To the Editor:
We would like to thank the authors1 for their interest in our study, “Outcomes and Spectrum of Major Neurovascular Events Among COVID-19 Patients: A 3-Center Experience,”2 as well as the editor for inviting us to respond.
The authors1 remind clinicians that the most common neurological manifestations of coronavirus disease-2019 (COVID-19) tend to be mild and self-limited (eg, anosmia, headaches, dizziness), and that cerebrovascular events are rare. The goal of our research2 was to focus on and bring awareness to the spectrum of potentially devastating neurovascular events that are likely to be seen in practice by neurosurgeons, neurologists, and neurointensivists who care for COVID-19 patients.
With regard to COVID-19 patients with ischemic stroke, particularly those with large-vessel occlusions (LVOs), we are in agreement with the author's statement that stroke mostly occurs in patients who are older or who have conventional risk factors for stroke (eg, hypertension, smoking)—indeed, these accounted for 13/15 of our LVO cases. However, we remind the clinician that a unique feature of COVID-19 is that, although rare, LVOs may occur in young, otherwise healthy patients, as reported in our series and previously.3 Furthermore, we wanted to highlight our clinical observation that COVID-19 patients with LVO had a higher case fatality rate than expected (56% in our series), even if treated with a mechanical thrombectomy. Nearly identical outcomes were found in a regional study from Paris, where the figure was 60%.4
The authors provide a succinct review of the postulated mechanisms by which the neurotropic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) affects, and infects, the nervous system, both directly and indirectly. Among the likely multiple mechanisms of injury, we have strong clinical suspicion for a coagulopathic, proinflammatory state that leads to vascular endothelial dysfunction and resulting cerebrovascular sequelae. There may be disruption of previously stable lesions, similar to those described in our study or the case of a destabilized internal carotid artery plaque cited by the authors.5
Now 1 yr into the COVID-19 pandemic, we hope that larger, population-based data, as well as in Vitro studies, will further elucidate the mechanisms by which COVID-19 affects the neurovasculature, and allow us to more effectively treat this patient population.
Funding
This study did not receive any funding or financial support.
Disclosures
The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.
Contributor Information
Blake E S Taylor, Department of Neurosurgery Rutgers New Jersey Medical School, Newark, New Jersey, USA; Department of Neurosurgery Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA; Rutgers Neurosurgery Health Outcomes Policy, and Economics (H.O.P.E.) Center, New Brunswick, New Jersey, USA.
Priyank Khandelwal, Department of Neurosurgery Rutgers New Jersey Medical School, Newark, New Jersey, USA; Rutgers Neurosurgery Health Outcomes Policy, and Economics (H.O.P.E.) Center, New Brunswick, New Jersey, USA.
Michael S Rallo, Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA.
Purvee Patel, Department of Neurosurgery Rutgers New Jersey Medical School, Newark, New Jersey, USA; Department of Neurosurgery Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA; Rutgers Neurosurgery Health Outcomes Policy, and Economics (H.O.P.E.) Center, New Brunswick, New Jersey, USA.
Lindsey Smith, Rutgers Neurosurgery Health Outcomes Policy, and Economics (H.O.P.E.) Center, New Brunswick, New Jersey, USA.
Hai Sun, Department of Neurosurgery Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA; Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA.
Anil Nanda, Department of Neurosurgery Rutgers New Jersey Medical School, Newark, New Jersey, USA; Department of Neurosurgery Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA; Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA; Department of Neurology Division of Stroke and Neurocritical Care Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA; Rutgers Neurosurgery Health Outcomes Policy, and Economics (H.O.P.E.) Center, New Brunswick, New Jersey, USA.
Amit Singla, Department of Neurosurgery Rutgers New Jersey Medical School, Newark, New Jersey, USA; Rutgers Neurosurgery Health Outcomes Policy, and Economics (H.O.P.E.) Center, New Brunswick, New Jersey, USA.
Sudipta Roychowdhury, Department of Neurosurgery Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA; Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA; Rutgers Neurosurgery Health Outcomes Policy, and Economics (H.O.P.E.) Center, New Brunswick, New Jersey, USA.
Roger C Cheng, Department of Neurology Division of Stroke and Neurocritical Care Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA.
Kiwon Lee, Department of Neurology Division of Stroke and Neurocritical Care Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA.
Gaurav Gupta, Department of Neurosurgery Rutgers New Jersey Medical School, Newark, New Jersey, USA; Department of Neurosurgery Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA; Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA; Rutgers Neurosurgery Health Outcomes Policy, and Economics (H.O.P.E.) Center, New Brunswick, New Jersey, USA.
Stephen A Johnson, Department of Neurosurgery Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA; Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA; Rutgers Neurosurgery Health Outcomes Policy, and Economics (H.O.P.E.) Center, New Brunswick, New Jersey, USA.
REFERENCES
- 1. Llamas-Nieves A, Lozada-Martínez I, Torres-Llinás D, Moscote-Salazar L, Escorcia-Del Ciaro J. Letter: outcomes and spectrum of major neurovascular events among COVID-19 patients: a 3-center experience. Neurosurgery Open. 2021. doi: 10.1093/neuopn/okab007. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Taylor B, Khandelwal P, Rallo Met al. Outcomes and spectrum of major neurovascular events among COVID-19 patients: a 3-center experience. Neurosurg Open. 2020;1(3). doi: 10.1093/neuopn/okaa008. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Oxley TJ, Mocco J, Majidi Set al. Large-vessel stroke as a presenting feature of COVID-19 in the young. N Engl J Med. 2020;382(20):e60. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. Escalard S, Maier B, Redjem Het al. Treatment of acute ischemic stroke due to large vessel occlusion with COVID-19: experience from Paris. Stroke. 2020;51:2540-2543. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5. Goldberg MF, Goldberg MF, Cerejo Ret al. Cerebrovascular disease in COVID-19. AJNR Am J Neuroradiol. 2020;41:1170-1172. [DOI] [PMC free article] [PubMed] [Google Scholar]