Acute Ischemic Stroke During the Convalescent Phase of Asymptomatic COVID-2019 Infection in Men

This case series reports the risk factors, incidence rate, and features of acute ischemic stroke experienced by a group of male patients aged 50 years or younger in the convalescent stage of COVID-19. Importance 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. Objective To assess AIS experienced by adults 50 years or younger in the convalescent phase of asymptomatic COVID-19 infection. Design, Setting, and Participants 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. Main Outcomes and Measures 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. Results 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). Conclusions and Relevance 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. Question Is the risk of acute ischemic stroke (AIS) elevated in patients in the convalescent phase of an asymptomatic COVID-19 infection? Findings In this case series of 18 male adults aged 50 years or younger who presented with AIS during the convalescent phase of an asymptomatic COVID-19 infection confirmed by a positive SARS-CoV-2 serological (antibodies) test result, the median onset of stroke was 2 months after the diagnosis of COVID-19. Meaning Results of this study suggest a persistent increased risk of AIS in individuals with asymptomatic COVID-19 months after serological diagnosis, warranting stroke units to be on alert and use SARS-CoV-2 serological testing.

Automated summary

This case series highlights the increased risk of acute ischemic stroke in male patients aged 50 years or younger during the convalescent phase of asymptomatic COVID-19 infection. The study suggests the importance of monitoring stroke risk and conducting serological testing in these patients to prevent potential complications.