Released: 6/29/2020 9:46:34 AM
By Scott Scanlon
June 29, 2020
Buffalo neurosurgeons established new protocols at the Stroke Care Center at Gates Vascular Institute after several patients showed up feverish since March and tested positive with Covid-19 after emergency treatment.
“These patients tend to be a little bit younger than our typical population, 50s and 60s, not 80s, 90s,” and mostly female, said Dr. Elad Levy, center co-director.
The novel coronavirus tends to attack the lungs, heart, kidneys or gastrointestinal system in most of its victims, causing multiple organ failure in the most severe cases.
Doctors also have learned since the global pandemic began that Covid-19 can spawn blood clots that travel through the bloodstream and wreak damage, including in the brain.
Doctors in China and Italy who conducted small studies early in the pandemic reported that 2% to 5% of their Covid-19 patients suffered a stroke. Last month, in the largest study so far of its kind, doctors affiliated with the New York University Grossman School of Medicine reported that 32 stroke patients, about 1%, were among 3,556 people also treated for Covid-19 at affiliated hospitals in New York City and Long Island from March 15 to April 19.
Several of those patients were in their 30s and 40s but most of them also had stroke risk factors, including high blood pressure and diabetes, study leaders told the medical journal Stroke. As a group, those with stroke and the novel coronavirus tended to have more severe symptoms and were seven times more likely to die.
These patients generally have had serious respiratory symptoms and suffered a large-vessel stroke when they arrive at Gates and elsewhere, Levy said.
“Social distancing, isolation, and reluctance to present to the hospital may contribute to poor outcomes,” doctors in New York City wrote in late April in the New England Journal of Medicine. “Two patients in our series delayed calling an ambulance because they were concerned about going to a hospital during the pandemic.”
The connection between stroke and Covid-19 remains unclear as doctors try to better understand the new coronavirus disease process.
“It may be the effects of your body having a severe flu, dehydration, lack of mobility, or it is something inherent to Covid-19? I don't think we know that right now. But there appears to be some association with increased risk of blood clotting with severe symptoms of Covid-19,” said Levy, professor and chairman of neurosurgery and radiology at the University at Buffalo Jacobs School of Medicine and Biomedical Sciences and president of UBMD Neurosurgery.
Gates specialists have treated fewer than a dozen patients rushed into surgery who tested positive for Covid-19 as they recovered. None of them died but some suffered considerable brain damage, he said.
Neurosurgeons can treat strokes with clot-busting drugs or by feathering specialized devices into blood vessels in the brain and removing obstructions.
Buffalo neurosurgeons have taken the latter route with Covid-related patients.
“Both options are on the table,” Levy said. “It depends on the size and location of the clot. The bigger it is, the more likely you’re going to have to go in and take it out.”
In either case, he said, “the faster we can get the brain tissue replenished with oxygen and blood, the more likely patients are going to have a better functional outcome.”
Stroke is the fifth leading cause of death in the United States after heart disease, cancer, accidents and chronic lower respiratory disease.
Levy urged those of any age to understand the stroke symptoms. They include a new onset of weakness or numbness in the face or limbs, difficulty with vision or speech, and an unexpected change in the level of consciousness.
“The acronym F-A-S-T is an easy way to remember what to look for and what to do if you suspect someone has had a stroke,” said Dr. Richard Vienne, Univera Healthcare vice president and chief medical officer.
F = Face: Ask the person to smile. Does one side of the face droop?
A = Arm: Ask the person to raise both arms. Is one arm drifting down or appearing weak?
S = Speech: Ask the person to repeat a simple phrase. Is speech slurred or confused?
T = Time: Time lost is brain lost. Call 911 or go to an emergency room if you detect any signs of stroke.
Levy and Dr. L. Nelson Hopkins, who spearheaded development of the Gates Vascular Institute, worked with colleagues at the University of Michigan and others in the national Endovascular Neurosurgery Research Group to publish protocols being used across the country to treat stroke emergencies in Covid-suspected patients while preventing transmission to other patients and health care workers.
Dedicated operating space and equipment are available, the treatment team is kept to a minimum and the highest level of personal protective equipment is used. Patients skip temporary recovery rooms and go directly to rooms away from other patients where they will stay while recovering.
Lessons learned will help doctors across specialties better understand the novel coronavirus while treatments remain unproven and contagion still troubling.
Doctors conducting Covid-19 treatment studies, including in Buffalo, have started hospitalized patients suspected to have the new disease with twice the original dosage of blood-thinning medication they first used because of how they saw the most serious cases worsen. Clot-busting drugs might even become a treatment option for some of the sickest patients.
“I think all these discussions right now are on the table,” Levy said. “The more time that goes by, the more patients we're treating and the more data we're collecting, the better our understanding is going to be of this disease process.”
Meanwhile, people can better protect themselves from Covid-19 and other debilitating conditions if they physically distance from others and wear facial masks when in public, eat right, and get plenty of exercise and sleep. It’s also important to take prescribed medications as directed, Levy and other doctors in the region stressed.
Obesity, smoking and underlying health conditions, as well as a sedentary lifestyle, Levy said, “enhance every single risk factor for stroke.”