The Relationship Between COVID-19 and Stroke
COVID-19 does not always fit into the pattern of respiratory illness. While initially unexpected, clinicians and researchers are learning more each day that COVID-19 infection wears many disguises. In some victims, it clearly does not make its initial appearance as a respiratory virus.
The Prevalence of Stroke in COVID-19 Patients
Over the past weeks, some of the most troubling reports about COVID infection involves the association of COVID with stroke, sometimes in younger people (30’s and 40’s) without traditional risk factors for stroke. Physicians in New York City, which sadly leads the nation in COVID-19 cases, recently reported 5 cases in a 2-week period of acute, large vessel strokes in young adults infected with COVID-19 in the New England Journal of Medicine.
Rapid, systematic assessment and acute treatment is critical in reducing morbidity and mortality in patients with acute stroke. Stroke teams evaluate patients with stroke symptoms, assess imaging studies, and upon identification of an ischemic stroke, (if no contraindications and with patient informed consent), triage to intravenous thrombolytic therapy and/or endovascular therapy. Recently, the American Heart /American Stroke Council leadership published a Temporary Emergency Guidance to US Stroke Centers During the COVID-19 Pandemic, advising that COVID-19 patients may present with stroke as the “first organ presentation,” and cautioning them to don appropriate personal protective equipment in every suspected patient. They advised the urgent need for research into a more comprehensive understanding of the pathophysiology of neurologic manifestations of COVID-19. There is much that we do not know.
The Link Between COVID-19 and Stroke
The link between infection (including seasonal influenza) and cardiovascular and cerebrovascular events has long been established; there may also be a link between COVID-19 infection and stroke. We know that the pathophysiology of COVID-19 infection in seriously ill hospitalized patients includes coagulopathies. Cardiac complications may result in cardioembolic stroke. COVID-19 infection may directly damage the heart (with potential to cause an embolic stroke) and the vascular endothelium, increase inflammation, and activate prothrombotic factors.
It is important to note that many anecdotal reports, in the US and across the world, report that numbers of patients presenting with acute stroke and acute coronary syndrome have been curiously low since the beginning of the pandemic. While there are a number of hypotheses, avoiding or delaying presentation to a hospital due to fear of COVID-19 exposure is a likely factor. We need to be sure the lay public gets the message that while staying home during the pandemic is the right thing to do, staying home with suspected stroke (or acute coronary syndrome) symptoms is absolutely not. The potential to reduce death and disability from stroke depends on a rapidly ticking clock. Time is brain.