Category Archives: Autopsy

Coronavirus autopsies: A story of 38 brains, 87 lungs and 42 hearts

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Coronavirus autopsies: A story of 38 brains, 87 lungs and 42 ...

What we’ve learned from the dead that could help the living.

When pathologist Amy Rapkiewicz began the grim process of opening up the coronavirus dead to learn how their bodies went awry, she found damage to the lungs, kidneys and liver consistent with what doctors had reported for months.

But something was off.

Rapkiewicz, who directs autopsies at NYU Langone Health, noticed that some organs had far too many of a special cell rarely found in those places. She had never seen that before, yet it seemed vaguely familiar. She raced to her history books and — in a eureka moment — found a reference to 1960′s report on a patient with dengue fever.

In dengue, a mosquito-borne tropical disease, she learned, the virus appeared to destroy these cells, which produce platelets, leading to uncontrolled bleeding. The novel coronavirus seemed to amplify their effect, causing dangerous clotting.

She was struck by the parallels: “Covid-19 and dengue sound really different, but the cells that are involved are similar.”

Autopsies have long been a source of breakthroughs in understanding new diseases, from HIV/AIDS and Ebola to Lassa fever — and the medical community is counting on them to do the same for covid-19, the disease caused by the coronavirus. With a vaccine probably many months away in even the most optimistic scenarios, autopsies are becoming a critical source of information for research into possible treatments.

When the pandemic hit the United States in late March, many hospital systems were too overwhelmed trying to save lives to spend too much time delving into the secrets of the dead. But by late May and June, the first large batch of reports — from patients who died at a half-dozen institutions — were published in quick succession. The investigations have confirmed some of our early hunches of the disease, refuted others — and opened up new mysteries about the pathogen that has killed more than 500,000 people worldwide.

Among the most important findings, consistent across several studies, is confirmation the virus appears to attack the lungs the most ferociously. They also found the pathogen in parts of the brain, kidneys, liver, gastrointestinal tract and spleen and in the endothelial cells that line blood vessels, as some had previously suspected. Researchers also found widespread clotting in many organs.

But the brain and heart yielded surprises.

“It’s about what we are not seeing,” said Mary Fowkes, an associate professor of pathology who is part of a team at Mount Sinai Health that has performed autopsies on 67 covid-19 patients.

Given widespread reports about neurological symptoms related to the coronavirus, Fowkes said, she expected to find virus or inflammation — or both — in the brain. But there was very little. When it comes to the heart, many physicians warned for months about a cardiac complication they suspected was myocarditis, an inflammation or hardening of the heart muscle walls — but autopsy investigators were stunned that they could find no evidence of the condition.

Another unexpected finding, pathologists said, is that oxygen deprivation of the brain and the formation of blood clots may start early in the disease process. That could have major implications for how people with covid-19 are treated at home, even if they never need to be hospitalized.

The early findings come as new U.S. infections have overtaken even the catastrophic days of April, amid what some critics say is a premature easing of social distancing restrictions in some states, mainly in the South and West. A new modeling study has estimated that about 22 percent of the population — or 1.7 billion people worldwide, including 72 million in the United States — may be vulnerable to severe illness if infected with the virus. According to the analysis published this month in Lancet Global Health, about 4 percent of those people would require hospitalization — underscoring the stakes as autopsy investigators continue their hunt for clues.

Microclots in lungs

At their best, autopsies can reconstruct the natural course of the disease, but the process for a new and highly infectious disease is tedious and requires meticulous work. To protect pathologists and avoid sending virus into the air, they must use special tools to harvest organs and then dunk them in a disinfecting solution for several weeks before they are studied. They must then section each organ and collect small bits of tissue for study under different types of microscopes.

One of the first American investigations to be made public, on April 10, was out of New Orleans. The patient was a 44-year-old man who had been treated at LSU Health. Richard Vander Heide remembers cutting the lung and discovering what was probably hundreds or thousands of microclots.

“I will never forget the day,” recalled Vander Heide, who has been performing autopsies since 1994. “I said to the resident, ‘This is very unusual.’ I had never seen something like this.”

But as he moved onto the next patient and the next, Vander Heide saw the same pattern. He was so alarmed, he said, that he shared the paper online before submitting it to a journal so the information could be used immediately by doctors. The findings caused a stir at many hospitals and influenced some doctors to start giving blood thinners to all covid-19 patients. It is now common practice. The final, peer-reviewed version involving 10 patients was subsequently published in the Lancet in May.

Other lung autopsies — including those described in papers from Italy of 38 patients, a Mount Sinai Health study on 25 patients, a collaboration between Harvard Medical School and German researchers on seven and an NYU Langone Health study on seven — have reported similar findings of clotting.

Most recently, a study out this month in the Lancet’s eClinicalMedicine, found abnormal clotting in the heart, kidney and liver, as well as the lungs of seven patients, leading the authors to suggest this may be a major cause of the multiple-organ failure in covid-19 patients.

Heart cells

The next organ studied up close was the heart. One of the most frightening early reports about the coronavirus from China was that a significant percentage of hospitalized patients — up to 20 to 30 percent — appeared to have a heart problem known as myocarditis that could lead to sudden death. It involves the thickening of the muscle of the heart so that it can no longer pump efficiently.

Classic myocarditis is typically easy to identify in autopsies, pathologists say. The condition occurs when the body perceives the tissue to be foreign and attacks it. In that situation, there would be large dead zones in the heart, and the muscle cells known as myocytes would be surrounded by infection-fighting cells known as lymphocytes. But in the autopsy samples taken so far, the dead myocytes were not surrounded by lymphocytes — leaving researchers scratching their heads.

Fowkes, from Mount Sinai, and her colleague, Clare Bryce, whose work on 25 hearts has been published online but not yet peer reviewed, said they saw some “very mild” inflammation of the surface of the heart but nothing that looked like myocarditis.

NYU Langone’s Rapkiewicz, who studied seven hearts, was struck by the abundance of a rare cell called megakaryocytes in the heart. Megakaryocytes, which produce platelets that control clotting, typically exist only in the bone marrow and lungs. When she went back to the lung samples from the coronavirus patients, she discovered those cells were too plentiful there, too.

“I could not remember a case before where we saw that,” she said. “It was remarkable they were in the heart.”

Vander Heide, from LSU, who reported preliminary findings on 10 patients in April and has a more in-depth paper with more case studies under review at a journal, explained that “when you look at a covid heart, you don’t see what you’d expect.”

He said a couple of patients he performed autopsies on had gone into cardiac arrest in the hospital, but when he examined them, the primary damage was in the lungs — not the heart.

Brain grid

Of all the coronavirus’s manifestations, its impact on the brain has been among the most vexing. Patients have reported a host of neurological impairments, including reduced ability to smell or taste, altered mental status, stroke, seizures — even delirium.

An early study from China, published in the BMJ, formerly the British Medical Journal, in March, found 22 percent of the 113 patients had experienced neurological issues ranging from excessive sleepiness to coma — conditions typically grouped together as disorders of consciousness. In June, researchers in France reported that 84 percent of patients in intensive care had neurological problems, and a third were confused or disoriented at discharge. Also this month, those in the United Kingdom found that 57 of 125 coronavirus patients with a new neurological or psychiatric diagnosis had had a stroke due to a blood clot in the brain, and 39 had an altered mental state.

Based on such data and anecdotal reports, Isaac Solomon, a neuropathologist at Brigham and Women’s Hospital in Boston, set out to systematically investigate where the virus might be embedding itself in the brain. He conducted autopsies of 18 consecutive deaths, taking slices of key areas: the cerebral cortex (the gray matter responsible for information processing), thalamus (modulates sensory inputs), basal ganglia (responsible for motor control) and others. Each was divided into a three-dimensional grid. Ten sections were taken from each and studied.

He found snippets of virus in only some areas, and it was unclear whether they were dead remnants or active virus when the patient died. There were only small pockets of inflammation. But there were large swaths of damage due to oxygen deprivation. Whether the deceased were longtime intensive care patients or people who died suddenly, Solomon said, the pattern was eerily similar.

“We were very surprised,” he said.

When the brain does not get enough oxygen, individual neurons die, and that death is permanent. To a certain extent, people’s brains can compensate, but at some point, the damage is so extensive that different functions start to degrade.

On a practical level, Solomon said, if the virus is not getting into the brain in large amounts, that helps with drug development because treatment becomes trickier when it is pervasive, for instance, in some patients with West Nile or HIV. Another takeaway is that the findings underscore the importance of getting people on supplementary oxygen quickly to prevent irreversible damage.

Solomon, whose work was published as a June 12 letter in the New England Journal of Medicine, said the findings suggest the damage had been happening over a longer period of time, which makes him wonder about the virus’s effect on people who are less ill. “The big lingering question is what happens to people who survive covid,” he said. “Is there a lingering effect on the brain?”

The team from Mount Sinai Health, which took tissue findings from 20 brains, was also perplexed not to find a lot of virus or inflammation. However, the group noted in a paper that the widespread presence of tiny clots was “striking.”

“If you have one blood clot in the brain, we see that all the time. But what we’re seeing is, some patients are having multiple strokes in blood vessels that are in two or even three different territories,” Fowkes said.

Rapkiewicz said it is too early to know whether the newest batch of autopsy findings can be translated into treatment changes, but the information has opened new avenues to explore. One of her first calls after noticing the unusual platelet-producing cells was to Jeffrey Berger, a cardiac specialist at NYU who runs a National Institutes of Health-funded lab that focuses on platelets.

Berger said the autopsies suggest anti-platelet medications, in addition to blood thinners, may be helpful to stem the effects of covid-19. He has pivoted a major clinical trial looking at optimal doses of 38 to examine that question as well.

“It’s only one piece of a very big puzzle, and we have a lot more to learn,” he said. “But if we can prevent significant complications and if more patients can survive the infection, that changes everything.”

 

 

 

 

ICUs become a ‘delirium factory’ for Covid-19 patients

Posted on by • Posted in Autopsy, Brain Care, Coronavirus, Delirium, Diagnostic MRI, Diagnostic Testing, Immune System Response, Infection Control, Infectious Virus, Intensive Care (ICU), Pandemic, Physician, Silent Hypoxia, Stroke • Leave a comment

https://www.cnn.com/2020/06/01/health/brain-coronavirus-delirium-kaiser/index.html

ICUs Become A 'Delirium Factory' For COVID-19 Patients | Health ...

Doctors are fighting not only to save lives from Covid-19, but also to protect patients’ brains.

Although Covid-19 is best known for damaging the lungs, it also increases the risk of life-threatening brain injuries — from mental confusion to hallucinations, seizures, coma, stroke and paralysis. The virus may invade the brain, and it can starve the brain of oxygen by damaging the lungs. To fight the infection, the immune system sometimes overreacts, battering the brain and other organs it normally protects.
Yet the pandemic has severely limited the ability of doctors and nurses to prevent and treat neurological complications. The severity of the disease and the heightened risk of infection have forced medical teams to abandon many of the practices that help them protect patients from delirium, a common side effect of mechanical ventilators and intensive care.
And while Covid-19 increases the risk of strokes, the pandemic has made it harder to diagnose them.
When doctors suspect a stroke, they usually order a brain MRI — a sophisticated type of scan. But many patients hospitalized with Covid-19 are too sick or unstable to be wheeled across the hospital to a scanner, said Dr. Kevin Sheth, a professor of neurology and neurosurgery at the Yale School of Medicine.
Many doctors also hesitate to request MRIs for fear that patients will contaminate the scanner and infect other patients and staff members.
“Our hands are much more tied right now than before the pandemic,” said Dr. Sherry Chou, an associate professor of critical care medicine, neurology and neurosurgery at the University of Pittsburgh School of Medicine.
In many cases, doctors can’t even examine patients’ reflexes and coordination because patients are so heavily sedated.
“We may not know if they’ve had a stroke,” Sheth said.
A study from Wuhan, China — where the first Covid-19 cases were detected — found 36% of patients had neurological symptoms, including headaches, changes in consciousness, strokes and lack of muscle coordination.
“Our hands are much more tied right now than before the pandemic,” said Dr. Sherry Chou, an associate professor of critical care medicine, neurology and neurosurgery at the University of Pittsburgh School of Medicine.
In many cases, doctors can’t even examine patients’ reflexes and coordination because patients are so heavily sedated.
“We may not know if they’ve had a stroke,” Sheth said.
A smaller, French study observed such symptoms in 84% of patients, many of which persisted after people left the hospital.
Some hospitals are trying to get around these problems by using new technology to monitor and image the brain.
New York’s Northwell Health is using a mobile MRI machine for Covid patients, said Dr. Richard Temes, the health system’s director of neurocritical care. The scanner uses a low-field magnet, so it can be wheeled into hospital rooms and take pictures of the brain while patients are in bed.
Staffers at Northwell were also concerned about the infection risk from performing EEGs, tests that measure the brain’s electrical activity and help diagnose seizures, Temes said. Typically, technicians spend 30 to 40 minutes in close contact with patients in order to place electrodes around their skulls.
“Right now, we actually don’t know enough to say definitely how Covid-19 affects the brain and nervous system,” said Chou, who is leading an international study of neurological effects of the virus. “Until we can answer some of the most fundamental questions, it would be too early to speculate on treatments.”
To reduce the risk of infection, Northwell is using a headband covered in electrodes, which can be placed on patients in just a couple of minutes, he said.

The brain under attack

Answering those questions is complicated by the limited data from patient autopsies, said Lena Al-Harthi, a professor and the chair of the microbial pathogens and immunity department at Rush Medical College in Chicago.
But many neuropathologists are unwilling or unable to perform brain autopsies, Al-Harthi said.
That’s because performing autopsies on patients who died of Covid-19 carries special risks, such as the aerosolization of the virus during brain removal. Pathologists need specialized facilities and equipment to conduct an autopsy safely.
Some of the best-known symptoms of Covid-19 might be caused by the virus invading the brain, said Dr. Robert Stevens, an associate professor of anesthesiology and critical care medicine at Johns Hopkins University.
Authors of a recent study from Germany found the novel coronavirus in patients’ brains.
Research shows that the coronavirus may enter a cell through a molecular gateway known as the ACE-2 receptor. These receptors are found not only in the lung, but also other organs, including many parts of the brain.
In a recent study, Japanese researchers reported finding the novel coronavirus in the cerebrospinal fluid that surrounds the brain and spinal cord.
Some of the most surprising symptoms of Covid-19 ― the loss of the senses of smell and taste ― remain incompletely understood, but may be related to the brain, Stevens said.
A study from Europe published in May found that 87% of patients with mild or moderate Covid-19 lost their sense of smell. Patients’ loss of smell couldn’t be explained by inflammation or nasal congestion, the researchers said. Stevens said it’s possible that the coronavirus interacts with nerve pathways from the nose to the brain, potentially affecting systems involved with processing scent.
A new study in JAMA provides additional evidence that the coronavirus invades the brain. Italian researchers found abnormalities in an MRI of the brain of a Covid-19 patient who lost her sense of smell.
Many coronavirus patients also develop “silent hypoxia,” in which they are unaware that their oxygen levels have plummeted dangerously low, Stevens added.
When hypoxia occurs, regulatory centers in the brain stem — which control respiration — signal to the diaphragm and the muscles of the chest wall to work harder and faster to get more oxygen into the body and force out more carbon dioxide, Stevens said. The lack of this response in some patients with Covid-19 could indicate the brain stem is impaired.
Scientists suspect the virus is infecting the brain stem, preventing it from sending these signals, Temes said.

Collateral damage

Well-intentioned efforts to save lives can also cause serious complications.
Many doctors put patients who are on mechanical ventilators into a deep sleep to prevent them from pulling out their breathing tubes, which would kill them, said Dr. Pratik Pandharipande, chief of anesthesiology and critical care medicine at Vanderbilt University School of Medicine in Nashville, Tennessee.
Both the disease itself and the use of sedatives can cause hallucinations, delirium and memory problems, said Dr. Jaspal Singh, a pulmonologist and critical care specialist at Atrium Health in Charlotte, North Carolina.
Many sedated patients experience terrifying hallucinations, which may return in recovery as nightmares and post-traumatic stress disorder.
Research shows 70% to 75% of patients on ventilators traditionally develop delirium. Delirious patients often “don’t realize they’re in the hospital,” Singh said. “They don’t recognize their family.”
In the French study in the New England Journal of Medicine, one-third of discharged Covid-19 patients suffered from “dysexecutive syndrome,” characterized by inattention, disorientation or poorly organized movements in response to commands.
Research shows that patients who develop delirium — which can be an early sign of brain injury — are more likely to die than others. Those who survive often endure lengthy hospitalizations and are more likely to develop a long-term disability.
Under normal circumstances, hospitals would invite family members into the ICU to reassure patients and keep them grounded, said Dr. Carla Sevin, director of the ICU Recovery Center, also at Vanderbilt.
Simply allowing a family member to hold a patient’s hand can help, according to Dr. Lee Fleisher, chair of an American Society of Anesthesiologists committee on brain health. Nurses normally spend considerable time each day orienting patients by talking to them, reminding them where they are and why they’re in the hospital.
“You can decrease the need for some of these drugs just by talking to patients and providing light touch and comfort,” Fleisher said.
These and certain innovative practices — such as helping patients to move around and get off a ventilator as soon as possible — can reduce the rate of delirium to 50%.
Hospitals have banned visitors, however, to avoid spreading the virus. That leaves Covid-19 patients to suffer alone, even though it’s well known that isolation increases the risk of delirium, Fleisher said.
Although many hospitals offer patients tablets or smartphones to allow them to videoconference with family, these devices provide limited comfort and companionship.
Doctors are also positioning patients with Covid-19 on their stomachs, rather than their backs, because a prone position seems to help clear the lungs and let patients breathe more comfortably.
But a prone position also can be uncomfortable, so that patients need more medication, Pandharipande said.
All of these factors make coronavirus patients extremely vulnerable to delirium. In a recent article in Critical Care, researchers said the intensive care unit has become a “delirium factory.”
“The way we’re having to care for patients right now is probably contributing to more mortality and bad outcomes than the virus itself,” said Dr. Sharon Inouye, a geriatrician at Harvard Medical School and Hebrew SeniorLife, a long-term care facility in Boston. “A lot of the things we’d like to do are just very difficult.”

Young and middle-aged people, barely sick with covid-19, are dying from strokes

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Young people with coronavirus are dying from strokes - The ...

Doctors sound alarm about patients in their 30s and 40s left debilitated or dead. Some didn’t even know they were infected.

Thomas Oxley wasn’t even on call the day he received the page to come to Mount Sinai Beth Israel Hospital in Manhattan. There weren’t enough doctors to treat all the emergency stroke patients, and he was needed in the operating room.

The patient’s chart appeared unremarkable at first glance. He took no medications and had no history of chronic conditions. He had been feeling fine, hanging out at home during the lockdown like the rest of the country, when suddenly, he had trouble talking and moving the right side of his body. Imaging showed a large blockage on the left side of his head.

Oxley gasped when he got to the patient’s age and covid-19 status: 44, positive.

The man was among several recent stroke patients in their 30s to 40s who were all infected with the coronavirus. The median age for that type of severe stroke is 74.

As Oxley, an interventional neurologist, began the procedure to remove the clot, he observed something he had never seen before. On the monitors, the brain typically shows up as a tangle of black squiggles — “like a can of spaghetti,” he said — that provide a map of blood vessels. A clot shows up as a blank spot. As he used a needlelike device to pull out the clot, he saw new clots forming in real-time around it.

“This is crazy,” he remembers telling his boss.

Stroke surge

Reports of strokes in the young and middle-aged — not just at Mount Sinai, but also in many other hospitals in communities hit hard by the novel coronavirus — are the latest twist in our evolving understanding of its connected disease, covid-19. Even as the virus has infected nearly 2.8 million people worldwide and killed about 195,000 as of Friday, its biological mechanisms continue to elude top scientific minds. Once thought to be a pathogen that primarily attacks the lungs, it has turned out to be a much more formidable foe — impacting nearly every major organ system in the body.

Until recently, there was little hard data on strokes and covid-19.

There was one report out of Wuhan, China, that showed that some hospitalized patients had experienced strokes, with many being seriously ill and elderly. But the linkage was considered more of “a clinical hunch by a lot of really smart people,” said Sherry H-Y Chou, a University of Pittsburgh Medical Center neurologist and critical care doctor.

Now for the first time, three large U.S. medical centers are preparing to publish data on the stroke phenomenon. The numbers are small, only a few dozen per location, but they provide new insights into what the virus does to our bodies.

A stroke, which is a sudden interruption the blood supply, is a complex problem with numerous causes and presentations. It can be caused by heart problems, clogged arteries due to cholesterol, even substance abuse. Mini-strokes often don’t cause permanent damage and can resolve on their own within 24 hours. But bigger ones can be catastrophic.

The analyses suggest coronavirus patients are mostly experiencing the deadliest type of stroke. Known as large vessel occlusions, or LVOs, they can obliterate large parts of the brain responsible for movement, speech and decision-making in one blow because they are in the main blood-supplying arteries.

Many researchers suspect strokes in covid-19 patients may be a direct consequence of blood problems that are producing clots all over some people’s bodies.

Clots that form on vessel walls fly upward. One that started in the calves might migrate to the lungs, causing a blockage called a pulmonary embolism that arrests breathing — a known cause of death in covid-19 patients. Clots in or near the heart might lead to a heart attack, another common cause of death. Anything above that would probably go to the brain, leading to a stroke.

Robert Stevens, a critical care doctor at Johns Hopkins Hospital in Baltimore, called strokes “one of the most dramatic manifestations” of the blood-clotting issues. “We’ve also taken care of patients in their 30s with stroke and covid, and this was extremely surprising,” he said.

Many doctors expressed worry that as the New York City Fire Department was picking up four times as many people who died at home as normal during the peak of infection that some of the dead had suffered sudden strokes. The truth may never be known because few autopsies were conducted.

Chou said one question is whether the clotting is because of a direct attack on the blood vessels, or a “a friendly-fire problem” caused by the patient’s immune response.

“In your body’s attempt to fight off the virus, does the immune response end up hurting your brain?” she asked. Chou is hoping to answer such questions through a review of strokes and other neurological complications in thousands of covid-19 patients treated at 68 medical centers in 17 countries.

Thomas Jefferson University Hospitals, which operates 14 medical centers in Philadelphia, and NYU Langone Health in New York City, found that 12 of their patients treated for large blood blockages in their brains during a three-week period had the virus. Forty percent were under 50, and they had few or no risk factors. Their paper is under review by a medical journal, said Pascal Jabbour, a neurosurgeon at Thomas Jefferson.

Jabbour and his co-author Eytan Raz, an assistant professor of neuroradiology at NYU Langone, said that strokes in covid-19 patients challenge conventional thinking. “We are used to thinking of 60 as a young patient when it comes to large vessel occlusions,” Raz said of the deadliest strokes. “We have never seen so many in their 50s, 40s and late 30s.”

Raz wondered whether they are seeing more young patients because they are more resistant than the elderly to the respiratory distress caused by covid-19: “So they survive the lung side, and in time develop other issues.”

Jabbour said many cases he has treated have unusual characteristics. Brain clots usually appear in the arteries, which carry blood away from the heart. But in covid-19 patients, he is also seeing them in the veins, which carry blood in the opposite direction and are trickier to treat. Some patients are also developing more than one large clot in their heads, which is highly unusual.

“We’ll be treating a blood vessel and it will go fine, but then the patient will have a major stroke” because of a clot in another part of the brain, he said.

The 33-year-old

At Mount Sinai, the largest medical system in New York City, physician-researcher J Mocco said the number of patients coming in with large blood blockages in their brains doubled during the three weeks of the covid-19 surge to more than 32, even as the number of other emergencies fell. More than half of were covid-19 positive.

It isn’t just the number of patients that was unusual. The first wave of the pandemic has hit the elderly and those with heart disease, diabetes, obesity or other preexisting conditions disproportionately. The covid-19 patients treated for stroke at Mount Sinai were younger and mostly without risk factors.

On average, the covid-19 stroke patients were 15 years younger than stroke patients without the virus.

“These are people among the least likely statistically to have a stroke,” Mocco said.

Mocco, who has spent his career studying strokes and how to treat them, said he was “completely shocked” by the analysis. He noted the link between covid-19 and stroke “is one of the clearest and most profound correlations I’ve come across.”

“This is much too powerful of a signal to be chance or happenstance,” he said.

In a letter to be published in the New England Journal of Medicine next week, the Mount Sinai team details five case studies of young patients who had strokes at home from March 23 to April 7. They make for difficult reading: The victims’ ages are 33, 37, 39, 44 and 49, and they were all home when they began to experience sudden symptoms, including slurred speech, confusion, drooping on one side of the face and a dead feeling in one arm.

One died, two are still hospitalized, one was released to rehabilitation, and one was released home to the care of his brother. Only one of the five, a 33-year-old woman, is able to speak.

Oxley, the interventional neurologist, said one striking aspect of the cases is how long many waited before seeking emergency care.

The 33-year-old woman was previously healthy but had a cough and headache for about a week. Over the course of 28 hours, she noticed her speech was slurred and that she was going numb and weak on her left side but, the researchers wrote, “delayed seeking emergency care due to fear of the covid-19 outbreak.”

It turned out she was already infected.

By the time she arrived at the hospital, a CT scan showed she had two clots in her brain and patchy “ground glass” in her lungs — the opacity in CT scans that is a hallmark of covid-19 infection. She was given two different types of therapy to try to break up the clots and by Day 10, she was well enough to be discharged.

Oxley said the most important thing for people to understand is that large strokes are very treatable. Doctors are often able to reopen blocked blood vessels through techniques such as pulling out clots or inserting stents. But it has to be done quickly, ideally within six hours, but no longer than 24 hours: “The message we are trying to get out is if you have symptoms of stroke, you need to call the ambulance urgently. ”

As for the 44-year-old man Oxley was treating, doctors were able to remove the large clot that day in late March, but the patient is still struggling. As of this week, a little over a month after he arrived in the emergency room, he is still hospitalized.