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COVID-19's excess stroke risk appeared to be largely related to large vessel strokes, an observational study showed.

Among stroke code patients at one large health system in New York City during the pandemic surge there, 38.3% had COVID-19 (126 of 329 seen from March 16 to April 30, 2020).

Large vessel occlusion (LVO) as a cause of the stroke was 2.4-fold more common with COVID-19 than without it after adjustment for race and ethnicity (P=0.011), Shingo Kihira, MD, of Icahn School of Medicine at Mount Sinai in New York City, and colleagues .

Of the stroke cases, 31.7% of those in COVID-19 patients were LVOs compared with 15.3% in those without COVID-19 (P=0.001). But there was not much difference between groups for small vessel occlusions (SVOs), at 15.9% and 13.8%, respectively (P=0.632).

"Physicians should lower their threshold of suspicion for large vessel stroke in patients with COVID-19 who present with acute neurologic symptoms," the researchers concluded, recommending prompt workup.

"Health care providers in the emergency department and inpatient areas should be cognizant of this association and not delay activating a stroke code," they wrote.

Notably, the most common location for the LVO strokes was middle cerebral artery segments M1 and M2 (62.0% [44 of 71 cases]), which are potentially .

"This association may aid neurointerventionalists assessing the presence and location of an LVO if they are aware of this elevated risk in the COVID-19 population," Kihira's group pointed out.

Also, for LVOs seen during the COVID-19 pandemic, it might be worth taking extra personal protective equipment and infection control precautions for patients who have not been tested for SARS-CoV-2 infection or are waiting for results, they added.

All patients with LVO are already currently treated as possibly having COVID until infection is ruled out, commented Larry B. Goldstein, MD, of the University of Kentucky in Lexington, although only one at his center has yet tested positive "despite unchanged high volumes of patients with LVO having thrombectomy since the beginning of the pandemic."

The American Heart Association/American Stroke Association have urged physicians to follow standard guidelines for stroke care during the pandemic when possible in terms of patient selection for therapy, treatment times, and monitoring after recanalization.

However, its temporary guidance noted that "in the setting of the pandemic full compliance has become a goal, not an expectation" and pointed to things that may help in the face of shortages in staff, personal protective equipment, and medical equipment.

One notable difference in care for LVO patients found to be SARS-CoV-2 positive is that they should have a more extensive evaluation for abnormal clotting, Goldstein said.

Strokes and coagulopathy have been noted with COVID-19, although the researchers said they couldn't determine causality for the link between LVO and the virus with their retrospective observational study.

Why LVO might be more common than SVO with COVID-19 isn't clear, but it's an area of active investigation, Kihira told MedPage Today.

The retrospective study included all 329 patients for whom a code for stroke was activated (53% men, mean age 67) out of the total 9,814 patients (5,862 with COVID-19) during the study period at the Mount Sinai system's six hospitals. Among these patients, 35.3% had acute ischemic stroke confirmed with imaging; 21.6% (71) had LVO; and 14.6% (48) had SVO.

The only stroke-related predictor of COVID-19-positive status was Hispanic ethnicity. This group accounted for 38.1% of patients with COVID-19 versus 20.7% of those without (P=0.001).

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