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Five COVID-19 patients ages 33 to 49 developed acute ischemic large-vessel stroke, data from a New York City health system showed.

All five presented to Mount Sinai Health System from March 23 to April 7 and all tested positive for SARS-CoV-2, the virus that causes COVID-19, wrote Thomas Oxley, MD, of Mount Sinai, and colleagues, in the on Tuesday.

In two of those cases, stroke was the presenting symptom of COVID-19, noted co-author Johanna Fifi, MD, a neuroendovascular surgeon at Mount Sinai. In the other three cases, COVID-19 symptoms were mild: cough, headache, lethargy in some, and one report of fever.

"We noticed a lot of the patients coming in were very young and some of them didn't have any traditional risk factors for stroke, except that they were testing positive for COVID-19," Fifi said.

"We realized we had seen five young people with large vessel stroke within 2 weeks when we normally see less than one patient that young every 2 weeks. This was seven times our normal rate," she told 麻豆传媒.

Similar cases have been seen at other hospitals, noted Pascal Jabbour, MD, of Thomas Jefferson University Hospital in Philadelphia, who was not involved with the Mount Sinai paper. Jabbour, who is collaborating with researchers at NYU Langone to publish a paper about COVID-19 and stroke, said that of 12 COVID-19 patients treated for stroke from March 20 to April 10 at both centers, half were in their 50s or younger. "The young patients didn't have any risk factors for strokes and mortality was much higher than expected, close to 50%," Jabbour told 麻豆传媒.

"What we've seen is that patients are presenting late because they are scared to go to the hospital," Jabbour said. "We have a short window to be able to intervene. If patients present in a delayed fashion, we lose this opportunity and we won't be able to help." Indeed, a suggested that a substantial number of individuals in northern Italy with acute coronary syndrome had refrained from seeking medical treatment and died as a result.

"And we've noticed in some of those young patients, stroke was the first symptom of COVID; in 50%, we diagnosed COVID when we admitted them. They didn't know they had COVID; they went to the hospital because of stroke symptoms," Jabbour said.

The possibility of stroke associated with COVID-19 had also been raised in a study from France earlier this month, in which clinicians noted cerebral infarcts among other neurological manifestations in a large case series.

In the Mount Sinai cases, two patients had no risk factors for stroke. One, a 39-year-old-man who died with multi-organ failure after the paper was accepted by New England Journal of Medicine, had hyperlipidemia and hypertension. Another man, age 44, had undiagnosed diabetes; the fifth patient, a 49-year-old man, had diabetes and a previous history of mild stroke, but "didn't have any residual deficits from his stroke and was functionally normal," Fifi said.

Four of the five patients had reduced consciousness as a presenting sign of stroke. The fifth patient, a 33-year-old woman, experienced progressive dysarthria with both numbness and weakness in her left arm and leg at home for about 28 hours, "She in particular was afraid," Fifi said. "She told us she was afraid of exposing her family, so she stayed at home."

Stroke severity levels ranged from 13 to 23 on the NIHSS scale at admission (NIHSS scores range from 0 to 42, with higher numbers indicating greater stroke severity). Four patients had anterior strokes; the 39-year-old patient who died had a stroke in the right posterior cerebral artery.

"These patients have a large amount of clot in the artery," Fifi said. "When we go in to try to take it out, we see just a large burden of thrombus inside the vessel." Coagulopathy and vascular endothelial dysfunction have been proposed as COVID-19 complications, but that's not known for certain, she added. "There are a few theories about what's happening and why it's happening, but we just don't know," she said.

These results "are very intriguing but must be interpreted with caution," noted Robert Stevens, MD, of Johns Hopkins University, who was not involved with the Mount Sinai cases. "While a relationship between COVID-19 and an increased risk of ischemic stroke seems plausible, a higher level of evidence will be needed to substantiate these findings and to demonstrate causality."

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