Abstract

Background: SARS-CoV-2 has been known to cause hypercoagulable states in patients. This hypercoagulable state is closely associated with severe COVID-19 disease. The pathophysiology of the disease has been elucidated. SARS-CoV-2’s pathogenicity is linked to its spike proteins, which bind to ACE2 receptors on vascular endothelial cells. ACE2 receptors can be found in the lungs and brain. Hypercoagulability and an ability to invade brain tissues can lead to increased risk of stroke. Preliminary searches show that COVID-19 and coinciding stroke are more common in older populations and in populations that have stroke comorbidities. We determine that not much information is known about risk of stroke in younger adults with COVID-19. We summarize the risk factors and outcomes for stroke in COVID-19 cases available data.

Methods: We use a systematic approach following PRISMA: Transparent Reporting of Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. We search three databases: ‘MEDLINE’, ‘CINAHL Complete’, and ‘Nursing & Allied Health Collection: Comprehensive’. Search parameters include peer-reviewed journal articles, English Language, and data gathered in the range of January 1, 2020 to Feb 1, 2021. The search term thread was: “(covid-19 or coronavirus or 2019-ncov or sars-cov-2 or cov- 19) AND (stroke or cerebrovascular accident or cva) AND risk NOT (pregnancy or pregnant or prenatal or antenatal or perinatal or maternal).” In order to further narrow down papers, the age of the patient is limited to less than 65 years of age and the paper must explicitly discuss risk of stroke in COVID-19 positive patients. Six independent reviewers each evaluated resulting papers to determine paper eligibility and collaborate on data collection and tabulation.

Results: Overall, COVID-19 infection was associated with increased numbers of both ischemic and hemorrhagic strokes, as well as cerebral venous sinus thrombosis. There was both an increased incidence in younger male adults and in Hispanic and African American populations. Patients presenting with stroke in COVID-19 had statistically significant elevations in D-dimer, ferritin, CRP and eGFR when compared to sample stroke populations from the year prior. 

Discussion: The number of subjects drastically varied between the articles used. It appears that most COVID-19 positive patients that experience ischemic strokes are male, but further research should be done with more subjects. Similar conclusions can be drawn when race and ethnicity are investigated. COVID-19 positive African American and Hispanic patients appear to present with ischemic strokes more than any other race or ethnicity. Some articles suggest that other hypercoagulable states, combined with COVID-19, prompt the development of strokes. The limitations in our research are the number of databases, the inconsistency between the number of patients included in different studies and the evolving nature of the COVID-19 Pandemic.