SARS-CoV-2 and Stroke Characteristics
Authors: Shahjouei Shima , Tsivgoulis Georgios , Farahmand Ghasem , Koza Eric , Mowla Ashkan , Vafaei Sadr Alireza , Kia Arash , Vaghefi Far Alaleh , Mondello Stefania , Cernigliaro Achille , Ranta Annemarei , Punter Martin , Khodadadi Faezeh , Naderi Soheil , Sabra Mirna , Ramezani Mahtab , Amini Harandi Ali , Olulana Oluwaseyi , Chaudhary Durgesh , Lyoubi Aicha , Campbell Bruce C.V. , Arenillas Juan F. , Bock Daniel , Montaner Joan , Aghayari Sheikh Neshin Saeideh , Aguiar de Sousa Diana , Tenser Matthew S. , Aires Ana , Alfonso Mercedes de Lera , Alizada Orkhan , Azevedo Elsa , Goyal Nitin , Babaeepour Zabihollah , Banihashemi Gelareh , Bonati Leo H. , Cereda Carlo W. , Chang Jason J. , Crnjakovic Miljenko , De Marchis Gian Marco , Del Sette Massimo , Ebrahimzadeh Seyed Amir , Farhoudi Mehdi , Gandoglia Ilaria , Gonçalves Bruno , Griessenauer Christoph J. , Murat Hanci Mehmet , Katsanos Aristeidis H. , Krogias Christos , Leker Ronen R. , Lotman Lev , Mai Jeffrey , Male Shailesh , Malhotra Konark , Malojcic Branko , Mesquita Teresa , Mir Ghasemi Asadollah , Mohamed Aref Hany , Mohseni Afshar Zeinab , Moon Jusun , Niemelä Mika , Rezai Jahromi Behnam , 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 K. , Steiner Thorsten , Tempro Kristi , Turc Guillaume , Ahmadzadeh Yasaman , Almasi-Dooghaee Mostafa , Assarzadegan Farhad , Babazadeh Arefeh , Baharvahdat Humain , Cardoso Fabricio Buchadid , Dev Apoorva , Ghorbani Mohammad , Hamidi Ava , Hasheminejad Zeynab Sadat , Hojjat-Anasri Komachali Sahar , 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 Alexandre , Ghabaee Mojdeh , Rahimian Nasrin , Harirchian Mohammad Hossein , Borhani-Haghighi Afshin , Azarpazhooh Mahmoud Reza , Arora Rohan , Ansari Saeed , Avula Venkatesh , Li Jiang , Abedi Vida , Zand Ramin 
Published: April 2021

Background and Purpose:
Stroke is reported as a consequence of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection in several reports. However, data are sparse regarding the details of these patients in a multinational and large scale.

Methods:
We conducted a multinational observational study on features of consecutive acute ischemic stroke, intracranial hemorrhage, and cerebral venous or sinus thrombosis among SARS-CoV-2–infected patients. We further investigated the risk of large vessel occlusion, stroke severity as measured by the National Institutes of Health Stroke Scale, and stroke subtype as measured by the TOAST (Trial of ORG 10172 in Acute Stroke Treatment) criteria among patients with acute ischemic stroke. In addition, we explored the neuroimaging findings, features of patients who were asymptomatic for SARS-CoV-2 infection at stroke onset, and the impact of geographic regions and countries’ health expenditure on outcomes.

Results:

Among the 136 tertiary centers of 32 countries who participated in this study, 71 centers from 17 countries had at least 1 eligible stroke patient. Of 432 patients included, 323 (74.8%) had acute ischemic stroke, 91 (21.1%) intracranial hemorrhage, and 18 (4.2%) cerebral venous or sinus thrombosis. A total of 183 (42.4%) patients were women, 104 (24.1%) patients were <55 years of age, and 105 (24.4%) patients had no identifiable vascular risk factors. Among acute ischemic stroke patients, 44.5% (126 of 283 patients) had large vessel occlusion; 10% had small artery occlusion according to the TOAST criteria. We observed a lower median National Institutes of Health Stroke Scale (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 with countries with lower health expenditure. Among 380 patients who had known interval onset of the SARS-CoV-2 and stroke, 144 (37.8%) were asymptomatic at the time of admission for SARS-CoV-2 infection.

Conclusions:
We observed a considerably higher rate of large vessel occlusions, a much lower rate of small vessel occlusion and lacunar infarction, and a considerable number of young stroke when compared with the population studies before the pandemic. The rate of mechanical thrombectomy was significantly lower in countries with lower health expenditures.