Large-Vessel Stroke as a Presenting Feature of Covid-19 in the Young

The new england journal of medicine


Covid-19 Cases

To rapidly communicate information on the global clinical effort against Covid-19, the Journal has initiated a series of case reports that offer important teaching points or novel findings. The case reports should be viewed as observations rather than as recommendations for evaluation or treatment. In the interest of timeliness, these reports are evaluated by in-house editors, with peer review reserved for key points as needed.

We report five cases of large-vessel stroke in patients younger than 50 years of age who pre- sented to our health system in New York City. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was diagnosed in all five patients.

Cough, headache, and chills lasting 1 week developed in a previously healthy 33-year-old woman (Patient 1) (Table 1). She then had pro- gressive dysarthria with both numbness and weakness in the left arm and left leg over a pe- riod of 28 hours. She delayed seeking emergency care because of fear of Covid-19. When she pre- sented to the hospital, the score on the National Institutes of Health Stroke Scale (NIHSS) was 19 (scores range from 0 to 42, with higher numbers indicating greater stroke severity), and computed tomography (CT) and CT angiography showed a partial infarction of the right middle cerebral artery with a partially occlusive thrombus in the right carotid artery at the cervical bifurcation. Patchy ground-glass opacities in bilateral lung apices were seen on CT angiography, and testing to detect SARS-CoV-2 was positive. Antiplatelet therapy was initiated; it was subsequently switched to anticoagulation therapy. Stroke workup with echocardiography and magnetic resonance im- aging of the head and neck did not reveal the source of the thrombus. Repeat CT angiography on hospital day 10 showed complete resolution of the thrombus, and the patient was discharged to a rehabilitation facility.

Over a 2-week period from March 23 to April 7,

n engl j med

2020, a total of five patients (including the afore- mentioned patient) who were younger than 50 years of age presented with new-onset symptoms of large-vessel ischemic stroke. All five patients tested positive for Covid-19. By comparison, every 2 weeks over the previous 12 months, our ser- vice has treated, on average, 0.73 patients younger than 50 years of age with large-vessel stroke.

On admission of the five patients, the mean NIHSS score was 17, consistent with severe large-vessel stroke. One patient had a history of stroke. Other pertinent clinical characteristics are summarized in Table 1.

A retrospective study of data from the Covid-19 outbreak in Wuhan, China, showed that the incidence of stroke among hospitalized patients with Covid-19 was approximately 5%; the youngest patient in that series was 55 years of age.1 Moreover, large-vessel stroke was re- ported in association with the 2004 SARS- CoV-1 outbreak in Singapore.2 Coagulopathy and vascular endothelial dysfunction have been proposed as complications of Covid-19.3 The association between large-vessel stroke and Covid-19 in young patients requires further in- vestigation.

Social distancing, isolation, and reluctance to present to the hospital may contribute to poor outcomes. Two patients in our series delayed calling an ambulance because they were con- cerned about going to a hospital during the pandemic. 1

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2 n engl j med

The New England Journal of Medicine
Downloaded from on May 3, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved.

Table 1. Clinical Characteristics of Five Young Patients Presenting with Large-Vessel Stroke.*

Variable Patient 1 Patient 2 Patient 3 Patient 4 Patient 5

Age—yr 33 37 39 44 49


Female Male None None

Male Hyperlipidemia, hypertension

Male Undiagnosed diabetes

Mild stroke, diabetes

Medical history and risk factors for

stroke† Medications

None None



Aspirin (81 mg), atorvastatin (80 mg)

NIHSS score‡
Onadmission 19 13 16 23 13 At24hr 17 11 4 19 11

At last follow-up 13
(on day 14)

(on day 10)

NA; intubated and sedated, with multiorgan failure

(on day 12)

7 (on day 4)

Outcome status Discharged to rehabilitation facility

Discharged home

Intensive care unit

Stroke unit

Discharged to rehabilitation facility

Timetopresentation 28 16 8 2 8 —hr

Signsandsymptoms of stroke

Hemiplegiaonleftside, facial droop, gaze pref- erence, homonymous hemianopia, dysarthria, sensory deficit

Reducedlevelofconscious- ness, dysphasia, hemiple- gia on right side, dysar- thria, sensory deficit

Reducedlevelofconsciousness, Reducedlevelofconsciousness,

Reducedlevelofconscious- ness, hemiplegia on left side, dysarthria, facial weakness

Vascular territory Imaging for diagnosis Treatmentforstroke

Right posterior cerebral artery CT, CTA, CTP, MRI

Left middle cerebral artery CT, CTA, MRI

Right middle cerebral artery CT, CTA, CTP

Covid-19 symptoms

Cough, headache, chills

No symptoms; recently exposed to family mem- ber with PCR-positive Covid-19



Fever, cough, lethargy

White-cell count — per mm3






Left middle cerebral artery
Apixaban(5mgtwicedaily) Clotretrieval,apixaban(5mg Clotretrieval,aspirin(81mg

Right internal carotid artery CT, CTA, CTP, MRI

twice daily)


Intravenoust-PA,clotretrieval, hemicraniectomy, aspirin (81 mg daily)

Clotretrieval,stent,aspirin (325 mg daily), clopido- grel (75 mg daily)

gaze preference to the right, left homonymous hemiano- pia, hemiplegia on left side, ataxia

global dysphasia, hemiplegia on right side, gaze preference


Thomas J. Oxley, M.D.
J. Mocco, M.D.
Shahram Majidi, M.D. Christopher P. Kellner, M.D. Hazem Shoirah, M.D.

I. Paul Singh, M.D.
Reade A. De Leacy, M.D. Tomoyoshi Shigematsu, M.D. Travis R. Ladner, M.D.
Kurt A. Yaeger, M.D.
Maryna Skliut, M.D.
Jesse Weinberger, M.D.
Neha S. Dangayach, M.D. Joshua B. Bederson, M.D. Stanley Tuhrim, M.D. Johanna T. Fifi, M.D.

Mount Sinai Health System New York, NY

Disclosure forms provided by the authors are available with the full text of this case at

We dedicate this case to our inspiring colleague Gary Sclar, M.D., a neurologist who died of Covid-19.

This case was published on April 28, 2020, at

1. Li Y, Wang M, Zhou Y, et al. Acute cerebrovascular disease following COVID-19: a single center, retrospective, observational study. March 13, 2020 ( ?abstract_id=3550025) (preprint).

2. Umapathi T, Kor AC, Venketasubramanian N, et al. Large artery ischaemic stroke in severe acute respiratory syndrome (SARS). J Neurol 2004;251:1227-31.
3. Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020;395:1054-62.

DOI: 10.1056/NEJMc2009787

Correspondence Copyright © 2020 Massachusetts Medical Society.



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