Risk, clinical course, and outcome of ischemic stroke in patients hospitalized with COVID-19: a multicenter cohort study

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 approximate to 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.Paroxysmal Cerebral Disorder

Outcome after aneurysmal subarachnoid haemorrhage

Aneurysmal subarachnoid haemorrhage (SAH) is a devastating disease. It accounts for approximately 5% of all strokes. Because it affects relatively young patients and often is fatal, the loss of productive life years is similar to that for cerebral infarction and intracerebral haemorrhage. Diagnostic and treatment strategies for SAH have advanced during the last decades. Whether these have led to a decrease in the case-fatality of SAH in the general population is not known. SAH used to be considered as once-in-a-lifetime disease, and patients surviving it to an independent state were considered to have a normal further life, but it has become clear that patients who survive an SAH have an increased risk of developing new intracranial aneurysms and new episodes of SAH. Some data also suggest an increased long-term mortality after SAH and increased risks of other vascular diseases. This thesis focuses on change in short-term outcome after SAH over time and on long-term outcome with special regard to new vascular diseases in the life after SAH. We found a decrease of worldwide case-fatality of 0.6% per study year, indicating an absolute decrease of 17% over the past thirty years. In more recent years in The Netherlands, a yearly decrease of the risk of death after admission for SAH of 1.6% was found. The reduction of case-fatality leads to increased numbers of patients who survive an episode of SAH. These patients were thought to have a normal life expectancy but evidence is emerging that this is not the case. We found a roughly twofold increased risk of death for SAH survivors compared with the general population. This is in part explained by an increased risk of other vascular diseases. The excess risk of vascular diseases and death was most pronounced in the older age groups, but the relative increase was most outspoken in younger patients. Our analysis with yearly standardised mortality ratios shows that the increased risk was stable over time up to 20 years after SAH and did not cluster in the first years after the SAH. The long-term risk of death in SAH patients did not differ from that in patients with TIA or minor ischaemic stroke. The high risk of other vascular diseases after SAH is probably explained by the shared risk factors smoking and hypertension. Our results underline the need of improving treatment of risk factors after SAH, not only because of the risk of developing new intracranial aneurysms or episodes of SAH, but also because of the observed increased risk of other vascular diseases. Treatment strategies could include lifestyle adaptations, cessation of smoking, stringent management of hypertension and secondary prevention with antihypertensives, statins and antiplatelet agents in SAH survivors. Although these treatments may seem intuitive with the current knowledge on long-term prognosis, the effects of these treatments in whole or part, are, however, unknown with regard to risk of rupture of aneurysms, new aneurysm formation and the risk of new vascular diseases and survival in general. They should be properly addressed in future studie

Very long-term outcome after aneurysmal subarachnoid haemorrhage - risk of new vascular events and death

Paroxysmal Cerebral Disorder

Long-term outcome after aneurysmal subarachnoid hemorrhage-risks of vascular events, death from cancer and all-cause death

Paroxysmal Cerebral Disorder

Excess mortality and cardiovascular events in patients surviving subarachnoid hemorrhage a nationwide study in Sweden

Background and Purpose-Survivors of aneurysmal subarachnoid hemorrhage (SAH) may have an increased risk of cardiovascular events because of shared risk factors. We compared incidences of vascular diseases, vascular death, and all-cause death after SAH with those in the general population. Methods-From the Swedish Hospital Discharge and Cause of Death registries, we identified patients with SAH between January 1987 and January 2003. Conditional on survival of 3 months after SAH, we calculated standardized mortality and incidence ratios with corresponding 95% CIs for vascular death, all-cause death, and fatal or nonfatal vascular diseases. Cumulative risks were estimated with survival analysis. Results-Of 17 705 patients with SAH (mean age, 59.7 years; 59.5% women), 11 374 survived at least 3 months after SAH. During follow-up (mean, 6.8 years), 2152 (18.9%) died. The risk of death was 12.9% within 5 years, 23.6% within 10 years, and 35.4% within 15 years after SAH. The overall standardized mortality ratio was 1.57 (95% CI, 1.44 to 1.70) for vascular death and 1.61 (95% CI, 1.52 to 1.70) for all-cause death. The standardized mortality ratios were particularly high in younger individuals, ranging from 2.1 to 3.7 for vascular death and from 2.1 to 2.6 for all-cause death for patients between 50 and 65 years of age. The standardized incidence ratio for fatal or nonfatal vascular diseases was 1.51 (95% CI, 1.45 to 1.56). Conclusions-Mortality and risk of vascular diseases are increased in survivors of SAH. Prevention of new vascular diseases after SAH by management of risk factors seems important. (Stroke. 2011; 42: 902-907.)

Timing of aneurysm surgery in subarachnoid haemorrhage - an observational study in The Netherlands.

Background. There is still lack of evidence on the optimal timing of surgery in patients with aneurysmal subarachnoid haemorrhage. Only one randomised clinical trial has been done, which showed no difference between early and late surgery. Other studies were observational in nature and most had methodological drawbacks that preclude clinically meaningful conclusions. We performed a retrospective observational study on the timing of aneurysm surgery in The Netherlands over a two-year period.Method. In eight hospitals we identified 1500 patients with an aneurysmal subarachnoid haemorrhage. They were subjected to predefined inclusion criteria. We included all patients who were admitted and were conscious at any one time between admission and the end of the third day after the haemorrhage. We categorised the clinical condition on admission according the World Federation of Neurological Surgeons (WFNS) grading scale. Early aneurysm surgery was defined as operation performed within three days after onset of subarachnoid haemorrhage; intermediate surgery as performed on days four to seven, and late surgery as performed after day seven. Outcome was classified as the proportion of patients with poor outcome (death or dependent) two to four months after onset of subarachnoid haemorrhage. We calculated crude odds ratios with late surgery as reference. We distinguished between management results (reconstructed intention to treat analysis) and surgical results (on treatment analysis). The results were adjusted for the major prognosticators for outcome after subarachnoid haemorrhage.Findings. We included 411 patients. There were 276 patients in the early surgery group, 36 in the intermediate surgery group and 99 in the late surgery group. On admission 78% were in good neurological condition (WFNS I-III).Management results. Overall, 93 patients (34%) operated on early had a poor outcome, 13 (36%) of those with intermediate surgery and 37 (37%) in the late surgery group had a poor outcome. For patients in good clinical condition on admission and planned for early surgery the adjusted odds ratio (OR) was 1.3 (95% CI 0.5 to 3.0). The adjusted OR for patients admitted in poor neurologicalcondition (WFNS IV-V) and planned for early surgery was 0.1 (95% CI 0.0 to 0.6).Surgical results. For patients in good clinical condition on admission who underwent early operation the adjusted OR was 1.1 (95% CI 0.4 to 3.2); it was 0.2 (95% CI 0.0 to 0.9) for patients admitted in poor clinical condition.Conclusions. In this observational study we found no significant difference in outcome between early and late operation for patients in good clinical condition on admission. For patients in poor clinical condition on admission outcome was significantly better after early surgery. The optimal timing of surgery is not yet settled. Ideally, evidence on this issue should come from a randomised clinical trial. However, such a trial or even a prospective study are unlikely to be ever performed because of the rapid development of endovascular coiling