Open Access

Shima Shahjouei, Georgios Tsivgoulis, Ghasem Farahmand, Eric Koza, Ashkan Mowla, Alireza Vafaei Sadr, Arash Kia, Alaleh Vaghefi Far, Stefania Mondello, Achille Cernigliaro, Annemarei Ranta, Martin Punter, Faezeh Khodadadi, Mirna Sabra, Mahtab Ramezani, Soheil Naderi, Oluwaseyi Olulana, Durgesh Chaudhary, Aicha Lyoubi, Bruce Campbell, Juan F. Arenillas, Daniel Bock, Joan Montaner, Saeideh Aghayari Sheikh Neshin, Diana Aguiar de Sousa, Matthew S. Tenser, Ana Aires, Merccedes De Lera Alfonso, Orkhan Alizada, Elsa Azevedo, Nitin Goyal, Zabihollah Babaeepour, Gelareh Banihashemi, Leo Bonati, Carlo Cereda, Jason J. Chang, Miljenko Crnjakovic, Gian Marco De Marchis, Massimo Del Sette, Seyed Amir Ebrahimzadeh, Mehdi Farhoudi, Ilaria Gandoglia, Bruno Gonçalves, Christoph J. Griessenauer, Mehmet Murat Hancı, Aristeides H. Katsanos, Christos Krogias, Ronen Leker, Lev Lotman, Jeffrey Mai, Shailesh Male, Konark Malhotra, Branko Malojcic, Teresa Mesquita, Asadollah Mir Ghasemi, Hany Mohamed Aref, Zeinab Mohseni Afshar, Jusun Moon, Mika Niemelä, Behnam Rezaei Jahromi, Lawrence Nolan, Abhi Pandhi, Jong-Ho Park, João Pedro Marto, Francisco Purroy, Sakineh Ranji-Burachaloo, Nuno Reis Carreira, Manuel Requena, Marta A. Rubiera del Fueyo, Seyed Aidin Sajedi, João Sargento-Freitas, Vijay Sharma, Thorsten Steiner, Kristi Tempro, Guillaume Turc, Yassaman Ahmadzadeh, Mostafa Almasi Dooghaee, Farhad Assarzadegan, Arefeh Babazadeh, Humain Baharvahdat, Fabricio Cardoso, Apoorva Dev, Mohammad Ghorbani, Ava Hamidi, Zeynab Sadat Hasheminejad, Sahar Hojjat-Anasri Komachali, Fariborz Khorvash, Firas Kobeissy, Hamidreza Mirkarimi, Elahe Mohammadi-Vosough, Debdipto Misra, Ali Reza Noorian, Peyman Nowrouzi-Sohrabi, Sepideh Paybast, Leila Poorsaadat, Mehrdad Roozbeh, Behnam Sabayan, Saeideh Salehizadeh, Alia Saberi, Mercedeh Sepehrnia, Fahimeh Vahabizad, Thomas Alexandre Yasuda, Ahmadreza Hojati Marvast, Mojdeh Ghabaee, Nasrin Rahimian, Mohammad Hossein Harirchian, Afshin Borhani Haghighi, Rohan Arora, Saeed Ansari, Venkatesh Avula, Jiang Li, Vida Abedi, Ramin Zand

• Background: Stroke is reported as a consequence of SARS-CoV-2 infection. However, there is a lack of regarding comprehensive stroke phenotype and characteristics Methods: We conducted a multinational observational study on features of consecutive acute ischemic stroke (AIS), intracranial hemorrhage (ICH), and cerebral venous or sinus thrombosis (CVST) among SARS-CoV-2 infected patients. We further investigated the association of demographics, clinical data, geographical regions, and countries’ health expenditure among AIS patients with the risk of large vessel occlusion (LVO), stroke severity as measured by National Institute of Health stroke scale (NIHSS), and stroke subtype as measured by the TOAST criteria. Additionally, we applied unsupervised machine learning algorithms to uncover possible similarities among stroke patients. Results: Among the 136 tertiary centers of 32 countries who participated in this study, 71 centers from 17 countries had at least one eligible stroke patient. Out of 432 patients included, 323(74.8%) had AIS, 91(21.1%) ICH, and 18(4.2%) CVST. Among 23 patients with subarachnoid hemorrhage, 16(69.5%) had no evidence of aneurysm. A total of 183(42.4%) patients were women, 104(24.1%) patients were younger than 55 years, and 105(24.4%) patients had no identifiable vascular risk factors. Among 380 patients who had known interval onset of the SARS-CoV-2 and stroke, 144(37.8%) presented to the hospital with chief complaints of stroke-related symptoms, with asymptomatic or undiagnosed SARS-CoV-2 infection. Among AIS patients 44.5% had LVO; 10% had small artery occlusion according to the TOAST criteria. We observed a lower median NIHSS (8[3-17], versus 11 [5-17]; p=0.02) and higher rate of mechanical thrombectomy (12.4% versus 2%; p<0.001) in countries with middle to high-health expenditure when compared to countries with lower health expenditure. The unsupervised machine learning identified 4 subgroups, with a relatively large group with no or limited comorbidities. Conclusions: We observed a relatively high number of young, and asymptomatic SARS-CoV-2 infections among stroke patients. Traditional vascular risk factors were absent among a relatively large cohort of patients. Among hospitalized patients, the stroke severity was lower and rate of mechanical thrombectomy was higher among countries with middle to high-health expenditure.