Category: COVID-19 Complications, Co-infections, and Clinical Outcomes

Poster Session: COVID-19 Complications, Co-infections, and Clinical Outcomes

404 - The occurrence of stroke in COVID-19

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Presenting Author(s)

Anna Wanahita

President/Medical Director
Regional Brain Institute
Tulsa, Oklahoma
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.

Co-Author(s)

DM

Daniel M. Musher

Distinguished Service Professor of Medicine, Professor of Molecular Virology and Microbiology
Baylor College of Medicine, Michael E DeBakey VA Medical Center
Houston, Texas
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.

Background: Patient with COVID-19 may exhibit a wide array of neurologic manifestations, including stroke; in some cases, stroke is the presenting or predominant manifestation. The frequency of stroke in COVID-19 has varied greatly in previous reports, probably reflecting the intensity with which neurologic abnormalities have been sought. The great majority of stroke have been thought to be ischemic.

Methods: Review of data, case reports, and case series

Results: See table 1 for a summary of reported data on neurologic manifestations of COVID-19. When MRI has been done, the great majority of strokes have been shown to be ischemic. COVID-19 causes a generalized hypercoagulable state, and arterial thromboses have been recognized in other organs, as well, involving pulmonary, mesenteric and coronary arteries. Coronavirus infection causes an intense release of cytokines with widespread activation of the coagulation cascade. In addition, SARS-CoV-2 attaches to ACE 2 receptors on endothelial surfaces via the S (spike) protein and invades causing a localized inflammatory response, with a resulting increase in local thrombotic activity. Antiphospholipid antibodies are sometimes present. New data suggest possible role of alpha-defensin level in creation and prevention of disintegration of blood clots. To date, reports of neurologic disease are based on case series, so there is no way, at present, to calculate the frequency of neurologic complications of COVID-19. A systematic, prospective study focusing on neurologic examination supplemented by MRI in hospitalized patients would answer the question of the incidence of this complication, but logistical problems including patients’ need for ICU care and concern for contagion resulting from sending patents out of the ICU for procedures mitigate against the likelihood of such a study being done.

Conclusion: We hypothesize that: (1) stroke occurs in COVID-19 more frequently than is recognized; (2) a hypercoagulable state with inflammation at the site of local invasion of vascular endothelial cells by SARS-CoV-2, perhaps with a role for antiphospolipid antibodies all contribute to the pathogenesis of stroke; and (3) more liberal use of anticoagulation in COVID-19 cases should be considered.