BACKGROUND AND OBJECTIVES: COVID-19-related inflammation, endothelial dysfunction, and coagulopathy may increase the bleeding risk and lower the efficacy of revascularization treatments in patients with acute ischemic stroke (AIS). We aimed to evaluate the safety and outcomes of revascularization treatments in patients with AIS and COVID-19. METHODS: This was a retrospective multicenter cohort study of consecutive patients with AIS receiving intravenous thrombolysis (IVT) and/or endovascular treatment (EVT) between March 2020 and June 2021 tested for severe acute respiratory syndrome coronavirus 2 infection. With a doubly robust model combining propensity score weighting and multivariate regression, we studied the association of COVID-19 with intracranial bleeding complications and clinical outcomes. Subgroup analyses were performed according to treatment groups (IVT-only and EVT). RESULTS: Of a total of 15,128 included patients from 105 centers, 853 (5.6%) were diagnosed with COVID-19; of those, 5,848 (38.7%) patients received IVT-only and 9,280 (61.3%) EVT (with or without IVT). Patients with COVID-19 had a higher rate of symptomatic intracerebral hemorrhage (SICH) (adjusted OR 1.53; 95% CI 1.16-2.01), symptomatic subarachnoid hemorrhage (SSAH) (OR 1.80; 95% CI 1.20-2.69), SICH and/or SSAH combined (OR 1.56; 95% CI 1.23-1.99), 24-hour mortality (OR 2.47; 95% CI 1.58-3.86), and 3-month mortality (OR 1.88; 95% CI 1.52-2.33). Patients with COVID-19 also had an unfavorable shift in the distribution of the modified Rankin score at 3 months (OR 1.42; 95% CI 1.26-1.60). DISCUSSION: Patients with AIS and COVID-19 showed higher rates of intracranial bleeding complications and worse clinical outcomes after revascularization treatments than contemporaneous non-COVID-19 patients receiving treatment. Current available data do not allow direct conclusions to be drawn on the effectiveness of revascularization treatments in patients with COVID-19 or to establish different treatment recommendations in this subgroup of patients with ischemic stroke. Our findings can be taken into consideration for treatment decisions, patient monitoring, and establishing prognosis. TRIAL REGISTRATION INFORMATION: The study was registered under ClinicalTrials.gov identifier NCT04895462.

1th Department of Neurology Institute of Psychiatry and Neurology Warsaw Poland

2nd Department of Neurology Institute of Psychiatry and Neurology Warsaw Poland

Ain Shams University Affiliated Saudi German Hospital Egypt

Alexandria University Hospitals and Affiliated Stroke Network Egypt

Center for Health Research Faculty of Medicine University of Ostrava Czech Republic

Centro de Investigaciones Clínicas Fundación Valle del Lili Cali Colombia

Cerebrovascular Centre Central Military Hospital Prague Czech Republic

Cerebrovascular Centre General University Hospital Prague Czech Republic

Cerebrovascular Centre Na Homolce Hospital Prague Czech Republic

Cerebrovascular Centre University Hospital in Motol Prague Czech Republic

Clinic of Neurology Military Institute of Medicine Warsaw Poland

Comprehensive Stroke Centre and Department of Neurosciences Spectrum Health and Michigan State University

Comprehensive Stroke Service University College London Hospitals NHS Foundation Trust and Stroke Research Centre University College London United Kingdom

Department of Clinical and Experimental Sciences Neurology Clinic University of Brescia Italy

Department of Clinical Neuroscience Sahlgrenska University Hospital Region Västra Götaland Gothenburg Sweden

Department of Clinical Therapeutics National and Kapodistrian University of Athens Greece

Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg Eppendorf Germany

Department of Internal Medicine Faculty of Medicine School of Health Sciences University of Thessaly Larissa Greece

Department of Interventional and Diagnostic Neuroradiology Bordeaux University Hospital France

Department of Interventional Neuroradiology Centre Hospitalier Régional Universitaire Hôpital Jean Minjoz Besançon France

Department of Interventional Neuroradiology Hôpital Fondation Ade Rothschild Paris France

Department of Neurology Akershus University Hospital Lørenskog and Department of General Practice University of Oslo Norway

Department of Neurology Amsterdam University Medical Centers Netherlands

Department of Neurology and Centre for Stroke Research Berlin Institute of Health Charité Universitätsmedizin Berlin Germany

Department of Neurology and Stroke Centre Madrid Spain

Department of Neurology and Stroke Spain

Department of Neurology and Stroke St John Paul 2 Western Hospital Grodzisk Mazowiecki Poland

Department of Neurology and Stroke Unit Azienda Socio Sanitaria Territoriale Lecco Italy

Department of Neurology and Stroke Unit Elias University Emergency Hospital University of Medicine and Pharmacy Carol Davila Bucharest Romania

Department of Neurology ASST Papa Giovanni XXIII Bergamo Italy

Department of Neurology Central Clinical Hospital of the Ministry of the Interior and Administration Warsaw Poland

Department of Neurology Centre Hospitalier Universitaire de Charleroi Belgium

Department of Neurology Centro Hospitalar de Vila Nova de Gaia Espinho Portugal

Department of Neurology Centro Hospitalar Universitário de Coimbra Portugal

Department of Neurology Centro Hospitalar Universitário do Porto Portugal

Department of Neurology Centro Hospitalar Universitário São João Porto Portugal

Department of Neurology České Budějovice Hospital Czech Republic

Department of Neurology Complejo Hospitalario Universitario de Albacete

Department of Neurology Comprehensive Stroke Centre Charles University Faculty of Medicine and University Hospital Hradec Králové Czech Republic

Department of Neurology Comprehensive Stroke Centre Hospital Clinic from Barcelona Spain

Department of Neurology Eskisehir Osmangazi University Turkey

Department of Neurology Fundación Valle del Lili Cali Colombia

Department of Neurology Grant Medical College and Sir JJ Hospital Mumbai India

Department of Neurology Haaglanden Medical Centre Hague and Department of Radiology Leiden University Medical Centre Netherlands

Department of Neurology Henry Ford Hospital Detroit MI

Department of Neurology Hôpital Fondation Ade Rothschild Paris France

Department of Neurology Hospital de Egas Moniz Centro Hospitalar Lisboa Ocidental Lisbon Portugal

Department of Neurology Hospital Garcia de Orta Almada Portugal

Department of Neurology Hospital Nacional Edgardo Rebagliati Martins EsSalud Lima Péru

Department of Neurology Hospital Nossa Senhora da Conceição Hospital Porto Alegre Brazil

Department of Neurology Hospital Universitario Virgen Macarena Seville Spain

Department of Neurology Ibn Sina Hospital Kuwait

Department of Neurology Institute of Medical Sciences Medical College of Rzeszow University Poland

Department of Neurology Institute of Medical Sciences University of Opole Poland

Department of Neurology Jaber Al Ahmad Hospital Kuwait

Department of Neurology Jihlava Hospital Czech Republic

Department of Neurology Karviná Miners Hospital Inc Czech Republic

Department of Neurology National Health Insurance Service Ilsan Hospital Goyang Korea

Department of Neurology Policlinico Universitario Agostino Gemelli Rome Italy

Department of Neurology Radiology Boston Medical Center Boston University School of Medicine MA

Department of Neurology San Gerardo Hospital Department of Medicine and Surgery and Milan Centre for Neuroscience University of Milano Bicocca Monza Italy

Department of Neurology School of Medicine Zanjan University of Medical Sciences Iran

Department of Neurology St John's Hospital Vienna Austria

Department of Neurology Stroke Unit Europe Hospitals Brussels Belgium

Department of Neurology Unidade Local de Saúde de Matosinhos Portugal

Department of Neurology Universitair Ziekenhuis Brussel Centre for Neurosciences Vrije Universiteit Brussel Belgium

Department of Neurology University Emergency Hospital Bucharest University of Medicine and Pharmacy Carol Davila Romania

Department of Neurology University Hospital Frankfurt Goethe University Germany

Department of Neurology University Hospital Jagiellonian University Cracow Poland

Department of Neurology University Hospital of Zurich Switzerland

Department of Neurology University of Arkansas for Medical Sciences Little Rock AR

Department of Neurology University of Kansas Medical Centre

Department of Neurology University of Warmia and Mazury Olsztyn Poland

Department of Neurology Upstate University Hospital NY

Department of Neurology Wayne State University Detroit Medical Center MI

Department of Neuroradiology Centro Hospitalar de Vila Nova de Gaia Espinho Portugal

Department of Neuroradiology Centro Hospitalar Universitário de Coimbra Portugal

Department of Neuroradiology Centro Hospitalar Universitário São João Porto Portugal

Department of Neuroradiology Charité Universitätsmedizin Berlin Germany

Department of Neuroradiology Geneva University Hospital Switzerland

Department of Neuroradiology Hospital de Egas Moniz Centro Hospitalar Lisboa Ocidental Lisbon Portugal

Department of Neuroradiology Hospital de Santa Maria Centro Hospitalar Universitário Lisboa Norte Lisbon Portugal

Department of Neurosurgery and Neurology Nicolaus Copernicus University in Torun Ludwik Rydygier Collegium Medicum Bydgoszcz Poland

Department of Neurosurgery Thomas Jefferson University Hospital PA

Department of Radiology Comprehensive Stroke Centre Charles University Faculty of Medicine and University Hospital Hradec Králové Czech Republic

Department of Radiology Institute of Clinical Sciences Sahlgrenska Academy at the University of Gothenburg and Department of Interventional and Diagnostic Neuroradiology Sahlgrenska University Hospital Region Västra Götaland Gothenburg Sweden

Department of Radiology Provincial Specialist Hospital Olsztyn Poland

Department of Radiology University Emergency Hospital Bucharest Romania

Departments of Neurology Hospital de Braga Portugal

Departments of Neurology Medical University of Innsbruck Austria

Departments of Neurology Wroclaw Medical University Poland

Departments of Radiology Neurology and Neurosurgery Grady Memorial Hospital Atlanta GA

Emergency Neurology and Stroke Unit IRCCS Humanitas Clinical and Research Center Rozzano Italy

Endovascular Neurological Surgery and Neurology Rutgers The State University of New Jersey Newark

Hospital General San Juan de Dios Guatemala

International Clinical Research Centre and Department of Neurology St Anne´s University Hospital and Faculty of Medicine at Masaryk University Brno Czech Republic

IRCCS Istituto delle Scienze Neurologiche di Bologna Department of Neurology and Stroke Centre Maggiore Hospital Bologna Italy

Neurocenter Regional Hospital Liberec Czech Republic

Neurology Department Leuven University Hospital Belgium

Neurology Stroke Unit Centre Hospitalier Universitaire Grenoble Alpes France

Neurology Unit Stroke Unit Azienda Unità Sanitaria IRCCS di Reggio Emilia Italy

Neuropsychiatry Department Tanta University Egypt

Neuroradiology Unit Azienda Unità Sanitaria IRCCS di Reggio Emilia Italy

Ramos Mejía Hospital Stroke Unit Buenos Aires Argentina

School of Biomedical Engineering and Imaging Sciences St Thomas Hospital King's College London UK

St Luke's Medical Center Global City Philippines

Stroke and Geriatric Medicine Aintree University Hospital United Kingdom

Stroke Center Department of Neurology Inselspital Bern University Hospital and University of Bern Switzerland

Stroke Center Neurocenter of Southern Switzerland EOC Lugano

Stroke Centre Geneva University Hospital Switzerland

Stroke Centre Hirslanden Hospital Zurich Switzerland

Stroke Centre Hospital General Universitario Gregorio Marañón Madrid Spain

Stroke Centre Kantonsspital Lucerne Switzerland

Stroke Centre Neurology Service Department of Neurological Sciences Lausanne University Hospital Switzerland

Stroke Centre University Hospital Basel and University of Basel Switzerland

Stroke Clinic Instituto Nacional de Neurologia y Neurocirugia Manuel Velasco Suarez Mexico City Mexico

Stroke Intervention Centre Department of Neurosurgery and Neurology Jan Biziel University Hospital Bydgoszcz Poland

Stroke Unit Azienda Ospedaliera Universitaria Integrata Verona Italy

Stroke Unit Department of Neurology and Interventional Neuroradiology Unit Hospital Universitario Miguel Servet Spain

Stroke Unit Department of Neurology Hospital de Santa Maria Centro Hospitalar Universitário Lisboa Norte Lisbon Portugal

Stroke Unit Department of Neurology Hospital Universitario Miguel Servet Spain

Stroke Unit Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan Italy

Stroke Unit Germans Trias Hospital Barcelona Spain

Stroke Unit Hospital de São José Centro Hospitalar Universitário Lisboa Central Lisbon Portugal

Stroke Unit Neurology Department Hillel Yaffe Medical Center Hadera Israel

University College London Queen Square Institute of Neurology London United Kingdom

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ClinicalTrials.gov
NCT04895462