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.

Keywords: COVID-19; Cerebral venous thrombosis; SARS-CoV-2; Stroke.

Fig. 1

51 year old male with R MCA stroke A. CT Angiogram demonstrating R ICA occlusion. B. Non-contrast CT Head demonstrating developing R MCA stroke.

Fig. 2

70 year old female with R MCA stroke. A. Angiogram pre-intervention demonstrating lack of flow consistent with a right M2 occlusion and post-intervention showing recanalization. B. Non-contrast CT Head demonstrating large hemispheric R MCA stroke with development of midline shift and cerebral edema.

Fig. 3

54 year old male with cerebral venous thrombosis. A. MRI brain T2 FLAIR sequence demonstrating bilateral thalamic venous infarctions and hydrocephalus. B. MRI brain GRE sequence demonstrating multiple deep internal cerebral vein thrombosis.

Fig. 4

48 year old male with L MCA stroke. A. Angiogram pre-intervention showing left M1 occlusion and post-intervention showing recanalization of the vessel. B. Non-contrast CT Head demonstrating L MCA stroke with development of midline shift and cerebral edema.