Large Vessel Stroke as Presenting Feature of Covid 19
Dr Sudhir Kumar MD DM,
Consultant Neurologist, Apollo Hospitals, Hyderabad
COVID-19 caused by SARS CoV2 is a global pandemic, which has affected about 3 million people worldwide, and has resulted in more than 2,00,000 deaths. Respiratory system seems to be the main target of COVID-19 as patients usually present with cough, chest pain and breathing difficulty. Recent data has shown involvement of other systems too. Neurological involvement in COVID-19 is not uncommon. This article focuses on large vessel stroke as a presenting feature of COVID-19.
A recent report from Mount Sinai Health System, New York described 5 patients who presented with features of large vessel stroke. The main features were as follows:
- They were young patients, with age ranging from 33 to 49 years.
- They were predominantly males (4 out of 5),
- 3 of them had no known risk factors for stroke,
- Two had diabetes (one de novo), one hypertension and one dyslipidemia,
- One had a prior history of stroke, and was on aspirin and atorvastatin,
- Strokes were of moderate severity, with NIHSS scores ranging from 13 to 23,
- Onset of symptoms to time of presentation to ED ranged from 2 to 28 hours (some patients delayed going to hospital due to fear of Covid-19),
- Vascular territory affected were: middle cerebral artery in 3, internal carotid artery and posterior cerebral artery in 1 each,
- Clot retrieval was done in 4 patients (with stent in one and one patient received IV tPA),
- Two patients were treated with apixaban, two with aspirin and one with aspirin/clopidogrel combination,
- Only two patients had typical COVID-19 symptoms (fever and cough), one had lethargy and two had no other symptoms,
- One patient had mild thrombocytopenia, one patient had mildly prolonged PT and two patients had prolonged PTT,
- Three patients had elevated fibrinogen; d-dimer and ferritin were elevated in 3 patients.
- There was no death. Two patients were in rehabilitation unit, one each in stroke unit and ICU, and one was discharged home.
- Coagulopathy and vascular endothelial dysfunction have been proposed as complications of Covid-19, which could be responsible for large vessel strokes in young.
(Source: NEJM, 28th April, 2020