The current COVID-19 pandemic has been a singular event with far-reaching societal and medical ramifications. The enormity of the crisis and the alacrity of its spread across the globe has led to a rapidly evolving understanding of the disease. Current knowledge of the pandemic and the effect of the virus on the human body may become obsolete by week’s end. The COVID-19 crisis’s impact on the care of stroke patients is emblematic of these issues. Over the past few months, several data points have emerged that have been interpreted in divergent ways.
For example, early on, there was speculation from New York City — one of the regions hardest hit by COVID-19 — that COVID-19 was associated with an increased risk of fatal ischemic stroke in young adults. Several physicians from New York authored a report of their experience with five stroke patients infected with SARS-CoV-2, aged 33 to 49. This study received significant attention in both the press and academic journals. We currently understand COVID-19 to be a mild disease in most people. However, occasionally it progresses to a more severe process, including acute respiratory distress syndrome (ARDS), multi-organ dysfunction, cytokine storm, inflammation, coagulation and death. Coagulopathy and vascular endothelial dysfunction have been proposed as complications of COVID-19. Although the authors shed light on the clinical characteristics of young adults with these two pathologies, they were not able to explain the possible association between stroke and COVID-19 fully.
On the contrary, several researchers have indicated a decreased incidence of ischemic stroke across the world during the COVID-19 pandemic. The drop in the rate of stroke presentations has been so dramatic that various medical societies and advocacy groups have issued statements urging patients not to delay stroke care out of fear of being exposed to SARS-CoV-2, the virus causing COVID-19. While this a plausible explanation for the decreased incidence of stroke during the height of the pandemic, we believe it may be too early to tell whether this is, in fact, the case.
Another data point suggests that patients are seeking care for stroke symptoms in a delayed fashion, resulting in suboptimal outcomes. Most stroke experts have attributed this phenomenon of “vanishing strokes and heart attacks” to the unwillingness of patients to be exposed to COVID-19 in an already overwhelmed emergency room. By contrast, researchers from Italy have hypothesized a pathophysiologic mechanism behind the decreased incidence of stroke in COVID-19 patients based on the controversial role of Interleukin 6 (IL-6) — a protein involved in inflammation — in stroke. There is experimental evidence that IL-6 — which is elevated in patients with more severe forms of COVID-19 — has a neuroprotective effect and enhances angiogenesis (formation of new blood vessels). Another possible explanation offered is the thrombocytopenia (low platelet counts) encountered in patients even with mild cases of COVID-19, as low platelet levels may prevent the formation of large clots in the intracranial circulation. Lastly, the widespread mitigation measures, which have minimized the prevalence of influenza in the community, may have attenuated the typical negative impact of the flu on cardiovascular disease and stroke. Further research into the effects of these various associations is warranted.
In these times of crisis, we remain dedicated to offering the highest level of care for stroke patients focusing on the following principles:
- Clear identification of Comprehensive Stroke Centers (CSCs), which can offer all stroke-related services even during the pandemic;
- Information for emergency medical services and the public that CSCs will be protected and will remain fully operational during crises; and
- Education for health professionals and the public — especially those who are at high risk of stroke — leading to early recognition of stroke symptoms and contacting emergency medical services immediately to be taken to a CSC to avoid significant delays in transferring patients between hospitals.
A full picture of how COVID-19 influences the phenotype, incidence, and demographics of acute ischemic stroke patients has yet to emerge and may not for many months. Until then, it remains paramount to focus on measurable outcomes and continue to leverage the proven components of our stroke system of care to the benefit of our patients. Education — as was emphasized throughout May’s National Stroke Awareness Month — needs to continue and must be the cornerstone of engagement of the health care system with the public to reassure that we are able and ready to take care of our patients safely.
Editor’s note: We hope that you will share what you learn from our posts. We invite you to be part of the conversation on Twitter by following and using the hashtag #COVID19.
Kimon Bekelis, MD
Vice-chair, AANS/CNS Communications and Public Relations Committee
Director of the Stroke & Brain Aneurysm Center and co-director of the Neuro ICU at Good Samaritan Hospital Medical Center
Chairman, Neurointerventional Services at Catholic Health Services of Long Island
Director, Population Health Research Institute of New York at CHSLI
Assistant Professor, The Dartmouth Institute for Health Policy and Clinical Practice
West Islip, N.Y.
Clemens M. Schirmer, MD, PhD, FAANS, FAHA
Chair, AANS/CNS Communications and Public Relations Committee
Geisinger
Wilkes Barre, Pa.
Finally, stroke, large vessel occlusions and mechanical thrombectomy have become an area of interest amid the COVID-19 pandemic. Evidence is emerging from epicenters of the crisis — like New York City — that patients, whether afflicted with COVID-19 or not, are seeking medical attention later in their stroke course due to fears regarding COVID-19. We expect many studies to be published in the ensuing months evaluating stroke and mechanical thrombectomy in COVID-19 patients. We are excited about what the future holds in cutting edge research to bring the best available care to stroke patients everywhere.
Justin R. Mascitelli, MD