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Sharp Increase in Large-Vessel Stroke Risk Seen In Young, Healthy COVID-19 Patients

A sharp increase in the incidence of serious large-vessel stroke among COVID-19 patients under age 50 has been reported by the largest medical system in New York City. The report, in a letter to the editor of the New England Journal of Medicine published on April 28, described a two-week period in which five patients between the ages of 33 and 49 presented to the Mount Sinai Health System with new-onset symptoms of large vessel ischemic stroke. (None had serious symptoms of COVID19, which was diagnosed only upon testing.) Their mean score at presentation on the NIH Stroke Scale was 17, which is consistent with a severe stroke. By comparison, the two-week average for such cases at Mount Sinai during the previous year was just 0.73 patients, according to the letter. Thus, the five cases between March 23 and April 7 represented a seven-fold increase over the usual rate. Outcomes have been serious, with two discharged to a rehabilitation facility, one still in the stroke unit, and only one having returned home. The remaining patient, described in the paper as experiencing multi-organ failure, has since died. The poorer-than-average outcomes were attributed in part to the patients’ delay in seeking medical care. The youngest, a female, presented at the hospital 28 hours after symptoms began, due to fear of COVID-19. Another presented 16 hours after symptom onset. Two presented at eight hours. The remaining patient presented after just two hours. Some stroke neurologists at other hospitals around the country told Neurology Today they are seeing a similar trend, consistent with an increased risk of clots forming in other organ systems; they are now recommending that all patients with COVID-19 be treated with heparin or other therapy as a preventive measure. Not all stroke neurologists, however, are convinced that the trend is real. Rather than an increase, some say they are seeing a sharp decline in strokes generally, especially mild strokes or transient ischemic attacks, in keeping with a broad decline in emergency department visits of all kinds other than those involving COVID-19. Even coauthors of the new report agreed that it’s too early to be sure what the true link is between COVID-19 and stroke. the Sidney Kimmel Medical College at Thomas Jefferson University. “In general, you cannot draw conclusions from a small case series. But in pandemics like this, everything moves quickly. If we see something unusual, we need to investigate it and report it.” Dr. Jabbour is now in the process of collaborating with other centers in the United States and Europe on a larger analysis of strokes in COVID-19 patients, he said.