Is the stroke-COVID link solid? A critical analysis of Aghamiri et al.’s research methodology and findings

Dear Editor, I have read the article titled “The Investigation of the Frequency of COVID-19 in Patients with a History of Stroke” by Aghamiri et al.,[1] published in the Journal of Family Medicine and Primary Care. The authors presented the topic very effectively. However, certain methodological and interpretative aspects of the study need to be discussed further. To begin with, the study says that about 53% of stroke patients were infected with COVID-19. Such a high prevalence raises significant methodological concerns. The reliance on a single-center dataset and with a relatively small sample size of 100 patients can affect the generalizability of the results. On the background of this high prevalence, one must consider potential selection bias, particularly because the sampling was conducted at a major referral hospital in Tehran, likely treating more severe cases. Comparable studies, such as those by Qin et al.[2] in 2020 and by Martí-Fàbregas et al.[3] 2021, have indicated varying prevalence rates, suggesting that multicenter data might provide a more comprehensive understanding of the intersection between COVID-19 and stroke. The study also reports that severe stroke patients are around eight times more likely to get affected by the COVID-19 virus when compared to the general population. This correlation, while noteworthy, certainly warrants a deeper investigation of potential confounding variables such as patients’ socioeconomic status, their preexisting health conditions, and their access to healthcare. Previously published research papers have highlighted that certain factors such as diabetes, hyperlipidemia and hypertension can significantly influence both stroke severity and the outcomes of COVID-19 infection.[4] The study also found that certain biomarkers, including lymphocytes, CRP, and ESR levels, are elevated in case of COVID-19 infection; this is in line with the previously published papers.[5] However, to reach at the conclusion that these biomarkers can predict COVID-19 infection in stroke patients, these studies have to be strengthened by having a longitudinal approach of tracking these biomarkers over a time period to establish a causal relationship rather than a mere association. Furthermore, the discussion on the increased incidence of neurological problems, particularly thrombotic strokes, builds on what we already know about the blood clotting problems linked to COVID-19. However, the study falls short in discussing the possible mechanisms that could have resulted in these increased thrombotic incidences among COVID-19 patients. When interpreting these results, it is important to take into consideration that previous studies have indicated that endothelial dysfunction and systemic inflammation are important factors in COVID-19-induced stroke.[6] In conclusion, even though Aghamiri, et al.’s research was able to provide important insights about the impact and the frequency of COVID-19 infection among stroke patients, future research should aim to reduce the limitations noted by incorporating larger, multicenter cohorts, addressing potential confounders, and elucidating underlying mechanisms behind this. This would not only enhance the clarity of the findings but also contribute to more effective clinical management strategies for stroke patients in the context of COVID-19 infection. Yours sincerely Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.