Why is the COVID-19 causing strokes in young people?

The new coronavirus appears to be causing sudden strokes in adults in their 30s and 40s who are not otherwise terribly ill, causing alarm among medical experts.

COVID-19 coronavirus attacks the lungs resulting in severe inflammation as they fill with fluid, ultimately reducing their ability to fulfil their intended purpose: transferring oxygen from the lungs to the bloodstream via red blood cells.

We are also learning more and more about the devastating effects of this virus as it attacks other organs including the kidney, heart and the brain. However, the virus’s ultimate target that may inflict the most damage—via either a direct effect of the virus, hypoxia, (low oxygen), secondary inflammation or disseminated intravascular coagulation (DIC)—are blood vessels, leading to the formation of blood clots, or excessive bleeding (DIC) in some cases, a consequence of consumption of clotting factors.

But the virus does not seem to be attacking just any size blood vessel in young adults, but larger blood vessels that feed important parts the brain that is critical to movement, thinking, and breathing. (These include large blood vessels such as the middle cerebral artery [MCA] or anterior cerebral artery [ACA] that supply large and critical areas the brain). When blockages in larger blood vessels known as “large vessel occlusions” or LVOs as they are referred to develop, the effects can be permanent or life-changing, if not diagnosed and treated immediately.

Over a two-week period, Mount Sinai doctors reported five patients who suffered large vessel strokes in patients under the age of 50, according to the letter they published in the New England Journal of Medicine (NEJM).

All five patients tested positive for COVID-19 but had very mild to no symptoms. “That creates a big alarm,” said Dr J Mocco, director of the Cerebrovascular Center at Mount Sinai and one of the letter’s authors. “Our spider-sense goes up to say that there’s something not right here.” Out of the five patients, one died, one is still hospitalized, one was discharged from the hospital and two are in rehabilitation. The youngest patient was 33 and only one patient had a history of stroke.

Dr. Shazam Hussain, director of the Cerebrovascular Center at the Cleveland Clinic, said he was surprised when he saw the reports coming from New York. The normal stroke population is typically older patients with high blood pressure or cholesterol problems.

According to the Mayo Clinic, a stroke occurs when blood supply to the brain is interrupted or reduced, preventing oxygenation and causing brain cells to die. Both Mocco and Hussain believe the coronavirus is causing blood clots that block or narrow the blood vessels.

“People were very focused on the fever and shortness of breath. There’s a lot of parts of the body that is affected by the virus as well.” Hussain said.

A study from the Netherlands published in early April looked at 184 patients who were checked into the intensive care unit for COVID-19 pneumonia. Nearly a third of those patients had suffered from thrombotic complications, more commonly known as blood clotting.

Recently, Broadway star Nick Cordera suffered a thrombotic complication related to COVID-19, requiring the amputation of one of his legs, highlighting the significant clotting risks associated with the virus. After he had spent nearly three weeks in an intensive care unit being treated for Covid-19, doctors were forced to amputate his right leg.

While the risks of clotting related to COVID-19 are now apparent, many patients who experience stroke-like symptoms including weakness, difficulty speaking, dizziness or numbness have been reluctant to seek care in the emergency department—for fear of exposure to the virus itself. Yet this delay to seek care could be disastrous, with life-altering consequences (paralysis, loss ability to think or speak) including death. In Oxley’s series, two of the five patients delayed calling 911 for assistance.

Although doctors can’t confirm why the coronavirus seems to induce this, some experts have an educated guess. Mocco said research suggests the virus attaches itself to a host cell that not only exist in the respiratory tract, but also in blood vessels. This means the virus can go anywhere inside the body.

“A big part of the way this disease hurts people is in blood clots whether it’s in the lungs or the kidney or the heart or the brain,” he said. While coronavirus hotspots, such as New York, are seeing a surge in strokes, Hussain said most of the country is seeing a decline. He believes fear of contracting COVID-19 is what’s keeping people away from the emergency rooms, even in the event of an emergency. Mocco said New York has experienced that fear as well. Anecdotally, he has patients who have had symptoms of a stroke but delayed calling the hospital because they said they’re afraid of catching COVID-19.

“We’re combating a population that has become petrified to go to the hospital,” Mocco said.

The Mayo Clinic says symptoms of a stroke can include:

  • Trouble speaking and understanding what others are saying

  • Paralysis or numbness of the face, arm or leg

  • Problems seeing in one or both eyes

  • Sudden severe headache accompanied by dizziness or vomiting

  • Trouble walking

Both Hussain and Mocco urge people to go to the hospital if they believe they're experiencing stroke symptoms. “The hospital is the best place for you to come,” Hussain said. 

The Best Protection

Thankfully, COVID-19 isn’t a death sentence for most people who become infected, but the symptoms described above are not pleasant. Until a vaccine is developed, the best defence is avoiding infection altogether through frequent, thorough hand washing, and physical distancing as recommended by health authorities.

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