Neurologists have reported a series of five cases of large-vessel stroke in adults under 50 years of age with COVID-19.

The New York cases, published as Correspondence in the NEJM, included patients who delayed acting on symptoms because they were fearful of going to hospital during the pandemic.

The time to presentation was 28 hours in one patient, a 33-year-old female with left-side hemiplegia, facial droop and gaze preference, and 16 hours in another patient, a 37-year-old male with reduced level of consciousness, dysphasia and right-side hemiplegia.

The mean NIHSS on admission was 17 – consistent with severe large-vessel stroke.

One patient, who presented within two hours, received intravenous t-PA and hemicraniectomy. Four of the five patients were managed with clot retrieval and all were variously treated with DOACs, aspirin or clopidogrel.

Only one patient was discharged home, with the others discharged to rehabilitation facilities, stroke units or ICU.

As previously reported in the limbic and reiterated in the case report, there are widespread concerns that social distancing, isolation, and reluctance to present to the hospital may contribute to poor outcomes in such stroke patients.

Two of the patients had no symptoms of COVID-19 with the others reporting combinations of cough, headache, chills, lethargy and fever.

The clinicians reporting the cases said having five relatively young patients presenting with new-onset symptoms of large vessel ischaemic stroke over a 2-week period was unusual.

“By comparison, every 2 weeks over the previous 12 months, our service has treated, on average, 0.73 patients younger than 50 years of age with large-vessel stroke.”

They noted that the incidence of stroke in hospitalised COVID-19 patients was 5% in one study from Wuhan but the youngest patient in that series was 55 years.

“Moreover, large-vessel stroke was reported in association with the 2004 SARS-CoV-1 outbreak in Singapore. Coagulopathy and vascular endothelial dysfunction have been proposed as complications of Covid-19. The association between large-vessel stroke and Covid-19 in young patients requires further investigation.”