A case series published in Neurological Sciences suggests that in adults under 55 who are diagnosed with coronavirus disease 2019 (COVID-19), the development of stroke, or its severity based on the National Institutes of Health Stroke Scale (NIHSS), is not necessarily linked to the extent of lung involvement.
“This is the first study evaluating the association of [the extent of] lung involvement…and stroke severity” in COVID-19-related strokes, noted Farzad Ashrafi, Shohada Tajrish Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran, and colleagues. “In this regard, our cases showed that lung involvement extension may be unrelated to developing a stroke and its severity based on NIHSS. On the other hand, D-dimer level may play a critical role as a prognostic factor as elevated D-dimer levels were seen in all of our patients.”
The cases involved six patients who presented to their academic tertiary hospital stroke unit with clinical symptoms of stroke from March 2020 to the end of April 2020. Excluded were those over 55 and all others with evidence of cardiac arrhythmia or cardiac valvular disease. Patients were evaluated for symptoms, lab data, imaging findings, and outcomes.
Although all patients primarily presented with neurological symptoms, the diagnosis of COVID-19 was made based on positive nasopharyngeal PCR and lung CT scan, except one case involving a 49-year-old female with a previous diagnosis of COVID-19 who was discharged from another hospital and admitted to the authors’ stroke unit 5 days later. The most common signs and symptoms of COVID-19 were fever (4/6), myalgia (4/6), cough (3/6), and dyspnea (3/6). All patients had O2 saturation below 92% in room air, while none were hypotensive.
Below is a summary of the (outcome), demographics and clinical stroke features of the patients in this case series:
- Patient 1 (deceased): 33-year-old female; reduced level of consciousness, global aphasia, right-side hemiplegia; NIHSS of 24
- Patient 2 (discharged): 39-year-old male; left-side hemiparesis, homonymous hemianopia, sensory deficit, dysarthria; NIHSS of 9
- Patient 3 (discharged): 49-year-old female with hypertension; left-side hemiplagia, heminimous hemianopia, dysarthria; NIHSS of 11
- Patient 4 (discharged): 40-year-old male; right-side hemiparesis, dysarthria; NIHSS of 6
- Patient 5 (discharged): 53-year-old male with hypertension; left-side hemiparesis, dysarthria; NIHSS of 5
- Patient 6 (discharged): 47-year-old female with hypertension and diabetes mellitus; right-side hemiparesis, dysarthria; NIHSS of 6
Baseline laboratory findings included mean C-reactive protein (CRP) of 15.0 mg/L (SD ± 8.57), lactic acid dehydrogenase (LDH) of 555.16 μ/L (SD ± 413.24), D-dimer of 844.50 (SD ± 250.63), prothrombin time (PT) of 13.33 seconds (SD ± 0.51), partial thromboplastin time (PTT) of 34.33 seconds (SD ± 5.57), and international normalized ratio (INR) 1.03 (SD ± 0.51).
As per national guidelines, all patients were placed on hydroxychloroquine 400 mg stat, lopinavir/ritonavir 400/100 mg twice daily and intravenous antibiotic. As none were candidates for thrombolytic therapy, the patients received ASA and Plavix for secondary prevention.
Initial chest CT scans evaluated for estimation of lung involvement score using zonal involvement percentage method with a maximum score of 24. The mean score was 13.16 (SD ± 6.49; ranged 2–16), with bilateral ground glass opacities being the predominant pattern. Brain CT scan findings revealed the stroke territories as right middle cerebral artery (MCA) infarction (n = 3), left MCA (n = 2), and left basal ganglia infarction (n = 1), and the majority of the patients had large vessel stroke. “Our data demonstrated that the majority of our patients had low lung involvement rates, while they had more severe conditions based on NIHSS score,” the authors said.
Despite limited information so far on the association between COVID-19 and ischemic stroke, the authors highlighted some recent published cases, including that of a 52-year-old man with COVID-19 who presented with sudden onset hemiparesis and aphasia (NIHSS: 20) on his seventh day of treatment, with brain CT scan confirming stroke in the MCA territory. On further work up, the patient did not appear to have any risk factor for stroke. Meanwhile, another study described large-vessel strokes presented in five COVID-19 cases younger than 50 years old, but “unlike our patients, all of them had severe COVID-19,” the authors noted.
They concluded that “COVID-19 can cause thrombotic complications, hyper-inflammation, and tissue damage, which may increase the risk of ischemic stroke in young and middle-aged patients, even in early stages and mild forms of COVID-19…Future studies with long-term follow-up and more cases are needed to assess prognostic factors.”