Large vessel stroke as a presenting feature of Covid-19 in young people

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We report five cases of large vessel stroke in patients under the age of 50 who presented to our health system in New York. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was diagnosed in all five patients.

Table 1. Table 1. Clinical features of five young patients with a large vessel stroke.

One week cough, headache and chills in a 33 year old woman who was previously healthy (patient 1) (Table 1). She then had progressive dysarthria with numbness and weakness in the left arm and left leg over a 28 hour period. She delayed seeking emergency care for fear of Covid-19. When presented to hospital, the score on the National Institutes of Health Stroke Scale (NIHSS) was 19 (scores range from 0 to 42, with higher numbers indicating greater severity stroke), and computed tomography (CT) and CT angiography showed a partial infarction of the right middle cerebral artery with a partially occlusive thrombus in the right carotid artery at the level of the cervical bifurcation. Irregular frosted glass opacities in the bilateral pulmonary apices were observed on CT angiography, and tests for SARS-CoV-2 were positive. Antiplatelet therapy has been initiated; it was then replaced by an anticoagulant treatment. The results of the stroke with echocardiography and magnetic resonance imaging of the head and neck did not reveal the source of the thrombus. Repeated CT angiography on day 10 of the hospital showed complete resolution of the thrombus and the patient was referred to a rehabilitation center.

Over a 2-week period from March 23 to April 7, 2020, a total of five patients (including the above patient) under the age of 50 experienced symptoms of recent onset of ischemic large vessel stroke. All five patients tested positive for Covid-19. In comparison, every 2 weeks in the past 12 months, our department treated, on average, 0.73 patients under the age of 50 who had a large vessel stroke.

On admission to the five patients, the average NIHSS score was 17, which corresponds to a severe large vessel stroke. One patient had a history of stroke. Other relevant clinical features are summarized in Table 1.

A retrospective study of data from the Covid-19 epidemic in Wuhan, China, showed that the incidence of stroke in hospital patients with Covid-19 was around 5%; the youngest patient in this series was 55 years old.1 In addition, a large vessel stroke has been reported in association with the 2004 SARS-CoV-1 epidemic in Singapore.2 Coagulopathy and vascular endothelial dysfunction have been proposed as complications of Covid-19.3 The association between a large vessel stroke and Covid-19 in young patients requires further investigation.

Social distancing, isolation, and unwillingness to go to the hospital can contribute to poor outcomes. Two patients in our series delayed calling an ambulance because they feared going to hospital during the pandemic.

Thomas J. Oxley, M.D.
J. Mocco, M.D.
Shahram Majidi, M.D.
Christopher P. Kellner, M.D.
Hazem Shoirah, M.D.
Paul Singh, M.D.
Reade A. De Leacy, M.D.
Tomoyoshi Shigematsu, M.D.
Travis R. Ladner, M.D.
Kurt A. Yaeger, M.D.
Maryna Skliut, M.D.
Jesse Weinberger, M.D.
Neha S. Dangayach, M.D.
Joshua B. Bederson, M.D.
Stanley Tuhrim, M.D.
Johanna T. Fiifi, M.D.
Mount Sinai Health System, New York, NY
[email protected]

The disclosure forms provided by the authors are available with the full text of this case on NEJM.org.

This case was published on April 28, 2020 on NEJM.org.

We dedicate this case to our inspiring colleague Gary Sclar, MD, a deceased neurologist from Covid-19.

  1. 1. Li Y, Wang M, Zhou Y, et al. Acute cerebrovascular disease after COVID-19: a retrospective monocentric observational study. March 13, 2020 (https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3550025) (preprint).

  2. 2. Umapathi T, Kor AC, Venketasubramanian N, et al. Ischemic stroke of the large arteries in severe acute respiratory syndrome (SARS). J Neurol 2004; 251:12271231.

  3. 3. Zhou F, Yu T, R, et al. Clinical evolution and risk factors for mortality in adult hospitalized patients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020; 395:10541062.

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