COVID-19 Exposures, Vaccines, and Acute Ischemic Stroke Risk: On Balance and in Balance

Abstract

Most stroke prevention strategies involve optimizing medication regimens, diet, activity, lifestyle, and behavioral changes to promote cerebrovascular and cardiovascular health.1 However, soon after the World Health Organization declared the SARS-CoV-2 infection COVID-19 a global pandemic, it became more apparent that SARS-CoV-2 infection would become an unignorable risk factor for stroke.2 Patients with COVID-19, particularly severe respiratory manifestations of the disease, were found early on to have evidence of a prothrombotic and proinflammatory state along with a propensity for cardiac dysfunction and stroke.3 Stroke incidence in patients with COVID-19 was particularly higher in those with cardiovascular risk factors but could also occur in younger patients and those without preexisting traditional cardiovascular risk factors.2 After the advent of COVID-19 vaccines, there emerged similarly concerning case reports of thrombotic events such as acute ischemic stroke (AIS) and cerebral venous thrombosis post-COVID-19 vaccine exposure, potentially resulting from thrombotic thrombocytopenia syndrome (TTS), cardiac dysfunction, or an excess of the vaccine-induced immune response.4-7 As the pandemic evolves to endemic and repeated "booster"doses of vaccine are inevitably needed to stave off severe COVID-19 illness, these events obligate us to weigh the stroke risks from COVID-19 infection against the stroke risks from COVID-19 vaccination.