COVID-19 Associated With Poor Outcomes and Incomplete Revascularization in Patients With Large Vessel Occlusion Stroke

April 12, 2022—In a multicenter, international, retrospective study of COVID-19–positive patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO), Jabbour et al found that COVID-19 was an independent predictor of poor outcomes and incomplete revascularization. Patients with COVID-19 and LVO were younger, had lower functional independence at stroke onset, and had fewer cerebrovascular risk factors. The study was published online in Neurosurgery.

The investigators retrospectively reviewed patients with COVID-19 and AIS due to LVO who presented to 48 thrombectomy comprehensive stroke centers primarily across North America and Europe between February 25 and December 30, 2020. A historical control group of patients with LVO who received mechanical thrombectomy between January 2018 and December 2020 was used for comparison.

The study included 575 patients, with 194 patients with COVID-19 and LVO and 318 patients with LVO as controls. Patients in the COVID-19 group were younger as compared with control group patients (62.5 ± 15.3 years vs 71.2 ± 15.9 years; P < .001). At stroke onset, 90% of COVID-19 patients were functionally independent (modified Rankin Scale [mRS] 0-2) versus 96.3% in the control group (P = .002).

As compared with controls, patients with the COVID-19 group had a lower Alberta Stroke Program Early Computed Tomography Score (ASPECTS) at admission and a higher National Institutes of Health Stroke Scale (NIHSS) score (ASPECTS, 8 vs 9 and NIHSS, 17.5 vs 14; both P ≤ .001). The location of the occlusion (anterior vs posterior) was not significantly different between groups.

Regarding stroke treatment, tissue plasminogen activator administration was similar between groups (34.3% vs 34.8%), and more patients in the COVID-19 group underwent mechanical thrombectomy under general anesthesia as compared with controls (31.5% vs 19.1%; P ≤ .001). The mechanical thrombectomy procedure was 11 minutes longer in the COVID-19 group as compared with the control group (62.2 + 47.3 min vs 51.9 + 31.9 min; P = .002). Although favorable revascularization, defined as modified thrombolysis in cerebral infarction (mTICI) 2b-3, was similar in both groups (83.6% vs 86.9%; P = .284), fewer patients in the COVID-19 group had complete revascularization (mTICI 3) (39.2% vs 67.2%; P < .001).

Patients in the COVID-19 group were more likely to have a poor functional outcome at discharge (defined as mRS 3-6; 79.8% vs 66.7%; P = .004). COVID-19 was independently associated with a lower likelihood of achieving a mTICI 3 (odds ratio [OR], 0.4; 95% CI, 0.2-0.7; P < .001) and unfavorable outcomes (OR, 2.5; 95% CI, 1.4-4.5; P = .002).

The strengths of this study included its large sample size, international patient cohort, and comparative analysis, whereas limitations included the retrospective design, absence of randomization, significant differences in baseline characteristics between groups (age, sex, comorbidities, and baseline functional status), and different treatment periods, noted the investigators.