COVID-19 with early neurological and cardiac thromboembolic phenomena—timeline of incidence and clinical features

Background

At our tertiary care public hospital, we saw COVID-19 presenting with thromboembolic phenomena, indicating a possible early thrombo-inflammatory pathology.

Objectives

We documented patients with cardiac and neurological thromboembolic phenomena as a primary presentation of COVID-19, and compared a subset of COVID associated strokes against COVID-19 patients without thrombotic manifestations.

Methods

We included all COVID-Stroke and COVID-ACS (COVID-19, with ischemic arterial stroke/Acute Coronary Syndrome presenting prior to/simultaneous with/within 72 hours of systemic/respiratory COVID manifestations) admitted from April to November 2020. In the nested case control analysis, we used unpaired T-test and chi-square test to study differences between COVID-Strokes (case group) and non-thrombotic COVID controls.

Results and Conclusions

We noted 68 strokes and 122 ACS associated with COVID-19. ACS peaked in May-June, while stroke admissions peaked later in September-October, possibly because severe strokes may have expired at home during the lockdown.

In the case-control analysis, cases (n=43; 12F:31M; mean age 51.5 years) had significantly higher D-Dimer values than controls (n=50; 9F:41M; mean age 51.6 years). Mortality was significantly higher in cases (51.2% vs. 26.0%; p = 0.018). We noted 7.5 times higher mortality in cases versus controls even among patients needing minimal oxygen support. Imaging in 37 patients showed both anterior and posterior circulation territories affected in seven, with almost half of Carotid territory strokes being large hemispherical strokes. Additionally, CT/MRI angiography in 28 strokes showed large vessel occlusions in 19 patients. Death in cases thus probably occurred before progression to intense respiratory support, due to severe central nervous system insult.

Binary logistic regression analysis showed respiratory support intensity to be the sole independent predictor of mortality among cases. Respiratory distress could have been due to COVID-19 lung infection or aspiration pneumonia resulting from obtunded sensorium. In controls, mortality was predicted by increasing age, female sex, and respiratory support intensity.