LARGE VESSEL STROKE AS PRESENTING FEATURE OF COVID-19

Large Vessel Stroke as Presenting Feature of Covid 19

Dr Sudhir Kumar MD DM,

Consultant Neurologist, Apollo Hospitals, Hyderabad

drsudhirkumar@yahoo.com

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:

1. They were young patients, with age ranging from 33 to 49 years.
2. They were predominantly males (4 out of 5),
3. 3 of them had no known risk factors for stroke,
4. Two had diabetes (one de novo), one hypertension and one dyslipidemia,
5. One had a prior history of stroke, and was on aspirin and atorvastatin,
6. Strokes were of moderate severity, with NIHSS scores ranging from 13 to 23,
7. 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),
8. Vascular territory affected were: middle cerebral artery in 3, internal carotid artery and posterior cerebral artery in 1 each,
9. Clot retrieval was done in 4 patients (with stent in one and one patient received IV tPA),
10. Two patients were treated with apixaban, two with aspirin and one with aspirin/clopidogrel combination,
11. Only two patients had typical COVID-19 symptoms (fever and cough), one had lethargy and two had no other symptoms,
12. One patient had mild thrombocytopenia, one patient had mildly prolonged PT and two patients had prolonged PTT,
13. Three patients had elevated fibrinogen; d-dimer and ferritin were elevated in 3 patients.
14. There was no death. Two patients were in rehabilitation unit, one each in stroke unit and ICU, and one was discharged home.  
15. 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