Arterial and venous strokes in the setting of COVID-19

Abstract

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.

COVID-19 and cerebrovascular diseases: a comprehensive overview

“…[21][22][23][24] The hypercoagulability may further add to the risk of developing cerebral venous thrombosis (CVT) or ischemic stroke (IS). [23][24][25] The COVID-19-associated prothrombotic state is accompanied by high D-dimer levels, elevated ferritin, and in some cases, detectable lupus anticoagulant, anticardiolipin immunoglobulin A (IgA), and antiphospholipid IgA and immunoglobulin M (IgM) autoantibodies directed against β2-glycoprotein-1. 22,26 On the other hand, it is well established that such autoantibodies appear in many conditions characterized by profound immune activation with no apparent pathogenic role.…”

Time of Stroke Onset in Coronavirus Disease 2019 Patients Around the Globe: A Systematic Review and Analysis

“…There are reported cases, where respiratory disease has occurred a few days prior to the onset of neurological symptoms 6 . On the other hand, cases of asymptomatic COVID-19 patients debuting with stroke have been reported 7 , rising concerns among physicians regarding adequate triage and classification of stroke patients. This raises the need for further investigations on temporality and specifically ischemic stroke events.…”

Decompressive hemicraniectomy for acute ischemic stroke associated with coronavirus disease 2019 infection: Case report and systematic review

“…Elevated D-dimer levels in COVID-19 patients increase blood coagulation, thrombin formation, and intravascular fibrin, which may lead to clot formation in large intracranial vessels. [ 13 ]…”