Acute Ischemic and Hemorrhagic Stroke in COVID-19: Mounting Evidence

Abstract

The novel coronavirus disease of 2019 (COVID-19) is caused by the binding of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) to angiotensin-converting enzyme 2 (ACE2) receptors present on various locations such as the pulmonary alveolar epithelium and vascular endothelium. In COVID-19 patients, the interaction of SARS-CoV-2 with these receptors in the cerebral blood vessels has been attributed to stroke. Although the incidence of acute ischemic stroke is relatively low, ranging from 1% to 6%, the mortality associated with it is substantially high, reaching as high as 38%. This case series describes three distinct yet similar scenarios of COVID-19 positive patients with several underlying comorbidities, wherein two of the patients presented to our hospital with sudden onset right-sided weakness, later diagnosed with ischemic stroke, and one patient who developed an acute intracerebral hemorrhage during his hospital stay. The patients were diagnosed with acute stroke as a complication of COVID-19 infection. We also provide an insight into the possible mechanisms responsible for the life-threatening complication. Physicians should have a low threshold for suspecting stroke in COVID-19 patients, and close observation should be kept on such patients particularly those with clinical evidence of traditional risk factors.

Keywords: co-morbidity; complication; covid-19; intracerebral hemorrhage; mortality; stroke.

Figure 1. MRI showing an acute/sub-acute infarct involving the left caudate nucleus (blue arrow) and putamen (yellow arrow).

Figure 2. CT scan of the head (2a) and MRI of the brain (2b) showing an evolving moderate-sized subacute left MCA branch infarct (arrows).

Figure 3. Chest CT illustrating diffuse bilateral ground-glass consolidation of lungs.

Figure 4. CT scan of the head with a low-density area in the right occipital lobe (4a) consistent with a subacute ischemic stroke (arrow); and right intraparenchymal hematoma (arrow) with midline shift with compression of the lateral ventricle and scattered subarachnoid hemorrhage (4b).