Locked-In with COVID-19

Abstract

Coronavirus Disease 2019 (COVID-19) can be associated with various neurological manifestations including acute strokes. Hyper acute diagnosis and treatment are key factors which decrease mortality and morbidity in stroke patients. The COVID-19 pandemic has introduced a great strain on the healthcare system, and as a result clinicians are facing several barriers in diagnosing and treating strokes. Delayed presentation of strokes is a problem as some in the general population defer the decision to seek immediate medical attention fearing contracting the virus. Also playing a role is the paucity of healthcare professionals available during a pandemic. Recent literature demonstrates the association of acute strokes in young patients with COVID-19. Lack of clear pathophysiology of the neurological manifestations from COVID-19 intensifies the problem. A thorough examination of the intensive care unit patient has always been a challenge owing to several factors including use of sedatives, sepsis, uremia, and encephalopathy secondary to medications. Locked-In Syndrome (LIS) secondary to stroke is much more challenging to diagnose as patients are unable to communicate or elicit any motor functions apart from certain ocular movements. We present the case of a 25 year old patient with no known history of coagulopathy, but had developed COVID-19 cytokine storm which culminated in LIS secondary to pontine strokes.

Keywords: COVID-19; Hypercoagulability; Locked in Syndrome; Stroke.

Fig. 1

MRI brain-DWI sequences showing acute bilateral pontine strokes.

Fig. 2

MRI brain-T2 Flair showing pontine hyper intensities.

Fig. 3

MRA head showing decreased flow in distal right vertebral artery but patent basilar artery.

Fig. 4

Trend of inflammatory markers and D-Dimer. Arrow represents the day of stroke diagnosis. The inflammatory markers trended while the D-dimer was trending up close to the stroke.