SARS-CoV-2 and Stroke Characteristics
This article has been Reviewed by the following groups
Listed in
- Evaluated articles (ScreenIT)
Abstract
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.
Article activity feed
-
-
SciScore for 10.1101/2020.08.05.20169169: (What is this?)
Please note, not all rigor criteria are appropriate for all manuscripts.
Table 1: Rigor
Institutional Review Board Statement IRB: This multicenter, multinational observational study was conducted and reported according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE),[28] and Enhancing the QUAlity and Transparency Of health Research (EQUATOR) guidelines. [29] The study protocol was designed by the investigators at the Neuroscience Institute of Geisinger Health System, Pennsylvania, USA, and received approval by the Institutional Review Board of Geisinger Health System and other participating institutions. Randomization not detected. Blinding not detected. Power Analysis not detected. Sex as a biological variable There were differences among men and women … SciScore for 10.1101/2020.08.05.20169169: (What is this?)
Please note, not all rigor criteria are appropriate for all manuscripts.
Table 1: Rigor
Institutional Review Board Statement IRB: This multicenter, multinational observational study was conducted and reported according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE),[28] and Enhancing the QUAlity and Transparency Of health Research (EQUATOR) guidelines. [29] The study protocol was designed by the investigators at the Neuroscience Institute of Geisinger Health System, Pennsylvania, USA, and received approval by the Institutional Review Board of Geisinger Health System and other participating institutions. Randomization not detected. Blinding not detected. Power Analysis not detected. Sex as a biological variable There were differences among men and women in smoking status (9.4% versus 21.2% in men, p=0.01), chronic kidney disease (7.9% versus 16.6% in men, p=0.01), NIHSS (12.0 [5.0 – 19.0] versus 8.0 [4.0 – 16.0] in men, p<0.001), and TOAST classification (p=0.05). Table 2: Resources
No key resources detected.
Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).
Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:This work has several limitations. Despite that we included centers from multiple countries and presented a comprehensive panel of patients’ characteristics, some of the specific laboratory parameters related to rare stroke causes (e.g., antiphospholipid antibodies) were not included in this study. The collaborators tried to identify SARS-CoV-2 patients who presented with stroke as the first and only symptom, but difficulty in measuring all symptoms related to COVID-19 (such as fatigue, anosmia, and ageusia) should be taken into consideration. Due to the small sample and heterogeneity of the patients with subclasses of SAH or CVST, we did not apply the machine learning on this subgroup for further exploration. Although attempts were made to minimize the selection bias by including patients from different ethnicities, ecological conditions, and health care systems, this study may suffer from selection bias and low power in some subgroups. Further studies that include a control population are warranted. In conclusion, 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
Results from TrialIdentifier: No clinical trial numbers were referenced.
Results from Barzooka: We did not find any issues relating to the usage of bar graphs.
Results from JetFighter: We did not find any issues relating to colormaps.
Results from rtransparent:- Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
- Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
- No protocol registration statement was detected.
-
-