Effect of Asymptomatic and Symptomatic COVID-19 on Acute Ischemic Stroke Revascularization Outcomes
Authors: Strambo Davide , Marto João Pedro , Ntaios George , Nguyen Thanh N. , Michel Patrik , Herzig Roman , Członkowksa Anna , Demeestere Jelle , Yassin Mansour Ossama , Georgiopoulos Georgios , Nogueira Raul G. , Salerno Alexander , Wegener Susanne , Baumgartner Philipp , Cereda Carlo W. , Bianco Giovanni , Beyeler Morin , Arnold Marcel , Carrera Emmanuel , Machi Paolo , Altersberger Valerian , Bonati Leo , Gensicke Henrik , Bolognese Manuel , Peters Nils , Wetzel Stephan , Magriço Marta , Nuno Ramos João , Sargento-Freitas João , Machado Rita , Maia Carolina , Machado Egídio , Paiva-Nunes Ana , Ferreira Patrícia , Pinho-e-Melo Teresa , Carvalho-Dias Mariana , Paula André , Alberto Correia Manuel , Castro Pedro , Azevedo Elsa , Albuquerque Luís , Nuno-Alves José , Ferreira-Pinto Joana , Meira Torcato , Pereira Liliana , Rodrigues Miguel , Araújo André , Rodrigues Marta , Rocha Mariana , Pereira-Fonseca Ângelo , Ribeiro Luís , Varela Ricardo , Cappellari Manuel , Zivelonghi Cecilia , Sajeva Giulia , Zini Andrea , Gentile Mauro , Forlivesi Stefano , Migliaccio Ludovica , Sessa Maria , Pezzini Alessandro , Sangalli Davide , Zedde Marialuisa , Pascarella Rosario , Diamanti Susanna , Beretta Simone , Schwarz Ghil , Frisullo Giovanni , Marcheselli Simona , Seners Pierre , Sabben Candice , Escalard Simon , Piotin Michel , Maier Benjamin , Charbonnier Guillaume , Vuillier Fabrice , Legris Loic , Cuisenier Pauline , Vodret Francesca R. , Marnat Gaultier , Liegey Jean-Sebastien , Sibon Igor , Flottmann Fabian , Broocks Gabriel , Gloyer Nils-Ole , Bohmann Ferdinand O. , Hendrik Schaefer Jan , Nolte Christian H. , Audebert Heinrich , Siebert Eberhard , Sykora Marek , Lang Wilfried , Ferrari Julia , Mayer-Suess Lukas , Knoflach Michael , Gizewski Elke-Ruth , Stolp Jeffrey , Stolze Lotte J. , Coutinho Jonathan M. , Nederkoorn Paul J. , van-den-Wijngaard Ido , de Meris Joke , Lemmens Robin , De Raedt Sylvie , Vandervorst Fenne , Pierre Rutgers Matthieu , Guilmot Antoine , Dusart Anne , Bellante Flavio , Calleja-Castaño Patricia , Ostos Fernando , Gonzalez-Ortega Guillermo , Martín-Jiménez Paloma , García-Madrona Sebastian , Cruz-Culebras Antonio , Vera Rocio , Matute Maria-Consuelo , Fuentes Blanca , Alonso-de-Leciñana María , Rigual Ricardo , Díez-Tejedor Exuperio , Pérez-Sánchez Soledad , Montaner Joan , Díaz-Otero Fernando , Perez de la Ossa Natalia , Flores-Pina Belén , Muñoz-Narbona Lucia , Chamorro Angel , Rodríguez-Vázquez Alejandro , Renú Arturo , Ayo-Martin Oscar , Hernandez-Fernandez Francisco , Segura Tomas , Tejada-Meza Herbert , Hlaing Thant , See Isaiah , Simister Robert , Werring David J. , Saxhaug Kristoffersen Espen , Nordanstig Annika , Jood Katarina , Rentzos Alexandros , Šimůnek Libor , Krajíčková Dagmar , Krajina Antonín , Mikulík Robert , Cviková Martina , Vinklárek Jan , Školoudík David , Roubec Martin , Hurtikova Eva , Hrubý Rostislav , Ostry Svatopluk , Skoda Ondrej , Pernicka Marek , Kočí Lubomír , Eichlová Zuzana , Jíra Martin , Kovář Martin , Panský Michal , Mencl Pavel , Paloušková Hana , Tomek Aleš , Janský Petr , Olšerová Anna , Šrámek Martin , Havlíček Roman , Malý Petr , Trakal Lukáš , Fiksa Jan , Slovák Matěj , Karliński Michał , Nowak Maciej , Sienkiewicz-Jarosz Halina , Bochynska Anna , Wrona Pawel , Homa Tomasz , Sawczynska Katarzyna , Slowik Agnieszka , Wlodarczyk Ewa , Wiącek Marcin , Tomaszewska-Lampart Izabella , Sieczkowski Bartosz , Bartosik-Psujek Halina , Bilik Marta , Bandzarewicz Anna , Dorobek Malgorzata , Zielińska-Turek Justyna , Nowakowska-Kotas Marta , Obara Krystian , Urbanowski Paweł , Budrewicz Sławomir , Guziński Maciej , Świtońska Milena , Rutkowska Iwona , Sobieszak-Skura Paulina , Łabuz-Roszak Beata , Dębiec Aleksander , Staszewski Jacek , Stępień Adam , Zwiernik Jacek , Wasilewski Grzegorz , Tiu Cristina , Terecoasă Elena-Oana , Radu Razvan-Alexandru , Negrila Anca , Dorobat Bogdan , Panea Cristina , Tiu Vlad , Petrescu Simona , Özcan-Özdemir Atilla , Mahmoud Mostafa , El-Samahy Hussam , Abdelkhalek Hazem , Al-Hashel Jasem , Ibrahim Ismail Ismail , Salmeen Athari , Ghoreishi Abdoreza , Sabetay Sergiu , Gross Hana , Klein Piers , Abdalkader Mohamad , Jabbour Pascal , El Naamani Kareem , Tjoumakaris Stavropoula , Abbas Rawad , Mohamed Ghada-A. , Chebl Alex , Min Jiangyong , Hovingh Majesta , Tsai Jenny , Khan Muhib-A. , Nalleballe Krishna , Onteddu Sanjeeva , Masoud Hesham E. , Michael Mina , Kaur Navreet , Maali Laith , Abraham Michael , Khandelwal Priyank , Bach Ivo , Ong Melody , Babici Denis , Khawaja Ayaz-M. , Hakemi Maryam , Rajamani Kumar , Cano-Nigenda Vanessa , Arauz Antonio , Amaya Pablo , Llanos Natalia , Arango Akemi , Vences Miguel A. , Barrientos José-Domingo , Caetano Rayllene , Targa Rodrigo , Scollo Sergio , Yalung Patrick , Nagendra Shashank , Gaikwad Abhijit , Seo Kwon-Duk 
Published: December 2023

BACKGROUND:
The association of COVID-19 with higher bleeding risk and worse outcomes in acute ischemic stroke (AIS) undergoing revascularization may be related to the presence of infection symptoms. We aimed to assess the safety and outcomes of revascularization treatments in patients with AIS with asymptomatic COVID-19 (AS-COVID) or symptomatic COVID-19 (S-COVID).

METHODS:
We conducted an international multicenter retrospective cohort study of consecutive AIS tested for SARS-CoV-2, receiving intravenous thrombolysis and endovascular treatment between 2020 and 2021. We compared COVID-negative controls, AS-COVID, and S-COVID using multivariable regression. We assessed symptomatic intracranial hemorrhage (symptomatic intracerebral hemorrhage), mortality, and 3-month disability (modified Rankin Scale score).

RESULTS:

Among 15 124 patients from 105 centers (median age, 71 years; 49% men; 39% treated with intravenous thrombolysis only; and 61% with endovascular treatment±intravenous thrombolysis), 849 (5.6%) had COVID-19, of whom 395 (46%) were asymptomatic and 454 (54%) symptomatic. Compared with controls, both patients with AS-COVID and S-COVID had higher symptomatic intracerebral hemorrhage rates (COVID-controls, 5%; AS-COVID, 7.6%; S-COVID, 9.4%; adjusted odds ratio [aOR], 1.43 [95% CI, 1.03–1.99]; aOR, 1.63 [95% CI, 1.14–2.32], respectively). Only in patients with symptomatic infections, we observed a significant increase in mortality at 24 hours (COVID-controls, 1.3%; S-COVID, 4.8%; aOR, 2.97 [95% CI, 1.76–5.03]) and 3 months (COVID-controls, 19.5%; S-COVID, 40%; aOR, 2.64 [95% CI, 2.06–3.37]). Patients with COVID-19 had worse 3-month disability regardless of disease symptoms although disability was affected to a greater extent in symptomatic patients (aOR for worse modified Rankin Scale score shift: AS-COVID, 1.25 [95% CI, 1.03–1.51]; S-COVID, 2.10 [95% CI, 1.75–2.53]). S-COVID had lower successful recanalization (74.9% versus 85.6%;
P
<0.001), first pass recanalization (20.3% versus 28.3%;
P
=0.005), and a higher number of passes.

CONCLUSIONS:
In AIS undergoing revascularization treatments, both AS-COVID and S-COVID influence the risk of intracranial bleeding and worse clinical outcomes. The magnitude of this effect is more pronounced in symptomatic infections, which also present less favorable recanalization outcomes. These findings emphasize the impact of SARS-CoV-2 infection on the prognosis of revascularized AIS independent of symptom status.

REGISTRATION:

URL:
https://www.clinicaltrials.gov
; Unique identifier: NCT04895462.