The Incidence of Stroke in Critically Ill COVID-19 Patients and Its Association With Elevated D-Dimers

Author Type(s)

Faculty

Document Type

Abstract

Publication Date

2021

Journal Title

American Journal of Respiratory and Critical Care Medicine

Department

Medicine

Abstract

Introduction:

Ischemic and hemorrhagic strokes appear to be complications of Coronavirus Disease 2019 (COVID-19). Implicated mechanisms include severity of inflammation in these patients that leads to endothelial injury and a more severe prothrombotic state. Patients with a more severe presentation appear to be at higher risk. Based on observational data, intracranial hemorrhage occurs in 0.2-0.9% of hospitalized COVID-19 patients, while ischemic stroke occurs in 0.9-2.5%. Small reports have indicated that d-dimer levels preceding the stroke are higher than in COVID-19 patients without strokes. In our study we aimed to determine the incidence of stroke in our intensive care unit (ICU) patients with COVID-19, and further assess the association between ddimer levels at the time of ICU admission and ischemic/hemorrhagic stroke.

Methods:

This study is retrospective analysis of all adult patients with COVID-related acute respiratory distress syndrome (ARDS) admitted to the ICUs of a tertiary care hospital between 03/01/2020 and 05/31/2020. We identified patients who had a stroke based on CT head findings. Demographic and clinical characteristics, inflammatory markers at the time of ICU admission and clinical outcomes of patients with stroke were compared and analyzed with patients who did not have stroke. Means, Medians and categorical variables were compared using t-test, Mann-Whitney U-test and Fisher's exact test, respectively. P-value of <0.05 was taken to be statistically significant.

Results:

Of the 210 patients admitted to our ICUs with COVID related ARDS, 20 (9.5%) had strokes (18 ischemic, 2 hemorrhagic) at some point in their hospitalization. There was no statistically significant difference between the groups in terms of demographics, comorbidities, and outcomes such as death. Therapies provided, including steroids and therapeutic anticoagulation, were similar in both groups. D-dimer levels at the time of ICU admission in the patients with stroke were significantly higher than in patients without stroke (p= 0.025).

Conclusion:

Our study shows that the incidence of stroke in COVID-19 patients admitted to ICUs is higher than previously reported, despite most being on anticoagulation. Our study also demonstrated that COVID-19 ICU patients who developed stroke during their hospitalization had significantly higher d-dimer levels at the time of ICU admission. Our findings suggest that intensivists need to be constantly vigilant about not missing strokes in critically ill COVID-19 patients. The findings also suggest that the magnitude of d-dimer elevation at the time of ICU admission may be a useful predictor of developing strokes during the hospitalization. Larger studies are needed to confirm our findings.

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