To the Editor: We read “Letter: Dismantling the Apocalypse Narrative: The Myth of the COVID-19 Stroke”1 with surprise and disappointment. The letter has major fallacies, misinterpretations, and attributing conclusions not implied by us.2 With the prolific and growing literature on COVID-19 and stroke,2-29it is clearly not a myth. We advise the authors to reconsider this fundamental feature of the current pandemic, and we strongly recommend them to get themselves familiar with the cited manuscripts that describe the pathophysiology of cerebrovascular events in COVID-19 patients.3-14,30-40 It is a moral imperative in a pandemic for clinicians to raise awareness about associations even when proof of causation is pending. The authors1 repeatedly made subjective false claims characterizing our honest observations as scientifically unfounded, and then themselves add their subjective baseless opinion “that this information exacerbates anxiety among the youth.”1 It is never one’s intent to raise public fear. Instead, it is to promptly increase awareness among the public and healthcare community, mainly that COVID-19 is a new virus, and we do not have a full grasp on its manifestations yet. The disease has been devastating, leading to more than 32 million cases and close to one million casualties. Our responsibility is to promptly report any noteworthy trends and be vocal in the media to reach the most massive audience to spread awareness. Neurointerventionalists from cities hit hard by the pandemic and working in comprehensive stroke centers were able to identify unusual trends that prompted further investigations, an observation that the senior author R. Rahme may not have experienced at his primary stroke center (SBH health system). Based on the data presented in their table, it seems that they are a low volume primary stroke center suggested by the sole case of LVO during March-April 2018 and 2019. Philadelphia was not hit as hard as New York. However, in early April, we encountered many cases of COVID-19 positive patients that required mechanical thrombectomies in addition to sinus thrombosis. We published numerous papers on our experience,2,25-29, 41-45 and we implemented a joint effort collaboration with other institutions in the U.S. and outside to better understand this phenomenon. Only a fraction of patients acquiring COVID-19 are at risk of stroke (1%-6%).17,46,47 As such, other institutions, that have not experienced a peak in COVID-19 cases, may miss such a trend. Therefore, during a pandemic, it is the duty of healthcare providers practicing in busy centers to raise awareness if they notice anything unusual. Such efforts may push the population to take the disease seriously and follow the guidelines to decrease their risk of getting the disease and its complications. In addition, reporting of such observations allows other healthcare practitioners to evaluate this phenomenon in their patient populations. Given the narrow time window of stroke intervention and outcomes being related to early intervention, it is vital to overemphasize stroke symptoms within the community to allow patients to gain from the current therapies. To help pinpoint and clarify the inaccuracies as presented by the authors,1 we provide the following responses to the statements made in their letter:

中文翻译：

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回复：拆解天启叙事：COVID-19 中风的神话

致编辑：我们带着惊讶和失望阅读了“信件：拆解天启叙事：COVID-19 中风的神话”1。这封信存在重大谬误、误解和我们未暗示的结论。2 随着关于 COVID-19 和中风的大量文献和不断增加，2-29 这显然不是神话。我们建议作者重新考虑当前大流行的这一基本特征，我们强烈建议他们熟悉所引用的描述 COVID-19 患者脑血管事件病理生理学的手稿。3-14,30-40 这是一个在大流行病中临床医生提高对关联的认识的道德必要性，即使在因果关系的证据尚待证明的情况下。作者 1 一再提出主观的虚假声明，将我们的诚实观察描述为在科学上没有根据，然后他们自己加上他们主观的、毫无根据的意见“这些信息会加剧年轻人的焦虑。”1 引起公众恐惧从来都不是一个人的意图。相反，它是要迅速提高公众和医疗保健界的认识，主要是 COVID-19 是一种新病毒，我们还没有完全掌握它的表现形式。这种疾病是毁灭性的，导致超过 3200 万病例和近 100 万人伤亡。我们的责任是及时报告任何值得注意的趋势，并在媒体上发声，以吸引最广泛的受众来传播意识。来自受大流行重创并在综合性卒中中心工作的城市的神经介入学家能够识别出促使进一步调查的异常趋势，资深作者 R. Rahme 可能没有在他的主要卒中中心（SBH 卫生系统）经历过。根据他们表格中提供的数据，他们似乎是 2018 年 3 月至 4 月和 2019 年 2019 年 3 月至 4 月和 2019 年唯一一例 LVO 所建议的低容量初级卒中中心。费城没有纽约那么严重。然而，在 4 月初，我们遇到了许多 COVID-19 阳性患者，除了鼻窦血栓形成外，还需要机械血栓切除术。我们发表了大量关于我们的经验的论文，2,25-29, 41-45，并且我们与美国和国外的其他机构进行了共同努力，以更好地了解这一现象。只有一小部分获得 COVID-19 的患者有中风风险 (1%-6%)。17,46,47 因此，其他尚未经历 COVID-19 病例高峰的机构可能会错过这种趋势. 所以，在大流行期间，在繁忙的中心执业的医疗保健提供者有责任在发现任何异常情况时提高认识。这样的努力可能会促使人们认真对待这种疾病，并遵循指导方针来降低他们患上这种疾病及其并发症的风险。此外，此类观察结果的报告允许其他医疗保健从业者评估其患者群体中的这种现象。鉴于中风干预的时间窗口很窄，结果与早期干预有关，因此在社区内过分强调中风症状以让患者从当前治疗中获益至关重要。为了帮助查明和澄清作者提出的不准确之处1，我们对他们信中的陈述做出以下回应：在繁忙的中心执业的医疗保健提供者有责任在发现任何异常情况时提高认识。这样的努力可能会促使人们认真对待这种疾病，并遵循指导方针来降低他们患上这种疾病及其并发症的风险。此外，此类观察结果的报告允许其他医疗保健从业者评估其患者群体中的这种现象。鉴于中风干预的时间窗口很窄，结果与早期干预有关，因此在社区内过分强调中风症状以让患者从当前治疗中获益至关重要。为了帮助查明和澄清作者提出的不准确之处1，我们对他们信中的陈述做出以下回应：在繁忙的中心执业的医疗保健提供者有责任在发现任何异常情况时提高认识。这样的努力可能会促使人们认真对待这种疾病，并遵循指导方针来降低他们患上这种疾病及其并发症的风险。此外，此类观察结果的报告允许其他医疗保健从业者评估其患者群体中的这种现象。鉴于中风干预的时间窗口很窄，结果与早期干预有关，因此在社区内过分强调中风症状以让患者从当前治疗中获益至关重要。为了帮助查明和澄清作者提出的不准确之处1，我们对他们信中的陈述做出以下回应：