Strokes in young, asymptomatic COVID-19 patients on the rise

Evelyn Lewin

27/04/2020 5:12:44 PM

Experts in the US are reporting a concerning increase in the presentation of stroke in young, previously healthy patients.

Patient sitting on hospital bed with back turned.
There are concerns patients with symptoms of stroke are delaying seeking hospital treatment.

Strokes are occurring in young COVID-19 patients who are asymptomatic or with mild symptoms, according to a rapid communication due to be published on 29 April in the New England Journal of Medicine (NEJM).
Written by the Head of Neurology Intensive Care at Mount Sinai Hospital in New York, Dr Thomas Oxley, it details five case studies of patients aged 33–49 who had strokes at home over an approximate two-week period between 23 March and 7 April.
Despite the patients possessing few or no cardiovascular risk factors, one has died and two are still in hospital. Of the five, only a 33-year-old woman is currently able to speak.
‘For comparison, our service, over the previous 12 months, has treated on average 0.73 patients every two weeks under the age of 50 years with large vessel stroke,’ the paper said.
The patients had either mild or nonexistent coronavirus symptoms, but the association between large vessel stroke and COVID-19 disease in young patients has prompted the authors to say the issue ‘requires further investigation’.
‘It’s certainly a small sample size and we are learning as we go,’ Dr Oxley told 7.30. ‘We are hearing from our colleagues … that stroke numbers are up all around the city.
‘It’s still too early to know absolutely what the real numbers are going to be.’
Other doctors are equally concerned about the emerging trend.
Neurosurgeon and researcher, Professor J Mocco from Mount Sinai Hospital, told the Washington Post the link between stroke in young patients and COVID-19 ‘is much too powerful of a signal to be chance or happenstance’.
The COVID-19 patients treated at Mount Sinai were, on average, 15 years younger than stroke patients without the virus and most had minimal or no risk factors for stroke.
‘These are people among the least likely statistically to have a stroke,’ Professor Mocco said, adding that he has been ‘completely shocked’ by the development.
He also said the link between COVID-19 and stroke ‘is one of the clearest and most profound correlations I’ve come across’.
Dr Robert Stevens, a critical care doctor at Johns Hopkins Hospital in Baltimore, told the Washington Post he has similar concerns.
‘We’ve also taken care of patients in their 30s with stroke and COVID-19, and this was extremely surprising,’ he said.
Another paper, currently under review, reports that Thomas Jefferson University Hospitals treated 12 COVID-19 patients over a three-week period for large blood blockages in their brains.
Forty per cent of those patients were aged under 50 and had few or no risk factors, challenging conventional assumptions around stroke.  
Eytan Raz, Assistant Professor of neuroradiology at NYU Langone told the Post he had never seen so many patients in their 30s to 50s.
‘We are used to thinking of 60 as a young patient when it comes to large vessel occlusions,’ Associate Professor Eytan Raz said.  
Associate Professor Raz theorises that increased presentations by younger patients could be because they are more resistant than older people to the respiratory distress caused by COVID-19.
‘So they survive the lung side, and in time develop other issues,’ he said.
Professor Bruce Campbell, Stroke Foundation Clinical Council Chair and Head of Stroke at the Royal Melbourne Hospital, told newsGP he has yet to see similar presentations here due to low numbers of infections. 

But he is not surprised to hear of reports emerging elsewhere.
‘There’s a theory that COVID-19 activates the body’s clotting pathways and so that’s probably the mechanism,’ he said.
Professor Campbell has worked closely with Associate Professor Thomas Oxley, who he said discussed seeing a 44-year-old patient with COVID-19 actively clot during an interventional procedure.
‘That’s certainly the case that Associate Professor Oxley was describing, where clots were actively forming on catheters during the procedure,’ Professor Campbell said.
He said the phenomenon of active clotting during a procedure is occasionally seen in patients with malignancy, where there is a similar activation of the clotting cascade.
‘We don’t have experience of that here, but that’s because we’ve so far been very fortunate in controlling the outbreak,’ he said.
The new paper, to be published in NEJM, adds further weight to mounting evidence linking thrombotic issues and COVID-19.
That includes research from the Netherlands, which studied 184 intensive care unit (ICU) patients with proven COVID-19 pneumonia and found a 31% incidence of thrombotic complications in ICU patients with infection.
Meanwhile, a paper published in The Lancet found that, of 221 patients with COVID-19, 11 (5%) developed acute ischaemic stroke.
However, in contrast to the NEJM paper, The Lancet study found patients with COVID-19 with new onset of acute cerebrovascular disease (CVD) were significantly older, more likely to present with severe COVID-19 disease, and were more likely to have cardiovascular risk factors.
While reports of stroke occurring in younger, asymptomatic patients with COVID-19 are concerning, Professor Campbell believes a different, though equally worrying, issue is also occurring: that of patients not seeking care for symptoms of stroke.
According to Professor Campbell, there has been a reduction in stroke presentations at The Royal Melbourne Hospital, and that this is not an isolated event.
He said the drop in presentations likely relates to patients’ fears of attending hospital and potentially catching COVID-19.
‘We’re worried that people are afraid to come to hospital and they’re delaying or not coming,’ he said.
Indeed, that was the case for the 33-year-old patient mentioned in the NEJM paper, who delayed seeking care despite developing stroke symptoms of slurred speech, numbness and weakness on the left side of her body in the 28 hours before she sought help.
Professor Campbell wants the message to be clear that patients must seek urgent medical care if they have symptoms of stroke, using the FAST acronym – Face drooping, Arm weakness, Speech difficulties and Time critical emergency response.
‘[We need] to remind the community that if someone has stroke symptoms then call 000 immediately and get to hospital,’ he said.
‘Even in these COVID times.’
The RACGP has more information on coronavirus available on its website.
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Dr Ros Hiddins   2/05/2020 8:43:37 AM

Should we be encouraging patients to take Aspirin rather than hydroxychloroquine?