COVID-19 Patients Face Greater Than Two-Times Risk for Large Vessel Occlusion Stroke

July 30, 2020

Clinicians should adopt a lower threshold for evaluating patients for stroke and providing care.

There is an elevated risk of large vessel occlusion stroke for patients, positive for COVID-19, who present to the emergency department with neurological symptoms. In these cases, providers should proactively evaluate them and implement any stroke work-ups.

In fact, this research, published July 29 in the American Journal of Roentgenology, reveals that, after adjusting for race and ethnicity, these patients face a 2.4-times greater likelihood of suffering a large vessel occlusion (LVO) than do healthy people who are not infected with the virus. Consequently, these patients should be monitored more closely with a lower threshold of suspicion for stroke.

“Healthcare providers in the emergency department and inpatient areas should be cognizant of this association and not delay activating a stroke code,” said first study author Shingo Kihira, M.D., a radiology resident at Mount Sinai Icahn School of Medicine. “This association may imply that patients with [large vessel occlusion] during the COVID-19 pandemic who have no undergone testing for SARS-CoV-2 infection or are waiting for results warrant higher suspicion and appropriate precautions.”

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The results of this study, which, the authors said is the first to describe the relationship between COVID-19 and LVO strokes, could help neuro-interventionalists evaluate and pinpoint the presence and locations of possible occlusions in these patients.

The team, he said, conducted this retrospective study because they noticed the increased frequency of acute strokes in patients who have been coming to Mount Sinai’s hospitals with acute neurological symptoms during the pandemic. They evaluated 329 patients for whom the stroke code was activated between March 16, 2020, and April 30, 2020.

The team reviewed all neuroimaging for this group. Of the patients evaluated, all 329 underwent head CT, 327 had CT angiography, 250 had MRI, 78 had MR angiography, and 59 underwent digital subtraction angiography. Based on those scans, the team determined the mean National Institutes of Health Stroke Scale score for this group was 9.5 +/- 8.5.

According to their analysis, 38.3 percent of patients with an initiated stroke code also tested positive for COVID-19. In particular, they identified that the virus is associated with LVO strokes, but not small vessel occlusion ones, with 62 percent of LVO strokes involving occlusion of the M1-M2 segments of the middle cerebral artery.

Given the growing body of knowledge around the association between COVID-19 infection and stroke, Kihira and his colleagues recommended that clinicians pay closer attention and be willing to jump in sooner with stroke evaluation and care.

“Patients with COVID-19 presenting with acute neurologic symptoms warrant a lower threshold of suspicious of large vessel stroke, and prompt work-up for large vessel stroke is recommended,” Kihira said. “Future investigation may focus on the exact pathophysiologic mechanism of large vessel strokes in patients with COVID-19 and validate contributing risk factors through a larger study.”