Post-COVID-19 Multisystem Inflammatory Syndrome-Related Cerebral Infarction in a Pediatric Patient Managed with Decompressive Craniectomy

Abstract

Most people who are infected with the novel severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) are asymptomatic or present with mild upper respiratory symptoms. This is especially true in the pediatric population; however, rarely, a massive cytokine storm can develop causing multisystem inflammatory syndrome associated with COVID (MIS-C). Furthermore, children may also suffer from acute ischemic strokes secondary to SARS-CoV-2 infection. Here, we present a 2-year-old male who was admitted to the hospital with MIS-C and evidence of a previous SARS-CoV-2 infection. On post-admission day 2, the patient was in cardiogenic shock, had acute kidney injury (AKI), liver dysfunction, and metabolic acidosis. He had concurrent altered mental status and his CT scan showed ischemic infarcts in the territory of the right middle cerebral artery and superior cerebellar artery bilaterally. Magnetic resonance angiography (MRA) confirmed occlusion of the right middle cerebral artery and right superior cerebellar artery. He underwent an emergent decompressive craniectomy due to rapid deterioration and cerebral edema. After the procedure, he continued to improve and was discharged with moderate disability that improved during outpatient rehab. Though rare in children, SARS-CoV-2 can lead to AIS, especially in the presence of underlying risk factors such as MIS-C and hypercoagulopathy. AIS can be associated with severe mortality and morbidity; however, even in this severe case of AIS, the patient was successfully treated with a decompressive craniectomy.

Association between SARS-CoV-2 Seropositivity and Severity of Out-of-Hospital Acute Ischemic Stroke Following Asymptomatic/Mild COVID-19 in Children

“…Therapeutic modalities described for COVID-19-associated AIS vary among studies, including anticoagulation, thrombolysis, steroids, immunoglobulins, remdesivir, and endovascular thrombectomy. 1,18,22,25,38 All children with AIS in the current study presented beyond the therapeutic window for intravenous tPA therapy. Likewise, Vielleux et al 18 reported that 75% of children with COVID-19-related AIS presented after the proper timing for tPA treatment.…”

“…29 Researchers have described the coexistence of MIS-C and AIS in several children with COVID-19. 1,18,25,38 In contrast, children could develop COVID-19-related AIS in the absence of MIS-C. 1,18,22 Furthermore, analysis of data from a U.S. pediatric center between March 2020 and June 2021 revealed a 2-to 3-month time lag in the peak of stroke cases compared with a 1-to 2month lag in the peak of MIS-C cases after the surge of COVID-19 rates. 18 Taken together, the risk of AIS in the postacute phase of COVID-19 seems to depart from the risk for MIS-C.…”

“…This goes in line with previous studies. 36,38 D-dimer is a biomarker of active coagulation and thrombosis. 3 High D-dimer level is an independent risk factor for the occurrence, severity, and outcome of AIS in both adults and children with COVID-19.…”

Case report: unprecedented case of infantile cerebral infarction following COVID-19 and favorable outcome

“…This pattern is consistent with the infarction locations observed in our case, suggesting a predilection for the basal ganglia in COVID-19-related cerebral infarctions in pediatric patients. However, some cases have reported involvement of the right middle cerebral artery and right posterior cerebral artery territories, as well as the bilateral superior cerebellar arteries ( 8 , 44 ). The detailed mechanisms underlying these observations warrant further exploration.…”

Acute Ischemic Stroke in an Infant With COVID-19 Infection and Delayed Diagnosis of Neurofibromatosis Type 1

“…Acute strokes are uncommonly encountered in the pediatric population with an incidence of 1.2 to 2.1 out of 100,000 [ 5 ]. During the COVID-19 pandemic, neurological complications, such as acute ischemic stroke, in the pediatric population were recognized even though there are isolated cases of acute ischemic stroke with COVID-19 in the pediatric age group [ 6 ].…”