Oxley gasped when he reached the patient’s age and the status of covid-19:44, positive.
The man was among several patients who recently suffered a stroke in their 30s and 40s, all infected with the virus. The median age for this type of severe stroke is 74 years.
As Oxley, an interventional neurologist, started the procedure to remove the clot, he observed something he had never seen before. On monitors, the brain usually appears as a tangle of black doodles – “like a can of spaghetti,” he said – which provides a map of blood vessels. A clot appears like a virgin spot. While using a needle-like device to remove the clot, he saw new clots forming around him in real time.
“It’s crazy,” he recalls saying to his boss.
Reports of stroke in young and middle-aged people – not just at Mount Sinai, but in many other hospitals in communities hard hit by coronavirus – are the latest modification to our evolutionary understanding of covid-19 . Even though the virus infected nearly 2.8 million people worldwide and killed 195,000 people on Friday, its biological mechanisms continue to elude the greatest scientific minds. Once thought to be a pathogen that primarily attacks the lungs, it has proven to be a much more formidable enemy – affecting almost every major organ system in the body.
Until recently, there was little reliable data on stroke and covid-19.
A report from Wuhan, China, showed that some hospital patients had suffered a stroke, but many were seriously ill and elderly. But the link has been viewed more as “clinical intuition by many truly intelligent people,” said Sherry H-Y Chou, neurologist and critical care physician at the University of Pittsburgh.
For the first time, three major American medical centers are preparing to publish data on the phenomenon of stroke. The numbers are small, only a few dozen per location, but they provide new information about what the virus is doing to our bodies.
Stroke, a sudden interruption in the blood supply, is a complex problem with many causes and presentations. It can be caused by heart problems, clogged arteries due to cholesterol, or even drug addiction. Mini-shots often don’t cause permanent damage and can resolve on their own within 24 hours. But the largest can be catastrophic.
Analyzes suggest that patients with coronavirus primarily experience the most lethal type of stroke. Known as large vessel occlusions or LVO, they can clear large parts of the brain responsible for movement, speech and decision-making at once, as they are found in the main blood arteries.
Many researchers suspect that strokes in new coronavirus patients may be a direct result of blood problems that produce clots all over the body of some people.
The clots that form on the walls of the vessels fly upward, so those that started in calves can migrate to the lungs, causing a blockage called a pulmonary embolism that stops breathing – a known cause of death in Covid-19 patients. Clots in or near the heart can cause a heart attack, another common cause of death. Anything higher would likely go to the brain, resulting in a stroke.
Robert Stevens, a specialist in intensive care at Johns Hopkins Hospital in Baltimore, called stroke “one of the most dramatic manifestations” of blood clotting problems. “We also took care of patients in their 30s who had a stroke or a seizure, and that was extremely surprising,” he said.
Chou said a question was whether the clotting was due to a direct attack on the blood vessels or “a friendly fire problem” caused by the patient’s immune response.
“In your body’s attempt to fight the virus, does the immune response eventually harm your brain?” ” she asked. Chou hopes to answer these questions by examining strokes and other neurological complications in thousands of Covid-19 patients treated at 68 medical centers in 17 countries.
Thomas Jefferson University Hospitals, which operate 14 medical centers in Philadelphia and NYU Langone in New York, have found that 12 of their patients treated for large blood blockages in their brains for a period of three weeks had the virus. Forty percent were under the age of 50 and had little or no risk factors. Their article is under review by a medical journal, said Pascal Jabbour, neurosurgeon at Thomas Jefferson.
Jabbour and co-author Eytan Raz, assistant professor of neuroradiology at NYU Langone, said that strokes in Covid-19 patients challenge conventional thinking. “We are used to thinking of 60 years as a young patient when it comes to large vessel occlusions,” said Raz of the deadliest stroke. “We have never seen so many in our 50s, 40s and late 30s.”
Raz wondered if they saw more young patients because they are more resistant than the elderly to the respiratory distress caused by covid-19: “So they survive on the pulmonary side and develop over time other problems. “
Jabbour said that many of the cases he had dealt with had unusual characteristics. Brain clots usually appear in the arteries, which carry blood away from the heart, but in covid-19 patients, it also sees them in the veins, which carry blood in the opposite direction and are more difficult to treat. Some patients also develop more than one large clot in their head, which is very unusual.
“We are going to treat a blood vessel and it will be fine, but then the patient will have a major stroke” due to a clot in another part of the brain, he said.
The 33 year old woman
At Mount Sinai, New York City’s largest medical system, medical researcher J Mocco said that the number of patients entering with large blood blockages in their brains doubled in the three weeks of Covid’s surge -19 to over 32, although the number of other emergencies has decreased. More than half of them were positive for Covid-19.
On average, Covid-19 stroke patients were 15 years younger than stroke patients without the virus.
“These are some of the people who are statistically less likely to have a stroke,” said Mocco.
Mocco, who has spent his career studying strokes and how to treat them, said he was “completely shocked” by the analysis. He noted the link between covid-19 and stroke “is one of the clearest and deepest correlations I have encountered. “
“This is far too strong a signal to be a fluke or a fluke,” said Mocco.
In a letter to be published in the New England Journal of Medicine next week, the Mount Sinai team details five case studies of young patients who have had strokes at home from March 23 to April 7. They make reading difficult: the victims ages are 33, 37, 39, 44 and 49 and were all at home when they started experiencing sudden symptoms, including slurred speech, confusion , a fall on one side of the face, a feeling of death in an arm.
One died, two are still in hospital, one was rehabilitated and one was released from his brother’s home. Only one of the five, a 33-year-old woman, is able to speak.
Oxley, the interventional neurologist, said one striking aspect of the cases is the time many have waited before seeking emergency care.
The 33-year-old woman was previously healthy, but had had a cough and headache for about a week. Within 28 hours, she noticed that her speech was disrupted and that she became numb and weak on the left side but, the researchers wrote, “delayed seeking emergency care because of fear of Covid-19 epidemic. ”
It turned out that she was already infected.
By the time she arrived at the hospital, a CT scan showed that she had two clots in her brain and a scattered “frosted glass” in her lungs – a hallmark of Covid-19 infection. She received two different types of therapy to try to break the clots and by day 10 she was well enough to be released.
Oxley said the most important thing for people to understand is that big shots are very treatable. Doctors are often able to reopen blocked blood vessels using techniques such as removing clots or inserting stents. But it should be done quickly, ideally within six hours, but not more than 24 hours: “The message we are trying to get out is that if you have stroke symptoms, you should call the ambulance urgently. ”
As for the 44-year-old man Oxley was treating, doctors were able to remove the big clot that day in late March, but the patient is still struggling. Since this week, just over a month after arriving in the emergency room, he is still hospitalized.