Explaining the Association Between COVID-19 and Stroke


Mark J. Alberts, MD; Jesse Weinberger, MD


May 22, 2020

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This transcript has been edited for clarity.

Mark J. Alberts, MD: Hello, and welcome to this Medscape update. My name is Dr Mark Alberts. I'm chief of neurology at Hartford Hospital and I'm a vascular neurologist.

Today I'm joined by my friend and colleague, Dr Jesse Weinberger. I'm going to let Dr Weinberger introduce himself now. Jesse?

Jesse Weinberger, MD: Thanks. I'm Jesse Weinberger. I'm a stroke neurologist at Mount Sinai and I'm coming to you from the neurovascular lab. I'm the director of the neurovascular laboratory at Mount Sinai.

Alberts: What we're going to be talking about for the next little while is something that I'm sure many of our colleagues on the Medscape platform are interested in, which is the association between COVID-19 infections and cerebrovascular disease.

Here at Hartford, we have seen our fair share of COVID-19 folks with strokes. I'm sure that Jesse, being at Mount Sinai, at sort of ground zero in New York, has also seen his fair share. So let's talk about the overall landscape of COVID-19–associated strokes.

Jesse, what have you seen, and [can you speak to] the epidemiology and some of the numbers?

Weinberger: Mount Sinai has affiliates all over Manhattan and in Queens. And it was our Queens affiliates, Elmhurst and Mount Sinai Queens, that were in the epicenter of stroke in New York. If you recall from the news, Elmhurst was the hospital that got flooded over and we got a lot of their transfers.

We have one interventional team that services all the hospitals and moves [to the patients] to avoid the patients having to be moved. That makes it much faster to get a fast thrombectomy time.

Our group has probably seen the most stroke COVID-19 patients because we've had the most COVID-19 patients. In terms of epidemiology, one of the papers that our interventional group is putting together compares the number of interventions we do in a given month prior to COVID to how many we're doing now. They found that we're doing twice as many interventions for large vessel thromboses than usual, over 50% of which were on COVID-19 patients.

These were mainly young patients who were forming clots in the arteries, and with no evidence of dissection or a cardiac source. [These were] spontaneous thrombi affecting large cerebral vessels, like the middle cerebral artery.

Alberts: One of the things that we've seen here at Hartford—and I want to see if your experience in New York has been the same—is that in general, we have seen a decline in terms of routine stroke patients and routine interventions, like use of TPA and endovascular therapy.

I think our colleagues around the country have also seen a general decline in stroke patients overall, even though as I've seen and as you just pointed out, in those COVID-19 patients, certainly there seems to be some coagulation and ischemic issues. Have you see an overall decline in the non–COVID-19 stroke population?

Weinberger: Not so much a decline as that they're coming in a day or two after. They're not coming in for the acute intervention, which is unfortunate because some of them might have been candidates for TPA or thrombectomy, and instead they come in too late.

Alberts: COVID-19 is attacking people in different age groups and [results in] very high mortality with older folks and those in nursing homes. But what about this younger population we're seeing?

Weinberger: These are patients primarily under 50. They're young patients that are getting this, for some reason.

Alberts: As we both know, there have been several reports about COVID-19 causing somewhat of a hypercoagulable state. We've certainly seen many folks with high D-dimers, DVTs, PEs, as well as ischemic stroke. Has that been your experience in New York, Jesse?

Weinberger: Well, we see a lot with elevated D-dimers. We had four patients with acute thrombi in the carotid bifurcation and two of them had normal D-dimers, so we weren't sure exactly why that happened. Some of the patients have had anticardiolipin antibody.

My rheumatology colleagues say that they're seeing many rheumatologic disease mimics from the COVID-19 infection that turn into Kawasaki syndrome. It may be that they're having an immune response that mimics a lupus anticoagulant or anticardiolipin antibody that contributes to the thrombosis.

Alberts: Very interesting. As we talk about specific stroke syndromes, we have seen two varieties. Number one are folks with MRIs showing a bunch of small strokes all over the place, like you could see in somebody hypercoagulable with cancer or with a central embolic source.

We're also seeing the same thing that you describe, which is large vessel strokes like M1 inclusions, in folks who don't have a good reason for it. There's no atrial fibrillation and they're not really atheropathic, per se. They're just having in situ clots. Are you seeing the same variety?

Weinberger: Oh, yeah. In addition to the ones that I mentioned with the large vessel thromboses, we're seeing many with multiple small infarcts, but we don't find anything in the heart causing it. We think it's probably multiple angiopathy due to COVID-19 thromboses.

Alberts: In the vascular studies that we've done here in the folks with strokes all over the place, I don't think we've seen many with an underlying vasculopathy. The vessels, as near we can tell, look normal. They're just having clots all over the place, producing this shotgun image of small strokes in different vascular territories.

Weinberger: Right. We're seeing the same thing, but it does seem to us that it was direct thromboses in these vessels rather than a shower of emboli.

Alberts: And it could be both. It's hard to tell. But I agree: We're not seeing any obvious central embolic source like clots in the left ventricle or left atrium, or myxomas or anything like that.

Weinberger: Our echocardiographers didn't want to do echos on the COVID-19 patients. Fortunately, the first one we sent to them actually had an atrial septal defect. After that, they acquiesced to doing all of our studies, and no one else had any positive [cardiac] findings.

Alberts: We and others are seeing folks with DVTs and PEs, which speaks to a hypercoagulable state, obviously.

Weinberger: Right. The people I'm thinking of that had the multiple infarcts also had PEs. They had both, so it wasn't a paradoxical embolus.

Alberts: Right. Again, when you have D-dimers in the thousands, it's not too surprising that we would see that.

How about your approach to treatment in terms of IV lytic therapy versus endovascular therapy? I know some of this is dictated by the underlying CTA results, but are most of your patients being treated with TPA, endovascular therapy, or both?

Weinberger: We approach it the same way as with any other stroke patient. If they're in the window for TPA, we'll give it and then proceed to the thrombectomy if they need it. We've had a couple of patients that actually got better right after the TPA, which was nice.

Alberts: Yes, very gratifying. How about the response to endovascular therapy? Are you able to do a thrombectomy or otherwise open up these vessels, or do some of them look like the clot is old and it's like a brick?

Weinberger: No, they mainly open with thrombectomy, but the results are a little bit mixed. I don't think we see the same percentage of recoveries with these patients as we do under normal circumstances.

Alberts: Yeah, we're tending to see that most of these clots are removable or otherwise treatable. To me, this speaks to the fact that they are probably acute, not like an old clot that's been sitting in the heart for months, which then embolizes and it's hard as a rock and you have a hard time getting it out.

Weinberger: That's probably why they responded to TPA as well.

Alberts: Right. Fresh clots. Now, you did mention that the overall recovery was not as good as you were hoping for. Can you shed some light on this?

Weinberger: I can't really. It's just an observation from a few patients, but it seems like they don't do as well.

Alberts: If your patients are like my patients, most of them are not on the primary neurology or stroke service. We're seeing them as consults because they're in the MICU or another ICU service due to their underlying COVID-19 infection. Is that your experience also?

Weinberger: No. We're admitting them to the neurology ICU or to the stroke service floor. We're taking care of the COVID-19 patients for primary care as well.

Alberts: Do you think COVID-19 patients with stroke as a complication differ from those coming in with a stroke, but in whom you then find have COVID-19?

Weinberger: Interestingly, when many patients go for CT angiography, they're not diagnosed with COVID-19. We pick it up as having a ground-glass appearance in the lungs and then we get to swab them. Once we see that, we assign them to the COVID-19 floor until proven otherwise.

Alberts: My rule of thumb nowadays is that anybody who comes in with a stroke has COVID-19 until proven otherwise.

Weinberger: Right.

Alberts: On the back end, are you having luck sending these folks to rehab or a nursing home? What is the paradigm like in the New York City area?

Weinberger: Actually, there are several nursing homes that take them for subacute rehabilitation. Our acute rehab service isn't taking them, but they're going to subacute centers.

Alberts: Got it. I think we're fortunate because we've had a number of these patients who actually made a good recovery and the nursing homes and rehab center were willing to take them. So we were able to offload some of the patients from the hospital to make room for the next round.

Weinberger: Actually, in the past couple of weeks that I've been on, it's really been slowing down. We haven't had a COVID-19 stroke patient in a couple of weeks now.

Alberts: Wow!

Weinberger: Mitigation.

Alberts: Mitigation is good.

Weinberger: The overall number of COVID-19 patients admitted to the Sinai system is going down and so are the strokes. The other thing is that as soon as somebody is diagnosed with COVID-19, they're being anticoagulated with Lovenox (enoxaparin) because of the known thrombosis risk.

Alberts: That's a great point. We also have a hospital policy that anybody admitted with COVID-19 gets at least prophylactic doses of an anticoagulant. Obviously, if they have ongoing thromboses, then they will get therapeutic doses.

Alberts: What about the lack of taste and smell? Are you seeing that in many of your patients?

Weinberger: I haven't noticed that. Frankly, I probably didn't ask about it.

Alberts: Yeah. Obviously, if they're really sick with a stroke or if they're intubated [it would be difficult]. But it's been reported by CDC that it's one of the cardinal signs to ask about. It would imply cranial nerve involvement, right?

Weinberger: Right. Going up the olfactory nerve into the brain.

Alberts: I think here in Connecticut, we're a few weeks behind you in terms of the curve—or maybe in front of you, depending on how you look at it—but like you, we have a number of different hospitals throughout the state [with varying rates]. St. Vincent's, which is in the western part of Connecticut in Fairfield County, is still seeing high volumes. But in general they are all coming down, which is very encouraging.

Weinberger: The question is whether it will stay coming down when we start trying to open up the city again.

Alberts: Right. The other interesting thing—and I don't have any answers or insights—is to see if there might be some sort of post–COVID-19 syndrome, like pulmonary fibrosis or some other systemic manifestations, after the infection.

You mentioned the autoimmune component. Like many autoimmune diseases, they do have the potential to fluctuate, and it's just going to be very interesting to have these patients followed long-term for 3 months, 6 months, a year, just to see if there are any long-term sequelae, either autoimmune or postinfectious or something in that realm.

I don't have any answers or insights, but that's why they call it "novel." This is a new disease that we don't have much experience with.

Weinberger: Correct.

Alberts: I think we've touched on a lot of the points about epidemiology, acute treatment, and long-term outcomes.

Thank you to our Medscape audience for joining us. I wish that all of our colleagues be well and that their patients have a rapid recovery.

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