Stroke Among Patients Hospitalized With COVID-19

Results From the American Heart Association COVID-19 Cardiovascular Disease Registry

Saate S. Shakil, MD; Sophia Emmons-Bell, BA; Christine Rutan, CPHQ; Jason Walchok, NREMT-P; Babak Navi, MD, MS; Richa Sharma, MD; Kevin Sheth, MD; Gregory A. Roth, MD, MPH; Mitchell S.V. Elkind, MD, MS


Stroke. 2022;29(2):800-807. 

In This Article

Abstract and Introduction


Background and Purpose: Coronavirus disease 2019 (COVID-19) may be associated with increased risk for ischemic stroke. We present prevalence and characteristics of strokes in patients with laboratory-confirmed severe acute respiratory syndrome coronavirus-2 infection enrolled in the American Heart Association COVID-19 Cardiovascular Disease Registry.

Methods: In this quality improvement registry study, we examined demographic, baseline clinical characteristics, and in-hospital outcomes among hospitalized COVID-19 patients. The primary outcomes were ischemic stroke or transient ischemic attack (TIA) and in-hospital death.

Results: Among 21 073 patients with COVID-19 admitted at 107 hospitals between January 29, 2020, and November 23, 2020, 160 (0.75%) experienced acute ischemic stroke/TIA (55.3% of all acute strokes) and 129 (0.61%) had other types of stroke. Among nonischemic strokes, there were 44 (15.2%) intracerebral hemorrhages, 33 (11.4%) subarachnoid hemorrhages, 21 (7.3%) epidural/subdural hemorrhages, 2 (0.7%) cerebral venous sinus thromboses, and 24 (8.3%) strokes not otherwise classified. Asians and non-Hispanic Blacks were overrepresented among ischemic stroke/TIA patients compared with their overall representation in the registry, but adjusted odds of stroke did not vary by race. Median time from COVID-19 symptom onset to ischemic stroke was 11.5 days (interquartile range, 17.8); median National Institutes of Health Stroke Scale score was 11 (interquartile range, 17). COVID-19 patients with acute ischemic stroke/TIA had higher prevalence of hypertension, diabetes, and atrial fibrillation compared with those without stroke. Intensive care unit admission and mechanical ventilation were associated with higher odds of acute ischemic stroke/TIA, but older age was not a predictor. In adjusted models, acute ischemic stroke/TIA was not associated with in-hospital mortality.

Conclusions: Ischemic stroke risk did not vary by race. In contrast to the association between older age and death from COVID-19, ischemic stroke risk was the highest among middle-aged adults after adjusting for comorbidities and illness severity, suggesting a potential mechanism for ischemic stroke in COVID-19 independent of age-related atherosclerotic pathways.


The possibility of increased ischemic stroke risk associated with severe acute respiratory syndrome coronavirus 2 infection was first noted among hospitalized patients in Wuhan, China, and shortly thereafter in the United States, when several young patients presented acutely with large-vessel stroke and were later diagnosed with coronavirus disease 2019 (COVID-19).[1,2] Subsequent studies observed elevated ischemic stroke risk in COVID-19 compared with similar conditions such as influenza.[3] Multiple registry-based studies have demonstrated variable ischemic stroke risk among hospitalized COVID-19 patients ranging from 0.9% to 2.8%.[2–6] The largest of these studies included 8163 COVID-19 inpatients across multiple centers in the United States and observed an ischemic stroke risk of 1.3%.[6] Outstanding questions remain regarding variable risk for ischemic stroke among COVID-19 patients by race and ethnic group, predictors of stroke, distribution of stroke severity, and outcomes in COVID-19 patients who experience stroke.

In this study, we describe characteristics of hospitalized COVID-19 patients with acute ischemic stroke and transient ischemic attack (TIA) in a large national sample (21 073 patients as of November 23, 2020) from the American Heart Association's (AHA) COVID-19 cardiovascular disease (CVD) registry.[7] Based upon existing literature, we hypothesized that male sex, non-White race, younger age, cardiovascular comorbidities, and COVID-19 severity are risk factors for acute ischemic stroke or TIA among hospitalized patients, after adjusting for other patient-level characteristics.[8–10] We also evaluated the impact of acute ischemic stroke or TIA on the risk of in-hospital mortality during a COVID-19 admission.