Reply.

Dear Editor:

In the letter to editor with title “COVID related strokes: Pandora's Box may open as the p(c)lot thickens”, to the COVID-19-specific stroke etiologies that have been hypothesized (prothrombotic state, cardiomyopathy, endothelial damage, sepsis with hypothension), another one is added: pulmonary hypertension that would cause or increase a right-to-left shunt through an until then incidental patent formamen ovale (PFO). Chronic pulmonary hypertension increases the risk of stroke but COVID-19-associated pulmonary hypertension is usually transient and there is debate about an increased risk of stroke with larger PFO or bigger right-to-left shunts.2, 3 Additionally to paradoxical embolism, pulmonary hypertension is associated to atrial fibrilation and polycithemia, which need different treatments to reduce their stroke risk. We have yet few data about the increase in stroke risk that the proposed mechanism – or other related to COVID 19 – will add. Until it is clarified we should be vigilant and include an echocardiogram in the study of COVID-19-related strokes, not only due to PFO and pulmonary hypertension but to COVID-19-associated cardiomiopathy.

Funding

This research has not received specific support from public sector, commercial or non-profit agencies.

Conflict of interest

None declared.

COVID-19 related strokes