Background and purpose: Coronavirus disease 2019 (COVID-19) is a global pandemic that causes flu-like symptoms. There is a growing body of evidence suggesting that both the central and peripheral nervous systems can be affected by SARS-CoV-2, including stroke. We present three cases of arterial ischemic strokes and one venous infarction from a cerebral venous sinus thrombosis in the setting of COVID-19 infection who otherwise had low risk factors for stroke. Methods: We retrospectively reviewed patients presenting to a large tertiary care academic US hospital with stroke and who tested positive for COVID-19. Medical records were reviewed for demographics, imaging results and lab findings. Results: There were 3 cases of arterial ischemic strokes and 1 case of venous stroke: 3 males and 1 female. The mean age was 55 (48-70) years. All arterial strokes presented with large vessel occlusions and had mechanical thrombectomy performed. Two cases presented with stroke despite being on full anticoagulation. Conclusions: It is important to recognize the neurological manifestations of COVID-19, especially ischemic stroke, either arterial or venous in nature. Hypercoagulability and the cytokine surge are perhaps the cause of ischemic stroke in these patients. Further studies are needed to understand the role of anticoagulation in these patients.
A 45-year-old woman presented with 7 days of worsening dyspnea, nonproductive cough, myalgias, and chills. The following day, the patient had acute respiratory failure, requiring mechanical ventilation, and eventually developed acute respiratory distress syndrome. Respiratory panel tested positive for influenza A. The patient's mental status progressively worsened to coma. Magnetic resonance imaging of the brain demonstrated relatively symmetrical bilateral T2 FLAIR abnormalities in the thalami, corpus callosum, pons, and cerebellum. Cerebrospinal fluid polymerase chain reaction was positive for influenza A. The patient was transitioned to high-dose oseltamivir and high-dose corticosteroids. Repeat magnetic resonance imaging demonstrated gross resolution of T2 FLAIR abnormalities. The patient's mental status continued to improve daily. At the time of discharge, 30 days after symptom onset, the patient was awake and following commands. Six months after hospitalization, the patient had successfully been able to return to her baseline function except for right homonymous quadrantanopia and some mild residual left upper extremity weakness.
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