After five days, the worst of the COVID-19 symptoms — the headache, the fever, the body ache — had ended. But it was only the start of the medical crisis for Troy L. Randle, a New Jersey cardiologist who is recovering from a devastating coronavirus consequence that doctors are only now learning about.
In mid-April, shortly after he was declared safe to go back to work treating patients in the Virtua Health System, Randle’s headache returned, more vicious than the last time.
“It felt like a sharp pain in the back of my head, and then I felt this intense pressure in the front,” the Mullica Hill man said. “It felt like a vise.”
Randle, 49, tried to wait it out at home. But after days of relentless pain, his wife, Melody, a nurse practitioner, broke into tears begging him to go to the hospital, where he had a CT scan and an MRI.
“I was totally blown away when they said I had a stroke,” Randle said.
Though it’s still fairly unusual, more people Randle’s age and younger appear to have suffered strokes as a result of infection with the coronavirus. The connections between the virus and strokes are just beginning to be understood, but seem related to blood clots that form at a shockingly high rate in certain patients. Clots cause strokes when they block blood flow to the brain, and in COVID-19 patients, these strokes may be especially dangerous and hard to treat.
“Those clots are stubborn clots — they are difficult, stubborn clots to be removed,” said Pascal M. Jabbour, a Thomas Jefferson University Hospital physician and head of the neurovascular division who recently reported on coronavirus-positive stroke patients he treated. “The outcome was worse.”
The article he coauthored, now under review by a medical journal, describes 12 stroke patients treated at Jefferson hospitals and NYU Langone Health in New York City between March 20 and April 10, who were positive for COVID-19. Some of the patients had no virus symptoms before their strokes. They were also much younger — 40% were under age 50 — than most stroke patients, who typically are in their 70s, Jabbour said.
Overall, Jabbour said, 35% of stroke patients at the two health systems were COVID-positive, an unusually high rate of infection.
His observations are similar to those reported in the New England Journal of Medicine by doctors at Mount Sinai Hospital in New York City, who treated five stroke victims, all under age 50. All tested positive for COVID-19.
“Even patients diagnosed with COVID but not sick with COVID, we need to keep an eye on those patients,” Jabbour said. “Those patients are at risk of stroke, and they need to be watched very carefully.”
Data from China suggest up to 3% of COVID-positive people could suffer a stroke, said Erol Veznedaroglu, director of the Global Neurosciences Institute, based at Crozer-Chester Medical Center in Upland. In the United States, more than a million people have tested positive for COVID-19, according to the Centers for Disease Control and Prevention, meaning at least 30,000 people could be at risk of stroke.
The type of stroke Randle had could have been fatal, said Veznedaroglu, who did not treat the cardiologist. His vertebral artery had clotted, cutting off blood to the cerebellum, the part of the brain that controls balance and motor functions.
“It’s basically our life center to the brain,” Veznedaroglu said of the artery that was clogged.
At the outset of the pandemic, Randle thought that risking infection was part of his job, though he was worried about passing on the virus to his wife and six children.
“I got into medicine because I wanted to take care of people,” he said. “That drive to take care of others and be there for others overrode any fear I had of catching the virus.”
He doesn’t think he contracted COVID-19 from a patient. He shared a small reading room with another doctor who tested positive, and believes their proximity led to his illness.
The initial sickness was difficult, he said, and the weakness that accompanied it was overwhelming. But the headaches were treatable with over-the-counter painkillers and the coughing was never too terrible.
When he returned to work, his colleagues joked that he no longer needed the protective gear medical workers wear when treating COVID-19 patients due the antibodies people who recover from the illness are believed to have.
“I don’t think you need all that,” one said. “You’ve already been exposed."
He briefly experienced weakness in his right arm, he said, that he passed off as a lingering symptom of his illness. The headaches that followed, though, were brutal and inexplicable. He contemplated the possibility that he would not recover.
“I was lying in bed not knowing what was going on, not feeling well, and I didn’t want to break down in front of my family,” he said. "So I grabbed a mask and I went for a walk in the neighborhood, and I prayed and I cried, because I knew something was wrong with me.”
His wife’s pleading finally got him to seek help. “Potentially she saved my life, kind of insisting on that,” he said.
He believes the clot that caused his stroke likely formed during his initial illness.
The clots are the subject of intense study and some mystery. They seem be related to inflammation and an extreme immune system response, called a cytokine storm, that some COVID-19 patients experience. At issue, said Veznedaroglu, may be ACE2, a protein receptor present in the endothelium, a thin layer of tissue that lines blood vessels and the interior of the lungs. This protein appears to be the coronavirus’ entry point into the body, through which it passes its genetic material into cells and begins replicating itself.
The virus’ links to ACE2 receptors may cause the endothelium, typically smooth to allow easy blood flow, to become inflamed. Clots form under normal circumstances to repair damage, but the response itself appears to be damaging, with clotting severe enough to inhibit blood flow throughout the body.
“Some other patients ended up dying from further strokes,” Jabbour said. “They kept on clogging.”
Clots can also cause heart attacks or pulmonary embolisms, which have also been associated with COVID-related causes of death, the Washington Post has reported.
Some people appear to have ACE2 (Angiotensin-converting enzyme 2) receptors that are more accessible to the coronavirus, which could explain why some experience significant clotting and others don’t, Veznedaroglu said.
Doctors treated Randle’s stroke with blood thinners and a cholesterol-lowering medication. The headaches subsided, and the stroke’s damage appears to be limited to some dizziness when he moves his head quickly.
“When you think of the disability rate and mortality rate of people who have strokes," Randle said, "I’m tremendously blessed that I’m still functional.”
It is unclear whether people should be taking blood thinners as a preventative measure if they have mild symptoms of the virus.
“I think it’s still too early to give recommendations,” Jabbour said. “Blood thinners have some risks.”
Anyone with stroke-like symptoms — such as sudden numbness in the face or arms, blurred vision, slurred speech, or severe headache — should seek treatment at a hospital immediately, doctors said.
“If you have any signs or symptom of a stroke, please, please, please go to the emergency room,” Veznedaroglu said. “We can reverse the effects of stroke if we can get to patients in time.”
Remaining as active as possible is a way to reduce the chances of serious clotting, he said, speculating that shutdown orders might be making people more sedentary. Smoking, eating poorly, or drinking heavily all can add to risks associated with the virus.
Randle is staying out of work for two more weeks to allow his dizziness to subside. He anticipates having a new sense of solidarity with his patients.