Safety and outcomes of intravenous thrombolytic therapy in ischemic stroke patients with COVID-19: CASCADE initiative

Payam Sasanejad, Leila Afshar Hezarkhani, Shahram Arsang-jang, Georgios Tsivgoulis, Abdoreza Ghoreishi, Barlinn Kristian, Jan Rahmig, Mehdi Farhoudi, Elyar Sadeghi Hokmabadi, Afshin Borhani-haghighi, Payam Sariaslani, Athena Sharifi-razavi, Kavian Ghandehari, Alireza Khosravi, Craig Smith, Yongchai Nilanont, Yama Akbari, Thanh N. Nguyen, Anna Bersano, Nawaf YassiTakeshi Yoshimoto, Simona Lattanzi, Animesh Gupta, Ramin Zand, Shahram Rafie, Seyede Pourandokht Mousavian, Mohammad Reza Shahsavaripour, Shahram Amini, Saltanat U. Kamenova, Aida Kondybayeva, Murat Zhanuzakov, Elizabeth M Macri, Christa O'hana S. Nobleza, Sean Ruland, Anna M. Cervantes-arslanian, Masoom J Desai, Annemarei Ranta, Amir Moghadam Ahmadi, Mahtab Rostamihosseinkhani, Razieh Foroughi, Etrat Hooshmandi, Fahimeh H Akhoundi, Ashfaq Shuaib, David S Liebeskind, James Siegler, Jose G. Romano, Stephan A. Mayer, Reza Bavarsad, Babak Zamani, Amadene Woolsey, Yasaman Fazli, Khazaei Mojtaba, Christian F. Isaac, Jose Biller, Mario Di Napoli, M. Reza Azarpazhooh

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There is little information regarding the safety of intravenous tissue plasminogen activator (IV-tPA) in patients with stroke and COVID-19.

This multicenter study included consecutive stroke patients with and without COVID-19 treated with IV-tPA between February 18, 2019, to December 31, 2020, at 9 centers participating in the CASCADE initiative. Clinical outcomes included modified Rankin Scale (mRS) at hospital discharge, in-hospital mortality, the rate of hemorrhagic transformation. Using Bayesian multiple regression and after adjusting for variables with significant value in univariable analysis, we reported the posterior adjusted odds ratio (OR, with 95% Credible Intervals [CrI]) of the main outcomes.

A total of 545 stroke patients, including 101 patients with COVID-19 were evaluated. Patients with COVID-19 had a more severe stroke at admission. In the study cohort, 85 (15.9%) patients had a hemorrhagic transformation, and 72 (13.1%) died in the hospital. After adjustment for confounding variables, discharge mRS score ≥2 (OR: 0.73, 95% CrI: 0.16, 3.05), in-hospital mortality (OR: 2.06, 95% CrI: 0.76, 5.53), and hemorrhagic transformation (OR: 1.514, 95% CrI: 0.66, 3.31) were similar in COVID-19 and non COVID-19 patients. High-sensitivity C reactive protein level was a predictor of hemorrhagic transformation in all cases (OR:1.01, 95%CI: 1.0026, 1.018), including those with COVID-19 (OR:1.024, 95%CI:1.002, 1.054).

IV-tPA treatment in patients with acute ischemic stroke and COVID-19 was not associated with an increased risk of disability, mortality, and hemorrhagic transformation compared to those without COVID-19. IV-tPA should continue to be considered as the standard of care in patients with hyper acute stroke and COVID-19.
Original languageEnglish
Article number106121
JournalJournal of Stroke and Cerebrovascular Diseases
Early online date20 Sept 2021
Publication statusPublished - 20 Sept 2021


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