Risk of ischemic stroke in patients with coronavirus disease 2019 (COVID-19) vs patients with influenza.
Open accessPublished version of a preprint
Abstract
IMPORTANCE: It is uncertain whether coronavirus disease 2019 (COVID-19) is associated with a higher risk of ischemic stroke than would be expected from a viral respiratory infection. OBJECTIVE: To compare the rate of ischemic stroke between patients with COVID-19 and patients with influenza, a respiratory viral illness previously associated with stroke. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study was conducted at 2 academic hospitals in New York City, New York, and included adult patients with emergency department visits or hospitalizations with COVID-19 from March 4, 2020, through May 2, 2020. The comparison cohort included adults with emergency department visits or hospitalizations with influenza A/B from January 1, 2016, through May 31, 2018 (spanning moderate and severe influenza seasons). EXPOSURES: COVID-19 infection confirmed by evidence of severe acute respiratory syndrome coronavirus 2 in the nasopharynx by polymerase chain reaction and laboratory-confirmed influenza A/B. MAIN OUTCOMES AND MEASURES: A panel of neurologists adjudicated the primary outcome of acute ischemic stroke and its clinical characteristics, mechanisms, and outcomes. We used logistic regression to compare the proportion of patients with COVID-19 with ischemic stroke vs the proportion among patients with influenza. RESULTS: Among 1916 patients with emergency department visits or hospitalizations with COVID-19, 31 (1.6%; 95% CI, 1.1%-2.3%) had an acute ischemic stroke. The median age of patients with stroke was 69 years (interquartile range, 66-78 years); 18 (58%) were men. Stroke was the reason for hospital presentation in 8 cases (26%). In comparison, 3 of 1486 patients with influenza (0.2%; 95% CI, 0.0%-0.6%) had an acute ischemic stroke. After adjustment for age, sex, and race, the likelihood of stroke was higher with COVID-19 infection than with influenza infection (odds ratio, 7.6; 95% CI, 2.3-25.2). The association persisted across sensitivity analyses adjusting for vascular risk factors, viral symptomatology, and intensive care unit admission. CONCLUSIONS AND RELEVANCE: In this retrospective cohort study from 2 New York City academic hospitals, approximately 1.6% of adults with COVID-19 who visited the emergency department or were hospitalized experienced ischemic stroke, a higher rate of stroke compared with a cohort of patients with influenza. Additional studies are needed to confirm these findings and to investigate possible thrombotic mechanisms associated with COVID-19.
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- Authors
- Merkler, A. E., Parikh, N. S., Mir, S., Gupta, A., Kamel, H., Lin, E., Lantos, J., Schenck, E. J., Goyal, P., Bruce, S. S., Kahan, J., Lansdale, K. N., LeMoss, N. M., Murthy, S. B., Stieg, P. E., Fink, M. E., Iadecola, C., Segal, A. Z., Cusick, M., Campion, T. R., Diaz, I., Zhang, C., & Navi, B. B.
- Affiliations
- Weill Cornell Medicine (US)
- Corresponding author
- Navi, Babak B.
- ORCID
- Merkler, Alexander E.
- Parikh, Neal S.
- Mir, Saad
- Gupta, Ajay
- Kamel, Hooman
- Lin, Eaton
- Lantos, Joshua
- Schenck, Edward J.
- Goyal, Parag
- Bruce, Samuel S.
- Kahan, Joshua
- LeMoss, Natalie M.
- Murthy, Santosh B.
- Stieg, Philip E.
- Fink, Matthew E.
- Iadecola, Costantino
- Segal, Alan Z.
- Cusick, Marika
- Campion, Thomas R.
- Diaz, Ivan
- Zhang, Cenai
- Navi, Babak B.
- Venue
- JAMA Neurology
- Publisher
- American Medical Association (AMA)
- Published
- 2020-11-01
- Volume
- 77
- Issue
- 11
- Pages
- 1366
- ISSN
- 2168-6149 (ISSN-L)
- PMC
- PMC7333175
- OpenAlex
- W3039241400
- Cited by
- 940
- References
- 26
- Citations by year
- 2026: 17 · 2025: 38 · 2024: 66 · 2023: 74 · 2022: 139 · 2021: 347 · 2020: 255 · 2012: 1
- FWCI
- 26.70
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- JAMA Neurology (publishedVersion)
- medRxiv (acceptedVersion, cc-by-nc-nd)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (submittedVersion, cc-by-nc-nd)
- Funders
- National Institutes of Health (UL1TR000457, UL1TR002384)
- Weill Cornell Medical College
- National Heart, Lung, and Blood Institute (R01HL144541)
- National Institute of Neurological Disorders and Stroke (K23NS091395, K23NS105948)
- Topics
- Health Sciences › Medicine › Infectious Diseases › COVID-19 Clinical Research Studies
- Health Sciences › Medicine › Neurology › Long-Term Effects of COVID-19
- Health Sciences › Medicine › Epidemiology › Acute Ischemic Stroke Management
- Keywords
- COVID-19 pandemic, influenza A/B, acute ischemic stroke, stroke risk, SARS-CoV-2, respiratory viral infections, stroke mechanisms, stroke outcome, vascular risk factors, intensive care unit admission, emergency department visits, hospitalization, New York City, sex differences in stroke outcomes, age differences
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