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Stroke and coronavirus: How are they related?
Researchers from Thomas Jefferson University claim that young patients without any stroke risk factors might have a higher risk experiencing a stroke if they have contracted COVID-19. That is regardless whether they are showing any stroke symptoms or not. Surgeons at Thomas Jefferson University with team analyzed patients with stroke from March 20th until April 10th at their institutions. The strokes they observed were unlike what they usually see. In this article, read about research and observations made by American medical specialists about stroke and coronavirus, and how they might be related.
Stroke and coronavirus – Observations are worrisome
"We were seeing patients in their 30s, 40s and 50s with massive strokes, the kind that we typically see in patients in their 70s and 80s," says Pascal Jabbour, MD, Chief of the Division of Neurovascular Surgery and Endovascular Surgery in the Vickie & Jack Farber Institute for Neuroscience – Jefferson Health. He is a senior author of a study published in the journal Neurosurgery June 4th that examines and characterizes strokes of patients who tested positive for COVID-19, performed in collaboration with surgeons from NYU Langone Medical Center in New York.
"Although we have to stress that our observations are preliminary, and based on observations from 14 patients, what we have observed is worrying," says Dr. Jabbour. "Young people, who may not know they have the coronavirus, are developing clots that cause major stroke."
The researchers, including first author Ahmad Sweid, MD, examined 14 patients who had come into their stroke unit for acute stroke. Eight patients were male, six were female, 50% did not know they had COVID-19, while the rest were already being treated for other COVID-19 symptoms when they developed stroke.
Some of the paper's major points:
Patients with signs of stroke were delaying coming to the hospital for fear of getting the coronavirus. There's a small window of time in which strokes can be treated, therefore delays to seek help can be life threatening.
The mortality rate in these COVID-19 stroke patients is 42.8%. The typical mortality from stroke is around 5-10%.
42% of the stroke patients with COVID-19 were under the age of 50. Most strokes in the US (over 75%) occur in people over the age of 65.
The incidence of coronavirus in the stroke population was 31.5%, according to this sample of patients.
These patients had stroke in large vessels, in both hemispheres of the brain, and in both arteries and veins of the brain. All of these observations are unusual in stroke patients.
The coronavirus, which was assumed to be a disease of the lungs, is apparently causing blood clots that lead to a higher incidence of stroke. Researchers have shown that the coronavirus enters human cells via a very specific access point – a protein on human cells called ACE2. The virus latches onto this protein and uses it as an entry point into the cell, where the virus can replicate. Not all cells have the same amount of ACE2. This protein is very abundant on cells that line blood vessels, the heart, kidney, as well as the lungs. Dr. Jabbour and colleagues speculate that the virus may be interfering with this receptor's normal function, which controls blood flow in the brain, also using it as a gateway to the cell.
Another possibility is that the inflammation of the blood vessels (called endothelium) causing vasculitis with injury to the cells lining the lumen of the vessel, and causing micro thrombosis in small vessels.
"Our observations, though preliminary, can serve as a warning for medical personnel on the front lines, and for all of those at home," says Dr. Jabbour. "Stroke is occurring in people who don't know they have COVID-19, as well as those who feel sick from their infections. We need to be vigilant and respond quickly to signs of stroke."
Observations of stroke patients with COVID-19 in New York
An article in New York Times reports disturbing cases of stroke among young adults. Neurologists in New York City, Detroit, New Jersey and other parts of the country have reported a high number of such cases. Many are now convinced that these unusual strokes represent yet another unknown manifestation of Covid-19.
The cases add to evidence that the avirus attacks not only lungs, but also kidneys, brain, heart and liver. In rare instances, it seems to trigger a life-threatening inflammatory syndrome in children. "We're seeing a startling number of young people who had a minor cough, or no recollection of viral symptoms at all, and they're self-isolating at home like they're supposed to – and they have a sudden stroke," said Dr. Adam Dmytriw, a University of Toronto radiologist who is a co-author of a paper describing patients who suffered strokes related to Covid-19. The paper has not yet been peer reviewed.
Though a number of those patients had diabetes and hypertension, none had heart risks known to be risk factors for developing stroke. Many were under age 65. For some, stroke was the first symptom of COVID-19, and they postponed going to the emergency room, fearing exposure.
Out of 10 patients described in Dr. Dmytriw's paper, two died because the coronavirus attacked their lungs, and two men (ages 46 and 55 respectively) died due to strokes.
Doctors at Mount Sinai Health System in New York have also seen an unusual number of young stroke patients. They claim they treated five such patients with Covid-19 during a recent two-week period. The hospital typically sees only one stroke patient under the age of 50 every three weeks, Dr. Johanna Fifi, a neurologist, and her colleagues noted in a letter in The New England Journal of Medicine.
Alarming observations in young people
An article in health portal Healthline, draws links between COVID-19 and strokes as well. It points out that:
Although typically considered a lung infection, COVID-19 has been found to cause blood clots that can lead to severe stroke.
Experts say that this can happen to anyone regardless of age, and even in those with few or no symptoms at all.
People with COVID-19 as young as 30 are experiencing strokes even when their symptoms were mild.
COVID-19, the disease caused by SARS-CoV-2, has been thought to attack lungs. Some of the symptoms it causes include cough and difficulty breathing, however doctors are noticing a disturbing trend. People as young as 30 are experiencing strokes, even when their symptoms were all in all very moderate. "The coronavirus has been shown to cause development of microthrombi [small clots]. These clots can travel to the lung and obstruct blood flow to the lung, which is called pulmonary embolism, or travel to brain circulation and cause ischemic stroke," Dr. Theresa Capriotti from Villanova University, told Healthline. "It seems to be happening to those affected with severe COVID symptoms," Capriotti said. "It can occur in any age group and it occurs suddenly."
Symptoms to watch out for include:
weakness or paralysis of arm and leg on one side of the body
lack of sensation in arm or leg on one side of the body
facial droop on one side of the face
To learn more about stroke signs and symptoms, read in our article "What are the symptoms of a stroke and when to seek medical help?".
Doctors in New York "sound the alarm" about stroke and COVID-19
When doctors like Dr. Johanna T. Fifi at Mount Sinai saw unusual numbers of stroke patients with COVID-19 in March, she and colleagues decided to release a public warning. "We're hypothesizing that the virus is having an effect on the lining of the blood vessels all through the body – and that is what is leading to the clots," she said. Their report was published in the New England Journal of Medicine (NEJM).
"We published that report because that was a little bit unusual to see so many young patients in such a short period of time," said Fifi. "But we have some other research looking at our overall numbers, and we saw about double the amount of large vessel strokes than normal during the peak weeks of COVID." She confirmed it's very likely these blood clots are COVID-19-related, and added that it can occur in any age group and can occur suddenly.
"It's definitely something that COVID is doing, it seems too strong of an association to be unrelated at all, it's just too much of a coincidence," said Fifi. "What we know is that COVID is causing blood vessel blockages in other regions, the legs for instance, and COVID is damaging the blood vessel lining throughout the body
How COVID-19 might be causing stroke
A recently published research finds COVID-19 and other diseases that cause severe inflammation throughout the body can increase the risk of fatty plaque buildup and blood vessels rupturing. This can lead to stroke and other cardiovascular diseases.
"Patients with COVID-19 are also at an increased risk of VTEs," the study authors wrote. According to the American Heart Association (AHA), a venous thromboembolism (VTE) is a blood clot that starts in a vein, and it's the third most common vascular diagnosis after heart attack and stroke. Influenza and other particular viruses have also been associated with an increased risk of plaque ruptures, noted the authors.
The research, conducted by University of Virginia (UVA) Health Systems' Dr. William Brady and team, is intended to serve as a guide for emergency medicine doctors treating people with, or suspected to have, COVID-19.
"In writing this article, we hope to increase emergency physicians' knowledge and awareness of this new pathogen and its impact on the cardiovascular system," said Dr. Brady in a statement.
Although typically considered a lung infection, COVID-19 has been found to cause blood clots that can cause severe stroke. Experts say that this can happen in any patients regardless of age, and even in those with few or no symptoms at all. Because of this, Mount Sinai Hospital in New York City began treating people with blood thinners in April. A new study released in May also found that severe inflammation from COVID-19 might lead to a build up of plaque that can increase the risk of stroke. Concerns regarding getting sick could delay stroke treatment, and doctors encourage not to delay getting treatment for stroke under any circumstances since it is a life threatening condition.
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