Covid-19 and Stroke
Q) What are stroke characteristics in patients with COVID-19?
A) Stroke is more commonly found in males than females, and in a younger age group (50’s-60’s). The stroke is more severe with higher NIHSS (median=17). They have more large vessel occlusions when compared to non-COVID patients. They have more tandem or multiple territory infarction. The clot burden is higher and there is high tendency to have clot fragmentation during thrombectomy. Reocclusion is more common. They have at least one vascular risk factor. The mortality in stroke patients with COVID was reported around 60-75%, which could come from severity of disease or stroke by itself. Most of them do not have a good outcome despite reperfusion, which they think that it could be from reocclusion from microcirculation.
Q) What are the possible mechanisms of stroke from COVID-19?
1) Abnormal coagulopathy (both macrothrombosis and microthrombosis) Virus can damage the endothelium and causes endothelitis. Inflammation from viral infection activates thrombus formation.They report the elevated level of antiphospholipid antibodies (IgA, IgM and IgG) and lupus anticoagulant in COVID-19 patients. However, we still need more studies on the cause and effect of these antibodies in this group of patients. Fibrinogen and D-Dimer are elevated and D-dimer level is associated with mortality. They found minimal changes in platelet counts, antithrombin levels, PT, and aPTT in COVID-19 patients.
2) Hemodynamic changes from the systemic involvement of COVID, which could lead to hypotension and hypoperfusion.
3) Atherosclerotic plaque rupture secondary to widespread inflammatory response.
4) Cardioembolic stroke from stress-induced cardiomyopathy or cardiac injury from the virus.
5) Superimposed bacterial infection leads to septic emboli.
1) Yaghi S, Ishida K, Torres J, et al. SARS2-CoV-2 and Stroke in a New York Healthcare System
[published online ahead of print, 2020 May 20]. Stroke. 2020;STROKEAHA120030335.
2) Markus HS, Brainin M. COVID-19 and stroke-A global World Stroke Organization perspective. Int J Stroke. 2020;15(4):361‐364.
3) Escalard S, Maïer B, Redjem H, et al. Treatment of Acute Ischemic Stroke due to Large Vessel Occlusion With COVID-19: Experience From Paris [published online ahead of print, 2020 May 29]. Stroke. 2020;STROKEAHA120030574.
4) Wang A, Mandigo GK, Yim PD, Meyers PM, Lavine SD. Stroke and mechanical thrombectomy in patients with COVID-19: technical observations and patient characteristics [published online ahead of print, 2020 May 25]. J Neurointerv Surg. 2020;neurintsurg-2020-016220.
5) Iba T, Levy JH, Levi M, Connors JM, Thachil J. Coagulopathy of Coronavirus Disease 2019
[published online ahead of print, 2020 May 27]. Crit Care Med. 2020;10.1097/CCM.0000000000004458.