COVID-19 and Stroke: Expert Q&A

UChicago Medicine experts Dr. Shyam Prabhakaran and Advanced Practice Nurse Cedric McKoy discuss the neurological effects of COVID-19, including stroke-like symptoms.

And today on At the Forefront Live, what should stroke and neurology patients do to stay safe and healthy during the golden COVID-19 pandemic? Does COVID-19 affect the brain or cause neurological conditions? Why is COVID-19 causing stroke or blood clots in young and middle aged people? Stroke expert, Dr. Shyam Prabhakaran, and associate director of the comprehensive stroke center, Cedric McKoy, will discuss this the neurologic effects of COVID-19. That's coming up right now on At the Forefront Live.

And we want to remind our viewers that today's program is not designed to take the place of a visit with your physician. Let's have each one of our guests introduce themselves and tell us a little bit about what happens here at UChicago Medicine under your watch. And Dr. Prabhakaran, we'll start with you and just have you tell us a little bit about yourself.

Sure. So I'm Shyam Prabhakaran, chair of Neurology at University of Chicago. So it's obviously been a privilege being here for the past year and a half or so. And now with the pandemic upon us, we obviously had to undertake a lot of changes, many of which have been very, very rapidly implemented. And it's been, again, a tremendous privilege to work with so many here who really rolled up their sleeves, gotten to work, and still done what I think is so incredibly important so that we can preserve patient care in this incredibly difficult time.

And Cedric, tell us a little bit about yourself and what you do here at UChicago Medicine.

Yeah. Well, thanks for having me on this show. I'm Cedric McKoy. I've had the privilege of working here for almost 15 years now. I'm the associate director of the comprehensive stroke program here at the University of Chicago Medicine. I see a lot of the patients that are discharged that have strokes and are discharged to our clinics. And I follow up with them throughout the course of their recovery as well as I am one of the guest hosts on the Community Help Focus Hour for WVON here through the university, as well as just getting out there in the community, and talking to churches, community centers, health fairs. And just really trying to help spread the word that stroke can be prevented.

And Cedric, I know all of your work here on the Hyde Park area, South Side of Chicago. You did some public service announcements, in fact, with us just a couple of weeks ago which were fantastic, and I think very helpful to the community, and just a great idea. So thanks for doing all that work. I think that's really important.

Let's jump right into the questions. I do want to remind our viewers that we will take your questions live on the air. So if you do have questions for our experts, just type them in the comments section on Facebook. We'll get to as many as possible over the next half hour.

First question we do have. We've heard a lot about kind of some connections potentially between stroke patients and COVID-19. Are people who've survived a stroke at a higher risk of contracting COVID-19? And if so, is the damage more profound for those folks? I don't know who wants to start with this one-- maybe Dr. Prabhakaran?

I could start and I'll hand over to Cedric, as well. So you know, what we know is that obviously, the disease is spread by respiratory pathways or droplets in the air. And so strictly speaking, there should be not an increased risk for stroke patients. We know that once you have the coronavirus, if you are older and have risk factors, including having had a stroke, you may be more likely to have more severe symptoms of COVID-19.

So I think the answer to that question really is there shouldn't be an increased risk to you unless you're immunocompromised in some way. But if you're not exposed to COVID-19 patients and/or other ways of contracting it, you should not be necessarily at increased risk. Cedric, have you thought about this in terms of how you've delivered that message to people?

Yeah. And I agree with that. It's more along the lines of as Dr. Prabhakaran just said, is those with the vascular risk factors. People that have the hypertension or have diabetes, or if you've had a stroke, the risk of complication may be higher with COVID-19. But just in general, you're at risk, just like everybody else. And we'll talk a little bit later about how to prevent yourself from just getting the virus in the first place.

Before we get too far into the show and too far into our questions from our viewers, I do want to talk about something that I think is very important, and I want to stress this throughout the program. We were discussing this in the moments leading up to the program-- and Cedric, we talked a little bit about this a couple of weeks ago when you were doing your public service announcements-- and we've actually seen cases where people aren't coming to the medical center people who have very serious significant health issues, because they're afraid to come here. And I want to dispel that fear, if we can.

And Cedric, I don't know if you can kind of start us off with that, because you've shared your thoughts on that with me earlier. So can you kind of start us in that area? This is a safe place.

Yeah, and that's the message we really want to get out there-- that this is a safe space. We're doing everything we can to make sure that the emergency room, the units are safe for you to come. And every minute that our patients do not come to the hospital, we're losing brain cells. Every minute, you lose millions of brain cells. And so I understand that there is a fear that if I come to the hospital, I may get COVID. I want to dispel that right now. We are doing everything. And we're a very safe place to be is here at the University of Chicago Medicine.

Dr. Prabhakaran?

Yeah, I think in fact, in many ways, the hospital, our hospital is probably one of the safest place you can be. And in the setting of an acute stroke or symptoms of stroke while waiting at home is just the wrong thing to do. And unfortunately, we've seen that trend play out nationally, locally. And it's been really concerning. Our numbers of stroke visits to the hospital, calls to 911 for stroke have dropped. It was precipitous in the first few weeks-- and obviously, a lot of reasons for that. People's concerns around whether they should stay at home or seek attention.

And while it's come back a little bit, it hasn't come back to where it was before. So we really do believe that a percentage of the population is staying home, even when they may be experiencing stroke symptoms. So that's really something that we want to discourage. That we have pathways to ensure their safety and their care. And in fact, we've delivered high level advanced stroke care to patients that have come in through the emergency room and still have been able to deliver that despite COVID-19.

That's a very sobering thought and it's a scary thought that people may be avoiding seeking treatment. But I am curious with you gentlemen as far as the video visits I know we've launched with patients, and I know we've had quite a bit of success with this. Can you describe your experiences with this? And Dr. Prabhakaran, I think you've had some. Cedric, I don't know if you have or not, but if you two can talk about that a little bit, that would be great.

Yeah, it's been a tremendous, I think, innovation for us. It's allowed us to connect with patients, which is first and foremost, what we wanted to be able to do. It's allowed us to be more nimble and allow us to provide care to people who can't come in or are at high risk and don't want the even minimal exposure in clinic.

And so we have been able to use it. And to date, I think the Medical Center has done over 30,000 virtual visits, video being the most common. And it's been quite successful. I've actually been very pleased with it. I think you can interact as a neurologist with the patient. You can do some basic examination, which is very helpful. You can also just see how your patient is doing and talk to them like we're doing today. And I think there's something to be said about seeing someone face to face as opposed to a phone call.

So I think it's been a nice tool to have during this pandemic. And I think it will continue to some degree as we continue to ramp up coming back into the clinic in person.

Cedric, I'm curious, do stroke survivors exhibit different symptoms with COVID-19? Have you all seen anything like that?

You know, besides being at risk for more severe cold symptoms, there doesn't really appear to be any difference. Stroke survivors may present with worsening of their previous strokes deficits when they get a fever or an infection. For example, a patient who has recovered well from a stroke may experience re-emergence of their deficit as if they were having another stroke again. Those symptoms are temporary and not necessarily signs of new strokes.

OK, we are starting to get questions from our viewers, so as always, I promise to try to do as many of those as possible. So let's jump right into them. And here's an interesting one-- and I've seen this myself. I'm seeing news reports of healthy and fit young men contracting COVID, and oddly developing blood clots, and having strokes. Do we know why this is happening?

This is a really sort of an interesting question. It's a sort of emerging health risk associated with COVID-19. We've seen the case reports. They're small numbers to date, so I don't think we can say with certainty that we know why this is happening. There are several theories.

As an infection, COVID-19 can trigger inflammation in one's body. And there's long standing literature papers and studies that have shown that inflammation in one's body when it's up regulated can trigger clots and plaque instability. So those are areas of the body that direct blood flow to the brain may be affected by clots. So that's one possibility. That it's just a part of having an infection in your body.

A second more concerning thought is that it's affecting the blood vessel lining-- so-called the endothelium. And it's inflaming it, causing it to get, again, affected by other cells that then produce a clot to stabilize it. And that has then led to stroke.

And then some evidence already exists that it changes your coagulation profile, your clotting profile. And that's been shown in some of the Chinese series as well as out of Europe that in late stage or severe forms of COVID-19, you are at risk of clotting in various organs, and the brain is one of them. And so all any of those could be the reason. We're obviously very concerned and want to investigate further when it's happening in mild COVID patients, and they're presenting with stroke as their initial presentation of COVID-19. That's what we're really wanting to get a handle on.

So follow up question from one of our viewers. Have we encountered neuro complications other than stroke. CSF infection was one thing that was mentioned.

There's been a few cases of that. We haven't here, to my knowledge. There may have been some that I'm unaware of. But in the literature, there's been a few case reports of direct infection of the virus into the brain causing meningitis, inflammation of the surface of the brain, or encephalitis, which is infection of the brain. And so those are, I think, accumulating. It seems to be rare to date. But we suspect that that is a rare complication of COVID-19.

Cedric, this one just came in from a viewer. If someone thinks you're having a stroke, does it matter what hospital they go to or is it just important get care ASAP? I think I know the answer to that one. And a follow up to that too is, what should people be aware of? What should they look for if they think they're having a stroke?

Well, I'll take the first one that you mentioned there. So it doesn't matter, not right away. What we want is for people to not hesitate, call 9-1-1, and get to the hospital as soon as they can. This doesn't mean wait for your relative to come give you a ride. It doesn't wait to for someone to get home from grocery shopping. You have to call 9-1-1 and get there immediately.

And the things that we're looking for, we here the University of Chicago, we use an acronym BEFAST and the B represents balance. If there is a sudden loss of balance or equilibrium. The E represents vision loss. So if you had sudden vision loss or blurred vision, that could be a sign of stroke. F represents facial asymmetry. So if your patient all of a sudden has of facial weakness or a facial droop on one side and not the other. A represents arm, where the arm can be weak or it just tends to fall or just sudden weakness in it.

And speech. If the patient has either heard speech or just difficulty getting words out or they're speaking to you and their speech seems nonsensical-- it's not making sense. Those are things that ultimately to the T in BEFAST and that's the time to call 9-1-1. So if you see any of these signs or these symptoms, we don't want to delay. We want to get our patients in emergency room right away, because there's medication and treatment that we can provide that can help decrease the damage that is done.

And why is time so critical on this?

I can answer it, but I want to echo something in a minute too, that Cedric mentioned. So time is important, because brain cells, as Cedric said earlier, die at a very rapid rate with the onset of blockage of blood flow to the tissue. So every minute that passes, you are reducing the chances of that tissue surviving. And if that's the case, your outcome, your ability to recover and do the things you used to do-- walk, talk, think-- are then going to be worse.

So the sooner we can intervene to stop the blood clot from progressing, and open up the artery and in ischemic stroke is the best way we to improve functional outcomes, reduce disability, and death. So that's why time matters.

To something that Cedric mentioned a moment ago, I would say that cities like ours, Chicago, many other areas around the country, have adopted really evidence-based triage protocols so that when you call 9-1-1, you are taken to the nearest qualified certified stroke center. And in addition, if you have severe stroke symptoms when the paramedics evaluate you, you are taken to the nearest advance stroke center a comprehensive stroke center.

So that is really important so that you're not trying to figure out where to go or drive-- they do it for you. The EMS system is there to help you get to the right hospital at the right time. And that's critical to why 9-1-1 is the right thing to do.

Now a question from a viewer, and I think this is a kind of a follow up to what both of you have said is, how safe is the emergency room?

Yeah, this is something that I feel very strongly about, because how well our health system has figured out how to manage and COVID-19 in terms of PPE, that term everyone has been hearing how do we use protective equipment so that we don't spread or contract the virus, that's all been implemented at a very high level with lots of, I think, emphasis on safety for patients and providers.

And an ED like ours, they've created hot and cold zones. They try to separate patients who are coming in with influenza-like or COVID symptoms versus those that are coming in with other routine symptoms. So geographically, to separate patients in the emergency room. So all of those things are already in place. So I feel that coming to the emergency room is not any different than going to the grocery store or to a pharmacy, which is also something that we feel people should be able to do safely.

So another question from a viewer. Apparently, the talk about video visits is triggering a little bit of a few questions from people. And one of them is, do I need a referral to schedule a video visit?

Yeah, you don't need a referral. You can make an appointment with self-referral. Some will be referred to see a neurologist. Others will self-refer. We are obviously able to see patients who don't have a referral.

That's great. One to one question that we received that I thought was kind of interesting-- and Cedric, I'll throw this one out there for you first. If you do think or if you think a loved one could potentially be experiencing a stroke, obviously, the first thing to do is call 9-1-1. But are there any other steps that you can take it at home while you're waiting for help?

Yeah, that's a really good question. The first thing, obviously, like you said, call 9-1-1. And the second one is just try to keep the patient calm. The last thing you want to do is stand the patient up. You don't want to get the patient moving around. Because the majority of our patients when they come to the ER, one of the things we're going to do is run away and flat. And we want to promote as much blood flow to the brain as possible. And so what I would do is try to basically keep your patient calm, wait for the ambulance to get there, and don't have them up moving around or straining or anything that's going to just make them more agitated.

Go ahead.

The only other thing I would say is not what you can do for the patient is make sure you have information about that person if you have access to it. What medicines they might be on, their medical history or medical condition. Those are all really valuable for the paramedics. And if you know when the symptoms started, that's really critical, and passing that along to the paramedics is really important.

So here's another question that is an interesting one. Is there anything we can do to prevent stroke?

Yeah. One of the things that we talk about, especially in our clinics, is trying to prevent you from having the next stroke. And the fact that we throw out there is that 80% of strokes can be prevented. So let me say that one more time-- is that 80% of strokes can be prevented. And it's a lot about the risk factors that lead you to having strokes.

So one of the things we think about is staying active. Exercising is one of them. And when we talk about exercising, it doesn't mean getting out there and running a marathon or doing 80 laps around your block. It's just getting it out so that you're moving at a rate that your heart rate is going. So that's one of them.

We ask that you eat better. We ask that you if you have high blood pressure, get it under control. If you have high cholesterol, get it under control. And a lot of those things can be corrected with exercise and diet. And if you smoke, stop smoking. It does nothing good for you. And it can only do things to damage your body your vessels. We hear about all the things that it does to your lungs, but it's damaging the arteries in your brain, as well.

So just being active, exercising, eating better. If you have diabetes, keep it under control. Take your medications. And I think that's the last big one-- is be compliant with your medications. You're prescribed them for a reason. And if you're having any complication with your medications, reach out to us, talk to us, and we can make the changes that are necessary. Don't make it on your own.

Yeah. All too often, we see that people stop their medications and then whamo, they come in with a. Stroke and it was a completely preventable event. And it's very tragic when that happens. But what Cedric said is so true-- that if we could do this at a high level, 80% of all strokes could be prevented.

Another question from a viewer, and sometimes, these are very specific, but good questions. Can you please detail any COVID-related risks for patients with a history of carotid or vertebral dissections?

Good question. Again, to date, we don't think that there is any specific risks for that population. Again, there are some prior papers and studies that have shown that infections, especially respiratory infections like COVID-19, do increase the chances of having a dissection-- so having another dissection or a or first dissection. But I don't think there's any data to date that COVID-19 will necessarily do that to a person who's had a previous stable dissection, has recovered well, and doing just fine.

Another question from a viewer. For follow up care, can I do a video visit?



Absolutely. One of things-- I'm sorry-- about the video visits is number one, thank you. Thank you for inviting us into your homes. And one of the things I also want to say is thank you for being so appreciative. One of the things, my experience when talking to my patients during video visits or even just the phone calls is they feel that they're not forgotten about. And it shows that we're still there for them, and they're so appreciative.

And so I want to say thank you. So yes, we definitely can do it. If you're worried about getting out of your house, just know that we're here for you. We're here to answer your questions. We're here to see you. We're here to refill your prescriptions. We're here for you.

You know, it's interesting-- Dr. Miller said this year the day and I thought it was a fantastic point. She said, really, the video visits in her mind were like making house calls. And she said, to your point, Cedric, it's the patient's welcoming you all into their home so they can kind of get a little snapshot of their home life. Oftentimes, family members will then join them for the visits and for their appointments, which is tremendously helpful, because sometimes family members notice things or remind patients of things that they may not be remembering or thinking of when they're talking to their physician or their representative from the hospital.

And it was just really neat what she said. And I thought it was it sounded incredibly valuable. Plus, the other added benefit-- you don't have to wait in the waiting room.



Go ahead, I'm sorry.

I had a patient, I was lucky her niece was a nurse. And so it was great having just an extra set of hands there so help me with the neurological exam and test certain things. And family members-- you made a really good point-- family members have been amazing. Holding the camera, holding the phones, getting the medications, reading the list for us. It's been extremely helpful.

Another couple of interesting questions coming in from patients-- from our viewers-- not necessarily patients. Are patients with diabetes at risk or at higher risk for stroke?

Yes. So that's been true before COVID-19 and it still remains true. Diabetes is a risk factor for atherosclerosis, which is hardening of the arteries throughout your body. And the brain is no different. And so patients who have diabetes do have an increased risk of stroke.

And Cedric, you mentioned just a moment ago, which I thought was good advice, You know you really have to watch your diet if you're a stroke patient. That's critical to your success in the days ahead. And diabetes, obviously, is a big, big part of that.

Another interesting question-- kind of an observation and question at the same time. I think mental health and stressors have increased with COVID. How much does this impact the risk of a stroke?

Yeah, this is a complex topic. There is a lot of evidence that stress plays a role in one's health. In cardiovascular health, that's very strongly linked. In cerebrovascular brain health, it's been also recently linked. And the ways it could work is you could have higher levels of stress hormones, which could raise your blood pressure, for instance. It could change your inflammatory profile in your body and cause the inflammation to build up during stress.

And so I think there's a lot of features about stress and depression that lead to increased risk of stroke. So I would say the answer probably is yes. It's not a clear cut direct path, but it's a risk factor.

Yeah, I think mental health tests such an impact in general on our overall health, and people tend to discount it, which is a shame. Gentlemen, we're out of time. That half hour went very quickly and your answers were really good. Thank you for being on the program with me today. I think you had some great answers.

That's all the time we have for the program. We have many more At the Forefront Lives coming up. Please remember to check out our Facebook page for our schedule of programs that are coming up in the future. Also, if you want more information about UChicago Medicine and COVID-19, take a look at our website, If you need an appointment, you can us a call at 888-824-0200. And remember, you can schedule your video visit by going to the website. Thanks again for being with us today and hope have a great weekend.

Shyam Prabhakaran, MD

Shyam Prabhakaran, MD, MS

Shyam Prabhakaran, MD, is the Chair of the Department of Neurology at UChicago Medicine. He is an internationally recognized leader in vascular neurology and stroke research and treatment, and has led projects focused on uncovering the underlying causes of recurrent strokes, improving stroke care, and optimizing patient outcomes and recovery.

See Dr. Prabhakaran's bio

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