Abstract
Acute ischemic stroke (AIS) is a known neurological complication in patients with respiratory symptoms of COVID-19 infection. However, AIS has not been described as a late sequelae in patients without respiratory symptoms of COVID-19. To assess AIS experienced by adults 50 years or younger in the convalescent phase of asymptomatic COVID-19 infection. This case series prospectively identified consecutive male patients who received care for AIS from public health hospitals in Singapore between May 21, 2020, and October 14, 2020. All of these patients had laboratory-confirmed asymptomatic COVID-19 infection based on a positive SARS-CoV-2 serological (antibodies) test result. These patients were individuals from South Asian countries (India and Bangladesh) who were working in Singapore and living in dormitories. The total number of COVID-19 cases (54 485) in the worker dormitory population was the population at risk. Patients with ongoing respiratory symptoms or positive SARS-CoV-2 serological test results confirmed through reverse transcriptase-polymerase chain reaction nasopharyngeal swabs were excluded. Clinical course, imaging, and laboratory findings were retrieved from the electronic medical records of each participating hospital. The incidence rate of AIS in the case series was compared with that of a historical age-, sex-, and ethnicity-matched national cohort. A total of 18 male patients, with a median (range) age of 41 (35-50) years and South Asian ethnicity, were included. The median (range) time from a positive serological test result to AIS was 54.5 (0-130) days. The median (range) National Institutes of Health Stroke Scale score was 5 (1-25). Ten patients (56%) presented with a large vessel occlusion, of whom 6 patients underwent intravenous thrombolysis and/or endovascular therapy. Only 3 patients (17%) had a possible cardiac source of embolus. The estimated annual incidence rate of AIS was 82.6 cases per 100 000 people in this study compared with 38.2 cases per 100 000 people in the historical age-, sex-, and ethnicity-matched cohort (rate ratio, 2.16; 95% CI, 1.36-3.48; P < .001). This case series suggests that the risk for AIS is higher in adults 50 years or younger during the convalescent period of a COVID-19 infection without respiratory symptoms. Acute ischemic stroke could be part of the next wave of complications of COVID-19, and stroke units should be on alert and use serological testing, especially in younger patients or in the absence of traditional risk factors.
Highlights
This case series suggests that the risk for Acute ischemic stroke (AIS) is higher in adults 50 years or younger during the convalescent period of a COVID-19 infection without respiratory symptoms
Acute ischemic stroke could be part of the wave of complications of COVID-19, and stroke units should be on alert and use serological testing, especially in younger patients or in the absence of traditional risk factors
Seventeen patients were asymptomatic for acute respiratory illness but were diagnosed with COVID-19 before their AIS
Summary
As the COVID-19 pandemic progresses, many asymptomatic or mildly symptomatic cases of COVID-19 infection have been identified, either by contact tracing[1,2,3] or through surveillance programs, in various risk-stratified population groups.[4,5,6] At the same time, there have been reports of symptoms emerging or persisting long after the resolution of the original acute infection, which have been described as long-haul symptoms of COVID-19.7Acute ischemic stroke (AIS) is a known neurological complication in patients with acute COVID-19 infection.[8,9] The mechanism of AIS that is associated with COVID-19 has been postulated to be secondary to an associated coagulopathy[10] either by antiphospholipid antibodies[11] or endotheliopathy.[12]. In the city-state of Singapore, COVID-19 has been confirmed in 57 889 individuals as of October 14, 2020.14 Most of the infections have been localized to clusters of workers from South Asian countries (India and Bangladesh) who were living in dormitories,[14,15] accounting for 94% (54 485 cases) of all COVID-19 cases in Singapore This clustering was primarily associated with the proximity of the inhabitants in residential complexes. Active surveillance of close contacts has identified many cases of COVID-19 through serological tests. In this case series, we assessed AIS that occurred in a series of men aged 50 years or younger in the convalescent phase of asymptomatic COVID-19 infection
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