Healthy people in their 30s and 40s, barely sick with COVID-19, are dying from strokes
Thomas Oxley wasn’t even on call the day he received the page to come into Mount Sinai Beth Israel Hospital in Manhattan. There weren’t enough doctors to treat all the emergency stroke patients, and he was needed in the operating room.
The patient’s chart appeared unremarkable at first glance. He was male, no medications, no history of chronic conditions. He had been feeling fine, hanging out at home during the lockdown like the rest of America, when suddenly, he had trouble talking and moving the right side of his body. Imaging showed a large blockage on the left side of his head.
Oxley gasped when he got to the patient’s age and COVID-19 status: 44, positive.
The man was among several recent stroke patients in their 30s to 40s who were all infected with the virus. The median age for that type of severe stroke is 74.
As Oxley, an interventional neurologist, began the procedure to remove the clot, he observed something he had never seen before. On the monitors, the brain typically shows up as a tangle of black squiggles - “like a can of spaghetti,” he said - that provide a map of blood vessels. A clot shows up as a blank spot. As he used a needlelike device to pull out the clot, he saw new clots forming in real time around it.
“This is crazy,” he remembers telling his boss.
Reports of strokes in the young and middle-aged - not just at Mount Sinai but in many other hospitals in hard-hit communities - are the latest twist in our evolving understanding of the mysteries of COVID-19. Even as the virus has infected nearly 2.8 million people worldwide and killed 195,000 as of Friday, its origins, biological mechanisms and weaknesses continue to elude top scientific minds. Once thought to be a pathogen that primarily attacks the lungs, it has turned out to be a much more formidable foe - affecting nearly every major organ system in the body.
Until recently, there was little hard data on strokes and COVID-19.
One report out of Wuhan, China, showed that some hospitalized patients had experienced strokes but many of those were seriously ill and elderly. But the linkage was considered more of “a clinical hunch by a lot of really smart people,” said Sherry H-Y Chou, a University of Pittsburgh neurologist and critical care doctor.
Now three large U.S. medical centers are preparing to publish data on the stroke phenomenon for the first time. The numbers are small, only a few dozen per location, but they provide new insights into what the virus does to our bodies.
Stroke, a sudden interruption the blood supply, is a complex problem with numerous causes and presentations. It can be caused by heart problems, clogged arteries due to cholesterol, even substance abuse. Mini-strokes often don’t cause permanent damage and can resolve on their own within 24 hours. Bigger ones can be catastrophic.
The analyses suggest coronavirus patients are mostly experiencing the deadliest type of stroke. Known as large vessel occlusions or LVOs, they can obliterate large parts of the brain responsible for movement, speech and decision-making in one blow because they are in the main blood-supplying arteries.
Many researchers suspect strokes in novel coronavirus patients may be a direct consequence of blood problems that are producing clots all over some people’s bodies.
Clots that form on vessel walls fly upward so one that started in the calves might migrate to the lungs, causing a blockage called a pulmonary embolism that arrests breathing - a known cause of death in COVID-19 patients. Clots in or near the heart might lead to a heart attack, another common cause of death. Anything above that would likely go to the brain, leading to a stroke.
Robert Stevens, a critical care doctor at Johns Hopkins Hospital in Baltimore, called stroke “one of the most dramatic manifestations” of the blood clotting issues. “We’ve also taken care of patients in their 30s with stroke and covid, and this was extremely surprising,” he said.
Many doctors expressed worry that, as the New York City Fire Department was picking up four times as many people who died at home as normal during the peak of infection, that some of the dead had suffered sudden strokes. The truth may never be known because so few autopsies were conducted.
Chou said one question is whether the clotting is a due to direct attack on the blood vessels, or a “a friendly fire problem” caused by the patient’s immune response.
“In your body’s attempt to fight off the virus, does the immune response end up hurting your brain?” she asked. Chou is hoping to answer such questions through a review of stroke and other neurological complication in COVID-19 patients treated at 68 medical centers in 17 countries.
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