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As if we don’t have enough to worry about with the novel coronavirus, last week came news — just in time for May’s National Stroke Awareness Month — that doctors in New York City’s Mount Sinai Health System have observed a heretofore unknown link between COVID-19 and large-vessel strokes in young, otherwise healthy, low-risk patients.
In a letter they sent last week to the New England Journal of Medicine, the doctors noted that the over a two-week span in late March and early April they treated “a total of five patients … who were younger than 50 years of age [and] presented with new-onset symptoms of large-vessel ischemic stroke. All five patients tested positive for Covid-19. By comparison, every 2 weeks over the previous 12 months, our service has treated, on average, 0.73 patients younger than 50 years of age with large-vessel stroke.”
While five patients (who ranged in age from 33 to 49) may not seem like a lot, the incidence rate in such a short time is statistically significant.
Also notable is the fact that all five patients had minimal or no COVID-19 symptoms — and that all five presented at the hospital because of their strokes, not because of their coronavirus illness.
These COVID-19/stroke cases differ from the previously published studies out of Wuhan, China and the Netherlands (as well as SARS studies out of Singapore in 2004) in which the strokes occurred in patients who were already gravely ill.
So what’s going on here?
According to Cleveland Clinic Florida neuro-interventional radiologist Dr. Michal Obzrut, doctors are learning more about the novel coronavirus every day.
“We know from having studied earlier data from around the world, as well as what we’re compiling as we treat patients in the U.S., that COVID-19 leads the body toward a coagulatory response. This is a natural response to inflammation. But in extreme cases, this coagulatory response has created pulmonary embolisms, arterial clots and venous clots, all of which can be life-threatening,” he said.
While Obzrut stresses that such cases are still pretty rare — “We haven’t had any at Cleveland Clinic Florida and I haven’t heard of any at other South Florida hospitals” — there are aspects about these cases that are especially troubling.
First, that in all five cases the blockages were in large vessels — what are known as “large vessel occlusions.”
According to Obzrut “only 10% percent of acute ischemic strokes are large vessel occlusions — and the outcomes tend to be far worse.”
Indeed, only one of the five New York City patients has been discharged to their home. The others are either still hospitalized or have been transferred to rehab facilities.
Another difficult aspect of treating these COVID-19-related large vessel occlusions is determining exactly why they’re happening in each patient.
“If we know the exact cause, then we’ll know how best to medicate,” explains Obzrut.
If it’s a matter of the blood’s coagulatory response, then blood thinners are the best medication. However, if the clotting is instead platelet-related, then aspirin is called for. And if the clots are a result of over-inflammation, then a steroidal protocol is warranted.
But perhaps the most concerning aspect of all stroke-patient treatment during our current coronavirus climate, is that hospitals are seeing fewer stroke patients than normal — likely because those who are suffering stroke symptoms (facial and/or arm weakness or paralysis, slurred speech, blurred vision, confusion) are delaying or foregoing treatment for fear of being exposed to COVID-19 at the hospital.
In late March, the University of Miami’s Florida Stroke Registry tweeted “we are seeing less patients with #stroke symptoms coming to our hospitals. We need to get the word out that our teams are working hard to safely provide care when needed during #COVID19.”
Obzrut echoes those sentiments, urging all South Floridians to “seek immediate emergency care at the first sign of a stroke because for every minute you delay treatment, two million brain cells die.”