab Sadat , Komachali Sahar Hojjat-Anasri , Khorvash Fariborz , Kobeissy Firas , Mirkarimi Hamidreza , Mohammadi-Vosough Elahe , Misra Debdipto , Noorian Ali Reza , Nowrouzi-Sohrabi Peyman , Paybast Sepideh , Poorsaadat Leila , Roozbeh Mehrdad , Sabayan Behnam , Salehizadeh Saeideh , Saberi Alia , Sepehrnia Mercedeh , Vahabizad Fahimeh , Yasuda Thomas , Marvast Ahmadreza Hojati , Ghabaee Mojdeh , Rahimian Nasrin , Harirchian Mohammad Hossein , Borhani-Haghighi Afshin , Arora Rohan , Ansari Saeed , Avula Venkatesh , Li Jiang , Abedi Vida , Zand Ramin 
Published: August 2020

Background

Stroke is reported as a consequence of SARS-CoV-2 infection. However, there is a lack of regarding comprehensive stroke phenotype and characteristics

Methods

We conducted a multinational observational study on features of consecutive acute ischemic stroke (AIS), intracranial hemorrhage (ICH), and cerebral venous or sinus thrombosis (CVST) among SARS-CoV-2 infected patients. We further investigated the association of demographics, clinical data, geographical regions, and countries’ health expenditure among AIS patients with the risk of large vessel occlusion (LVO), stroke severity as measured by National Institute of Health stroke scale (NIHSS), and stroke subtype as measured by the TOAST criteria. Additionally, we applied unsupervised machine learning algorithms to uncover possible similarities among stroke patients.

Results

Among the 136 tertiary centers of 32 countries who participated in this study, 71 centers from 17 countries had at least one eligible stroke patient. Out of 432 patients included, 323(74.8%) had AIS, 91(21.1%) ICH, and 18(4.2%) CVST. Among 23 patients with subarachnoid hemorrhage, 16(69.5%) had no evidence of aneurysm. A total of 183(42.4%) patients were women, 104(24.1%) patients were younger than 55 years, and 105(24.4%) patients had no identifiable vascular risk factors. Among 380 patients who had known interval onset of the SARS-CoV-2 and stroke, 144(37.8%) presented to the hospital with chief complaints of stroke-related symptoms, with asymptomatic or undiagnosed SARS-CoV-2 infection. Among AIS patients 44.5% had LVO; 10% had small artery occlusion according to the TOAST criteria. We observed a lower median NIHSS (8[3-17], versus 11 [5-17]; p=0.02) and higher rate of mechanical thrombectomy (12.4% versus 2%; p<0.001) in countries with middle to high-health expenditure when compared to countries with lower health expenditure. The unsupervised machine learning identified 4 subgroups, with a relatively large group with no or limited comorbidities.

Conclusions

We observed a relatively high number of young, and asymptomatic SARS-CoV-2 infections among stroke patients. Traditional vascular risk factors were absent among a relatively large cohort of patients. Among hospitalized patients, the stroke severity was lower and rate of mechanical thrombectomy was higher among countries with middle to high-health expenditure.