Stroke patients with COVID fared worse than noninfected patients

Host Amber Smith: Upstate Medical University in Syracuse New York invites you to be "The Informed Patient," with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. People who had strokes during the pandemic and who were also found to be infected with COVID had worse outcomes than those who were COVID-free, according to research in the journal, neurology. I'll be talking about the possible reasons for this with Dr. Navreet Kaur, who is completing her fourth year of residency in neurology at Upstate. Welcome to "The Informed Patient," Dr. Kaur.

Navreet Kaur, MD: Good morning.

Host Amber Smith: The paper published in the journal Neurology references the global COVID-19 Stroke Registry. What is that?

Navreet Kaur, MD: The global registry is basically a database, which is IRB (Institutional Review Board) approved research where data is collected and coordinated at a specific site. So this site is affiliated with a center in Switzerland, and they did a couple of studies during the COVID time to obtain this data and research how the things were in the stroke world before pandemic and during pandemic.

So how many institutions across the world are part of the registry? And I'm assuming Upstate is one of them, right?

Yes, Upstate is one of them. So this particular study that we are talking about today involved 105 centers, from roughly 20-plus countries in the world. And then we got the approval from IRB before collecting the data and sending it to the coordinating site.

Host Amber Smith: Now this is a retrospective study, meaning researchers looked back at a group of patients after they received care. What time period did this cover?

Navreet Kaur, MD: This covered the time period from March 2020, which was beginning of the pandemic, till June 2021. So these were the initial time period where everything was new with regards to COVID and stroke care. So these time periods were covered among all the 105 centers from where data was collected.

Host Amber Smith: And which types of patients were included?

Navreet Kaur, MD: All the patients who had acute stroke concerns on admission, which we usually triage with one-sided weakness, numbness, speech trouble, vision trouble. So all those patients that had these symptoms within 24 hours of onset, and then they arrived in the hospital during that time, were screened and were given care based on the criteria they meet with two different therapies.

Host Amber Smith: What are the two different therapies?

Navreet Kaur, MD: One therapy is an intravenous injection. We call it clot-busting medication. That is given within four and a half hours of symptom onset. And another therapy is endovascular therapy, where doctors go all the way into the brain to take out the clot that is blocking large vessels in the brain, causing the stroke symptoms.

Host Amber Smith: Now before we get into the results or the findings, can you give us some background? Do doctors think there's a connection between COVID-19 and stroke?

Navreet Kaur, MD: Yes. I think COVID-19, the general decision is that it affects the lungs the first, that you'll get runny nose, fever, sore throat. But in fact, it does infect the multisystem organs, so it'll have effect on all the organs, primarily brain. It leads to damage to the vessels in the brain, can cause inflammation that leads to formation of more clots. And that leads to stroke. So there is a direct connection.

Host Amber Smith: So this inflammation affects the whole body, not just the lungs, certainly, and not just the neurological?

Navreet Kaur, MD: Yes. So there are different ways that COVID can affect us, so one being that it damages the vessels in the brain. We call it quote-unquote, "endothelial dysfunction." So our brain has small vessels that has the lining with the cells, and when we have any infections, be it COVID or anything else, it affects those vessels.

We discovered that COVID affected us more. It directly damages those blood vessels, and people far more clots that lead to stroke. Another thing being that it can lead to coagulopathy. That prompts us to make more strokes.

Host Amber Smith: And are those conditions that stay with a person forever after they've had COVID?

Navreet Kaur, MD: It is really hard to comment on that, but we do know that short-term effects are there, that predisposes patients to have more strokes. So when we say coagulopathy, just to describe it in a simple way, people will have a problem where they will form clot or break down clots. So both the things are affected. They will form more clots, and then those clots will break up more and they will go to the other parts of the body affecting us. In stroke, we say that the clots can break into small fragments, go with the blood flow to the brain, causing more strokes.

So that's kind of a cycle of more stroke clots, and then them breaking, giving more strokes.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith, and I'm talking with Dr. Navreet Kaur about an interesting global study she was involved in that looked at patients who had strokes during the pandemic and compared the outcomes between those who tested positive for COVID and those who were found to be COVID-free.

Now the global COVID-19 stroke registry included more than 15,000 patients from 105 centers. What percentage were found to have COVID-19?

Navreet Kaur, MD: Roughly 5.6% of the patients, a total of 853 patients in the study, were COVID-positive at the time of stroke.

Host Amber Smith: For the treatment, what percent of those got clot-busting medication, and what percent underwent the endovascular procedure you described?

Navreet Kaur, MD: Roughly 38% of the people got the IV medication that we were talking about, the clot-busting medication. And about 61% of the people got the endovascular therapy where we go all the way up in the brain to take the clot out.

Host Amber Smith: So looking at those with COVID-19, how did their outcomes compare with those who did not have COVID-19?

Navreet Kaur, MD: When we compared the patients with COVID positive and without COVID positive, we saw that the patient who had COVID during the time of the stroke had a worse outcome. So when we say in our stroke world, the worst outcome means their exam is worsening, like they are more weak, they're more numb. And we measure it with doing repeat scans of the brain.

So our threshold for doing a repeat scan is if their stroke scale is worse than more than four points of what was when they came in. So let's say they had a weakness, they had numbness, their stroke scale was 10. And then they got treated for the stroke, and now is 14. And then you see do a CAT scan, and there is a bleed. We say that that's significant. So these patients had more bleeds in the brain. They had poorer outcomes at 24 hours. And when we tracked them across the three-month period, they had worse outcomes as compared to people who were COVID negative at the time of stroke.

Host Amber Smith: Can you explain or can you speculate why their outcomes were so much worse?

Navreet Kaur, MD: From what we think, is that the same thing we were talking about earlier. More clot formation, more inflammation, more damage. So we realized that these people who were getting treated for stroke had more stroke within the acute short period when they were in the hospital or followed through.

One certain thing was that the clots, they were very difficult to take out. Like we have seen that the patients who required the interventional endovascular therapy, they had more failed outcomes, which we measure with the perfusion. Or the amount of blood they are taking back to the brain after we take the clot out. So they were not able to have that good blood supply and perfusion after the surgery, which tells us maybe these clots are different to take out as compared to normal.

Host Amber Smith: Now this study was from a time period before there was a vaccine available. Do you think the results would be different today if the patients testing positive for COVID had previously been vaccinated?

Navreet Kaur, MD: I think that would be very difficult to say as well because COVID has many variants, and some people get more inflammatory response as compared to others. So if we think in a way that patient who got vaccine, they're not that severely sick, perhaps they did not have that amount of damage or inflammation. So their symptoms and stroke symptoms were less severe. But we don't have any data or big study to prove that. So theoretically, maybe yes, they will have lesser stroke, but we need more research to conclude that point.

Host Amber Smith: Have the findings from this paper altered the way you treat patients with stroke? Who test positive for COVID-19?

Navreet Kaur, MD: We always do the same treatments for our patients, the intravenous therapy within four and a half hours and the endovascular therapy within 24 hours of the symptom onset.

The only thing we think that is a patient who had COVID, we have to be very vigilant that these patients have tendency to form more clots and have more strokes. So we do close monitoring for everyone. So we do them the same treatment. Although they did have worse outcomes in this study, still it's a standard of care and should be given to all the patients. So I think we, we are doing the things that we do with the known COVID patients as well, and we shall continue to do so until we have more data.

Host Amber Smith: Do you think any of the same concerns that apply to stroke patients who test positive might also apply to a stroke patient who survived COVID but has the lingering long COVID symptoms that we've heard about?

Navreet Kaur, MD: That is a great question. So, COVID we know that within six months to a year -- and there have been studies to say that -- that people have more tendency to form more clots within first six months to a year of a COVID infection. So perhaps yes.

In this particular study, we did not include the patients who were positive more than seven days before they received this treatment. So we just included the acute patients. But if we think about the inflammatory response that COVID brings to patients body, yes, there is a chance that they are hypercoagulable, which means they have more tendency to form clots within first few months, particularly three to six months of the infection. But again, we don't have any research to prove that.

Host Amber Smith: Dr. Kaur, thank you so much for making time for this interview.

Navreet Kaur, MD: Thank you so much for having me.

Host Amber Smith: My guest has been Dr. Navreet Kaur, who is finishing a four year residency in neurology at Upstate. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at Upstate.edu/Informed. This is your host, Amber Smith, thanking you for listening.