COVID-19-Related Stroke in Young Individuals

Evidence is mounting on the diverse neurological presentations associated with COVID-19.  This is highlighted in a comment by Dr Johanna Fifi from Mount Sinai in The Lancet. 

It is known that SARS-CoV-2 causes thrombotic vascular events, including stroke, and this is more than other Coronavirus and seasonal infectious diseases.

There is a 7.6 fold increase in the odds of stroke with COVID-19 compared with influenza.

The reported incidence of cerebrovascular disease in patients with SARS-CoV-2 ranges from 1% to 6% and clearly this equates to a large number of individuals.

The proposed mechanism for these cerebrovascular events includes a hypercoagulable state from systemic inflammation and a cytokine storm, and direct viral induced endotheliitis or endotheliopathy. Post-infectious immune-mediated responses leading to angiopathic thrombosis with viral particles have been isolated from the endothelium of various tissues, including vein tissues.

Many regions with a high prevalence of COVID-19 have reported stable or increased incidences of large vessel stroke and increased incidence of cryptogenic stroke. These are patients who had no found typical cause of stroke.

Interestingly, these areas have a decrease in mild stroke that is possibly secondary to quarantine and self-isolation.

This quarantine effect is supported by analysis in the United States of automated stroke imaging processing software which showed a decreased imaging evaluation for stroke during the pandemic.

This observation of COVID-19 related strokes in young patients has been supported by additional data from other centres worldwide.  The mean patient ages in several thrombectomy case series of COVID-19 was 52.8 years in New York City, 59.5 years in Paris, 59.5 years in a combined series from New York City and Philadelphia, and this is younger than the typical population having this procedure.

Furthermore, patients presenting with large vessel stroke during the pandemic in Mount Sinai were found to be significantly younger, with a mean age of 59, than those patients who tested negative for SARS-CoV-2, who had a mean age of 74 years. 

Many reports have documented an increased thrombosis risk early in COVID-19 and coagulation abnormalities in both D-dimer and fibrinogen can be found in patients with mild symptoms.  There are many reports of early COVID-19 presenting with thrombotic events, which has led to the consensus to start anticoagulation therapy early in COVID-19 disease before any thrombotic event. 

There are reports in the literature which show that patients with mild respiratory symptoms of COVID-19 have macro thrombosis in the internal carotid arteries.  Stroke here was the presenting symptom of the disease.

Concluding, the data supports an association between COVID-19 and stroke in young populations without typical vascular risk factors, at times with only mild respiratory symptoms, is increasing.  This suggests that patients with mild COVID-19 respiratory symptoms should be investigated, if appropriate, for stroke if they present with new neurological symptoms.

The London General Practice has kept abreast with all aspects of COVID-19 disease and has implemented a COVID-19 safety net video consultation service for those diagnosed.

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