COVID-19-Related Acute Ischemic Stroke in Young Adults: What Is the Optimal Antithrombotic Regimen for Secondary Prevention?

Acute ischemic stroke (AIS) has been reported as a serious neurological complication after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. It was shown that occurrence of AIS in coronavirus disease -19 (COVID-19) was correlated with the severity of respiratory illness [1, 2]. Despite many reports of AIS and COVID-19 in older patients with established cardiovascular risk factors, there are several reports of AIS in young patients without any significant past medical history or cardiovascular risk factors [2, 3]. Such reports suggest hypercoagulability and/or endothelial dysfunction within the arteries of the COVID-19 patients. Furthermore, it has been shown that inflammation and hypercoagulable processes contribute to developing both venous and arterial thromboembolism following infection with SARS-CoV-2 [1, 4-7]. These potential mechanisms as well as the clinical and epidemiological differences in patients with COVID-19 compared to non-COVID-19 patients, raise the question of the optimal secondary stroke prevention antithrombotic regimen in young COVID-19-related AIS patients. To address such an important question, there is need for randomized clinical trials and high-quality prospective studies with reasonable duration of follow-up. However, given lack of such studies to date, we aimed to review the limited current literature to investigate the optimal antithrombotic regimen for secondary prevention strategy in this group of patients. We carried out a review in PubMed to find all articles evaluating secondary prevention of AIS following COVID-19 from December 1, 2019 to June 30, 2020. The keywords: “COVID-19” or “SARS-CoV-2 “or “coronavirus” and “stroke” or” cerebrovascular” and “treatment “or “secondary prevention” were used in different combinations. All pertinent case reports, case series and original research articles in English language were included. The literature search revealed 430 articles. After eliminating the duplications and non-relevant articles, seven articles were included in the study. We identified only the patients with COVID-19-related AIS who did not have any pertinent past medical history or cardiovascular risk factor and were 50 years old or younger. Data for secondary prevention antithrombotic regimen in 16 patients with above-mentioned inclusion criteria were available. Mean age of the patients was 39.5 years (range: 31 50). Anticoagulation was administered for 10 (62.5%), single antiplatelet for three (18.7%) and dual antiplatelet for three (18.7%) patients (Table 1) [2-4, 8-11]. Despite the fact that several studies have shown the possibility of hypercoagulable state in the young COVID-19 patients, so far, no consensus on the secondary prevention antithrombotic regimen exists. Furthermore, the optimal secondary prevention measures in this particular group of patients might differ from the usual secondary prevention strategies in AIS patients with established cardiovascular risk factors [12]. Based on the findings of this review, it appears that there is a tendency toward utilizing anticoagulation rather than antiplatelets for secondary stroke prevention in this cohort of patients [2-4]. However, the efficacy of such approach for secondary prevention remains unclear given absence of long term follow ups and limited duration of the COVID-19. Furthermore, risk of intracranial hemorrhage (ICH) following administration of anticoagulation in the acute phase of AIS should be weighed against its potential benefit in these patients. To better identify the optimal antithrombotic regimen for secondary prevention in COVID-19-related AIS, it is imporManuscript submitted July 16, 2020, accepted July 23, 2020 Published online August 2, 2020