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Young stroke risk and COVID-19

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Staff at Mount Sinai Hospital have reported a sevenfold increase in incidence of sudden stroke in patients in their 30s and 40s over the last fortnight.

Neurosurgeon Thomas Oxley told the press that he and his colleagues had seen some younger coronavirus patients with mild or no symptoms experiencing large-vessel strokes.

The findings will be published this week in the New England Journal of Medicine.

Speaking to CNN, Oxley said: “Our report shows a sevenfold increase in incidence of sudden stroke in young patients during the past two weeks. Most of these patients have no past medical history and were at home with either mild symptoms (or in two cases, no symptoms) of COVID-19.”

However, given that the hospital is dealing with a miniscule sample size compared to the overall number of coronavirus patients, he cautioned: “It’s still too early to know what the real numbers are going to be” in terms of younger COVID-19 patients having strokes.

A retrospective observational study of COVID-19 cases in Wuhan, China, found further evidence of links between the virus and brain conditions.

In a case series of 214 patients with coronavirus, neurologic symptoms were seen in 36.4 per cent of patients.

These were more common in patients with severe infection (45.5 per cent) according to their respiratory status, which included acute cerebrovascular events, impaired consciousness and muscle injury.

The study, published by JAMA Network, concluded: “[The virus] may infect nervous system and skeletal muscle as well as the respiratory tract. In those with severe infection, neurologic involvement is greater, which includes acute cerebrovascular diseases, impaired consciousness, and skeletal muscle injury.

“Their clinical conditions may worsen, and patients may die sooner. This study may offer important new clinical information on COVID-19 that would help clinicians raise awareness of its involvement of neurologic manifestations. It is especially meaningful to learn that for those with severe COVID-19, rapid clinical deterioration or worsening could be associated with a neurologic event such as stroke, which would contribute to its high mortality rate.

“Moreover, during the epidemic period of COVID-19, when seeing patients with these neurologic manifestations, clinicians should consider SARS-CoV-2 infection as a differential diagnosis to avoid delayed diagnosis or misdiagnosis and prevention of transmission.”

Clearly much more evidence of the neurological threat of COVID-19 is needed before conclusions that affect government responses to the virus are drawn.

One very real threat, however, is the danger of stroke patients avoiding hospital and GP visits for fear of exposure to the new coronavirus.

This week the government will launch a new campaign to encourage people seriously ill with non-coronavirus conditions to seek medical help.

Patients affected by stroke are among those being targeted by the campaign amid dramatically declining numbers of people going to accident and emergency (A&E) departments.

A&E visits for non-coronavirus conditions have reportedly dropped by half, prompting NHS England to respond.

NHS England will underline the fact that vital services are still available for serious non coronavirus conditions like heart attacks and strokes.

Quoted in the Guardian, Toby Lewis, chief executive of the Sandwell and West Midlands NHS Trust, said since the beginning of the month around 300 people with acute and severe conditions had refused to be taken to hospital.

He said: “These are people with severe and acute conditions where an ambulance has been sent but they have refused to go to the hospital and a clinician has walked away very concerned about that person.

“In general attendances at A&E departments and at GPs is very low among those people and they are generally declining care because of fear of being in a hospital setting. People are also not wanting to bother the NHS because they believe that medical professionals are busy on other things – both of these things are understandable but this is the wrong way to go and we want people to know the NHS is open for business. You are not alone.”

At the start of the month, the Stroke Association warned that thousands of people could be at risk of severe disability, or even stroke-related death, if they didn’t respond to stroke symptoms during the crisis.

Dr Deb Lowe, NHS national clinical director for stroke and consultant stroke physician at Wirral University Teaching Hospital, said: “We’re beginning to see some quite striking reductions in the number of people coming into hospital with the symptoms of stroke.

“It appears that people aren’t seeking emergency help or going to hospital when they suspect a stroke, possibly due to fear of the virus or not wanting to be a burden on the NHS.

“Stroke is a medical emergency and it’s essential that you call 999 straight away if you suspect you or someone around you is having a stroke. Our hospitals are equipped and ready to treat stroke patients. Given the emergency changes being made across the NHS, it’s possible that a patient’s treatment or journey might be a bit different while we put measures in place to deal with coronavirus safely.”

At that time figures from Public Health England showed attendance to emergency departments in England had dropped by over a third (34.5 per cent) on the same week last year, from 136,669 to 89,58.

Public Health Scotland figures report attendance to emergency departments dropped by over a third (40.1 per cent) on the same week last year.

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