The Icahn School Medicine at Mount Sinai team studying the relationship between stroke and COVID-19 included, from left, Thomas J. Oxley, MD, PhD; Johanna T. Fifi, MD; and J Mocco, MD, MS.
Cerebrovascular stroke specialists at the Icahn School of Medicine at Mount Sinai have reported on five patients younger than 50 years of age who presented to the Mount Sinai Health System in New York City with large-vessel stroke and COVID-19, surprising observations that were documented in The New England Journal of Medicine (NEJM) on Tuesday, April 28, 2020. Significantly, they have also determined that stroke patients may be delaying emergency care because of fear of COVID-19.
Large-vessel stroke, the most devastating form of stroke, occurs when there is a large blood clot in a major artery of the brain. It may cause severe symptoms in the patient and, when not diagnosed or treated quickly, may result in death or major disabilities. This form of stroke is typically seen in patients older than age 50.
“As the pandemic surged, we noticed a lot of the patients coming in for stroke were very young, and some of them did not have any traditional risk factors for stroke—but they were testing positive for COVID-19,” says the study’s senior author, Johanna T. Fifi, MD, Associate Director of the Mount Sinai Cerebrovascular Center, Director of Endovascular Stroke, and Associate Professor of Neurosurgery, Neurology, and Radiology. “We realized we had seen five young people with large vessel stroke within two weeks, and that was not usual,” adds Dr. Fifi. “By comparison, every two weeks over the previous 12 months, our service had treated, on average, less than one [0.73] patient younger than 50 years of age with large-vessel stroke.”
The patients described in the report were 33, 37, 39, 44, and 49 years old who presented to Mount Sinai during a two-week period, from March 23 to April 7, 2020. First author Thomas J. Oxley, MD, PhD, Instructor in Neurosurgery, and a specialist in vascular neurosurgery, was in the process of removing a blood clot from one patient. He was threading a tiny device through the artery to retrieve the clot, using an imaging monitor to guide him, and then he saw, he says, “There were new clots forming around the existing clot, in real time.” This was a very unusual finding.
While such observations are limited, and did not receive full peer review, NEJM says that it is sharing case reports like these that offer important teaching points or novel findings to communicate information on the global clinical effort against COVID-19. J Mocco, MD, MS, Director of the Cerebrovascular Center for the Mount Sinai Health System, Vice Chair of Neurosurgery, and Professor of Neurosurgery, says these five cases served as “an alert” to his stroke peers. The discovery of clots forming in the small vessels of many organs—in the lungs, heart, liver, and kidney—had already been reported in COVID-19 patients by several physicians from around the world, including pulmonologists and cardiologists at Mount Sinai.
One case highlighted in the NEJM report was that of a 33-year-old patient—a female who was described as previously healthy, and not having any of the usual risk factors for stroke.
She had reported symptoms of cough, fever, and chills for one week—possible symptoms of COVID-19—which were followed by progressive slowing or slurring of speech, with both numbness and weakness in the left arm and left leg over a period of 28 hours—symptoms of stroke. When she presented to Mount Sinai Brooklyn, her score on the National Institutes of Health Stroke Scale (NIHSS) was 19 (scores range from 0 to 42, with higher numbers indicating greater stroke severity). Dr. Mocco described it as “profound” stroke—the type, he said, that has the potential to result in the most severe physical and cognitive deficiencies.
Adding to the medical challenge was this patient’s delay in seeking medical care. Large-vessel strokes are very treatable, says Dr. Oxley, especially when treated within 6 hours, and up to 24 hours of the onset of symptoms. This patient, however, took more than a day to seek medical care. “She delayed seeking emergency care because of fear of COVID-19,” the report says. “She told us that she lives with elderly relatives, and she was afraid of exposing her family by going to the hospital, so she stayed home,” says Dr. Fifi.
Computed tomography (CT) and CT angiography showed a partial infarction of the right middle cerebral artery with a partially occlusive thrombus (blood clot) in the right carotid artery in the neck. Significantly, patchy ground-glass opacities in the lungs—a finding characteristic of COVID-19—were also seen on CT angiography. Testing to detect SARS-CoV-2, the virus that causes COVID-19, was positive.
The patient received antiplatelet therapy, which was subsequently switched to anticoagulation therapy. After a repeat CT angiography on Day 10 showed a complete resolution of the blood clot, the patient was discharged to a rehabilitation facility.
Among the four other patients, one was discharged home, another to a rehabilitation facility, one to the Mount Sinai stroke unit, and the fourth succumbed to his illness.
Since submitting their NEJM report, Dr. Mocco and his team have begun to analyze every stroke case that occurred while Mount Sinai hospitals were treating COVID-19 patients. “We saw a doubling in the rate of severe strokes, and more than half of the patients were positive for COVID-19,” he says. “And, we saw that they looked very different from the normal stroke population—they looked younger, and they were more likely to be men. It appears—very strongly—that there is an association here between the virus and forming blood-clots.” All of this requires more rigorous research, and the Mount Sinai stroke team will continue to observe and to collaborate on new investigations to increase understanding of the stroke and COVID-19 relationship.
In the meantime, each of them urges any individual who has stroke symptoms to seek immediate help. “Social distancing, isolation, and reluctance to present to the hospital may contribute to poor outcomes,” they wrote in the NEJM report. “Two patients in our series delayed calling an ambulance because they were concerned about going to a hospital during the pandemic.” Adds Dr. Oxley: “You need to call the ambulance urgently if symptoms such as facial drooping, arm weakness, and speech difficulties appear.”