The receiving desk of the Mass General Clinical Microbiology Laboratory is always bustling. “But when COVID-19 hit, routine work plummeted, and the avalanche of COVID specimens began,” says Heather Wilson, receiving desk supervisor.
In this Q&A, Aneesh Singhal, MD, vice chair of the Department of Neurology, describes the risk of clotting disorders among COVID-19 patients, the treatment options available, how patients can prevent stroke and what to do if they experience symptoms.
Q: Are younger COVID-19 patients more vulnerable to strokes?
A: Data concerning COVID-19 associated stroke is limited to a few small case series. One report describes five young patients (age 33-49 years) with major stroke due to blockage of the major brain arteries from blood clots. All five patients presented to the hospital over a two-week span and proved to have COVID-19 infection. This suggests a high rate of severe strokes in young and otherwise healthy adults. However, studies from China and the U.K. have reported stroke in much older patients with cardiovascular risk factors and severe COVID-19 infection between one and three weeks after admission. More research is needed, but there does appear to be a small increased risk across older as well as younger adults.
Q: What could be causing this?
A: Patients with COVID-19 have a high risk for developing blood clots that can occlude or travel into brain arteries or veins, resulting in stroke. Indeed, abnormal coagulation appears to be the major mechanism of stroke in published cases. SARS-CoV-2, the virus that causes COVID-19, may directly invade brain vessels, damage their inner lining (endothelium), or induce immunological and inflammatory mechanisms that can also result in stroke. Some patients have developed brain hemorrhage. Of course, older people who are more vulnerable to COVID-19 also have a naturally higher risk for stroke due to their age and cardiovascular co-morbidities such as hypertension and diabetes.
Q: How are clinicians treating COVID-19 patients who have strokes or clotting issues?
A: Given the high risk for clotting, especially with severe COVID-19 illness, it makes sense to administer blood thinners like heparin to prevent blood clots in the brain, lungs, legs and other tissues in admitted patients. However, this strategy needs to be balanced against the small risk of brain hemorrhage.
In patients presenting to the hospital within hours of stroke symptom onset, there is no evidence that we need to change management. The clot-busting drug intravenous tPA and catheter-based clot removal strategies are highly effective in improving outcomes.
Routine inpatient management has not changed due to COVID-19. Medications such as aspirin, clopidogrel, warfarin, apixaban and others are being given to prevent stroke progression or recurrence. Patients with large stroke or brain hemorrhage are offered neurosurgical intervention. Advanced neuro-critical care is available despite the burden on ICU bed capacity during this pandemic. It is essential to control blood pressure and blood sugar levels, prevent complications such as aspiration pneumonia and treat fever and any infection. It is not known whether the risk of stroke can be reduced by drugs being used to treat COVID-19 such as remdesivir and tocilizumab.
Q: Is there anything patients can do to prevent strokes?
A: Given the concern for COVID-19 associated stroke, it is essential to wear masks and follow guidelines such as social distancing and hand hygiene to reduce the risk of viral infection. It is very important to remain physically active even during this stay-at-home order. A healthy diet, regular exercise, smoking cessation and medication compliance remain the pillars of stroke prevention. Please keep extra refills of medications on hand in case of a prolonged period of unavailability. While there is some evidence that certain blood pressure medications (ACE-inhibitors and ARBs) can facilitate COVID-19 infection, these drugs may also benefit since they reduce lung injury in viral pneumonias. Current national guidelines do not recommend stopping or changing ACE-inhibitors or ARBs.
Q: What symptoms should patients be on the lookout for?
A: With regards to the brain, COVID-19 patients can develop confusion, headache, loss of the sense of smell, lethargy, drowsiness and symptoms of stroke. The most common symptoms of stroke are sudden-onset face, arm or leg weakness or numbness, lack of coordination, loss of vision, double vision, trouble speaking or understanding and severe headache.
Q: What should patients do if they’re experiencing stroke symptoms?
A: It’s simple. Call 911 immediately, and state “I think I’m having a stroke.” Paramedics have been trained to transport stroke patients to the closest hospital, where brain imaging and life-saving stroke treatment can be promptly offered under the supervision of stroke experts. Regardless of COVID-19, I hope patients will continue to benefit from the amazing advances in stroke treatment and the phenomenal stroke infrastructure that has been developed over the last few years.
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