Risk, Clinical Course, and Outcome of Ischemic Stroke in Patients Hospitalized With COVID-19: A Multicenter Cohort Study
Authors: Sluis Wouter M. , Linschoten Marijke , Buijs Julie E. , Biesbroek J. Matthijs , den Hertog Heleen M. , Ribbers Tessa , Nieuwkamp Dennis J. , van Houwelingen Reinier C. , Dias Andreas , van Uden Ingeborg W.M. , Kerklaan Joost P. , Bienfait H. Paul , Vermeer Sarah E. , de Jong Sonja W. , Ali Mariam , Wermer Marieke J.H. , de Graaf Marieke T. , Brouwers Paul J.A.M. , Asselbergs Folkert W. , Kappelle L. Jaap , van der Worp H. Bart , Algra Annemijn M. , Donders Richard C.J.M. , Pruissen D. Martijn O. , Kuijper Aaf F.M. , van Ofwegen-Hanekamp Clara E.E. , Hermanides Rik S. , Haerkens-Arends Hortence E. , Anthonio Rutger L. , Emans Mireille E. , Tio René A. , ten Berg Jur M. , Groenemeijer Björn E. , Pisters Ron , van der Zee P. Marc , Siebelink Hans-Marc J. , Verschure Derk O. , Meijs Matthijs F.L. , Schut Astrid , Tieleman Robert G. , Hermans-van Ast Wanda , Schaap Jeroen , Jewbali Lucia S. , Smits Peter C. , van der Harst Pim , van Smeden Maarten , van Gilst Wiek H. 
Published: November 2021

Background and Purpose:
The frequency of ischemic stroke in patients with coronavirus disease 2019 (COVID-19) varies in the current literature, and risk factors are unknown. We assessed the incidence, risk factors, and outcomes of acute ischemic stroke in hospitalized patients with COVID-19.

Methods:
We included patients with a laboratory-confirmed SARS-CoV-2 (severe acute respiratory syndrome coronavirus-2) infection admitted in 16 Dutch hospitals participating in the international CAPACITY-COVID registry between March 1 and August 1, 2020. Patients were screened for the occurrence of acute ischemic stroke. We calculated the cumulative incidence of ischemic stroke and compared risk factors, cardiovascular complications, and in-hospital mortality in patients with and without ischemic stroke.

Results:

We included 2147 patients with COVID-19, of whom 586 (27.3%) needed treatment at an intensive care unit. Thirty-eight patients (1.8%) had an ischemic stroke. Patients with stroke were older but did not differ in sex or cardiovascular risk factors. Median time between the onset of COVID-19 symptoms and diagnosis of stroke was 2 weeks. The incidence of ischemic stroke was higher among patients who were treated at an intensive care unit (16/586; 2.7% versus nonintensive care unit, 22/1561; 1.4%;
P
=0.039). Pulmonary embolism was more common in patients with (8/38; 21.1%) than in those without stroke (160/2109; 7.6%; adjusted risk ratio, 2.08 [95% CI, 1.52–2.84]). Twenty-seven patients with ischemic stroke (71.1%) died during admission or were functionally dependent at discharge. Patients with ischemic stroke were at a higher risk of in-hospital mortality (adjusted risk ratio, 1.56 [95% CI, 1.13–2.15]) than patients without stroke.

Conclusions:
In this multicenter cohort study, the cumulative incidence of acute ischemic stroke in hospitalized patients with COVID-19 was ≈2%, with a higher risk in patients treated at an intensive care unit. The majority of stroke patients had a poor outcome. The association between ischemic stroke and pulmonary embolism warrants further investigation.