COVID-19 presenting as stroke

Abstract

Objective: Acute stroke remains a medical emergency even during the COVID-19 pandemic. Most patients with COVID-19 infection present with constitutional and respiratory symptoms; while others present with atypical gastrointestinal, cardiovascular, or neurological manifestations. Here we present a series of four patients with COVID-19 that presented with acute stroke.

Methods: We searched the hospital databases for patients that presented with acute stroke and concomitant features of suspected COVID-19 infection. All patients who had radiographic evidence of stroke and PCR-confirmed COVID-19 infection were included in the study. Patients admitted to the hospital with PCR- confirmed COVID-19 disease whose hospital course was complicated with acute stroke while inpatient were excluded from the study. Retrospective patient data were obtained from electronic medical records. Informed consent was obtained.

Results: We identified four patients who presented with radiographic confirmation of acute stroke and PCR-confirmed SARS-CoV-2 infection. We elucidate the clinical characteristics, imaging findings, and the clinical course.

Conclusions: Timely assessment and hyperacute treatment is the key to minimize mortality and morbidity of patients with acute stroke. Stroke teams should be wary of the fact that COVID-19 patients can present with cerebrovascular accidents and should dawn appropriate personal protective equipment in every suspected patient. Further studies are urgently needed to improve current understandings of neurological pathology in the setting of COVID-19 infection.

Keywords: COVID-19; SARS-CoV2; Stroke.

Fig. 1a

A CT of the head demonstrating loss of gray-white differentiation at the left occipital and parietal lobes, consistent with acute infarct.

Fig. 1b

CT chest demonstrating bilateral peripheral dominant patchy airspace opacities and diffuse ground glass opacities, characteristic for atypical pneumonia/viral infection from COVID-19.

Fig. 2a

CTA of head and neck demonstrated no large vessel occlusion, focal moderate stenisis of right MCA.

Fig. 2b

CXR demonstrating worsening bilateral opacities.

Fig. 2c

CT of the head demonstrated new moderate hypodensity in the right frontal lobe representing acute infarct.

Fig. 3a

CT head demonstrating acute right MCA stroke.

Fig. 3b

CTA of the head and neck demonstrating occlusion of the right internal carotid artery at origin.

Fig. 3c

CT perfusion demonstrating large core infarct.

Fig. 4a

MRI of the brain demonstrating acute infarct in the left medial temporal lobe.

Fig. 4b

MRA of the head and neck demonstrating mild stenosis of right M1 segment.