Acutely altered mental status as the main clinical presentation of multiple strokes in critically ill patients with COVID-19

Abstract

Background and aims Cerebral infarction in COVID-19 patients might be associated with a hypercoagulable state related to a systemic inflammatory response. Its diagnosis might be challenging. We present two critically ill patients with COVID-19 who presented acutely altered mental status as the main manifestation of multiple strokes. Methods Clinical presentation and diagnostic work-up of the patients. Results Two patients in their sixties were hospitalized with a bilateral pneumonia COVID-19. They developed respiratory failure and were admitted to ICU for mechanical ventilation and intense medical treatment. They were started on low-molecular-weight heparin since admission. Their laboratory results showed lymphopenia and increased levels of C-reactive protein and D-dimer. Case 1 developed hypofibrinogenemia and presented several cutaneous lesions with biopsy features of thrombotic vasculopathy. Case 2 was performed a CT pulmonary angiogram at ICU showing a bilateral pulmonary embolism. When waking up, both patients were conscious but with a remarkable global altered mental status without focal neurological deficits. A brain MRI revealed multiple acute bilateral ischemic lesions with areas of hemorrhagic transformation in both patients (case 1: affecting the left frontal and temporal lobes and both occipital lobes; case 2: affecting both frontal and left occipital lobes). Cardioembolic source and acquired antiphospholipid syndrome were ruled out. COVID-19-associated coagulopathy was suspected as the possible main etiology of the strokes. Conclusion Acutely altered mental status might be the main manifestation of multiple brain infarctions in critically ill COVID-19 patients. It should be specially considered in those with suspected COVID-19-associated coagulopathy. Full-dose anticoagulation and clinical-radiological monitoring might reduce their neurological consequences.

Coexistence of neurological diseases with Covid-19 pneumonia during the pandemic period

“…That our patients were diagnosed with Covid-19 pneumonia and neurological disease after presenting to the emergency room suggests the neurological presentation of Covid-19. Acute change in consciousness, which was the most common complaint in our study, may be an ischaemic stroke symptom in severe Covid-19 cases [27] . Hypercoagulopathy is the cause of cerebrovascular diseases pathogenesis in Covid-19.…”

Paraneoplastic Syndrome and SARS-CoV-2—Incremental Effect of 2 Thrombogenic Conditions?

“…5 Hypercoagulation during SARS-CoV-2 infection has been linked to cerebral embolism in several cases. 6,7 In our case, the patient was asymptomatic, and therefore, the duration of infection remains unknown. However, a second test performed 7 days after the positive one was already negative, thus suggesting that infection occurred earlier.…”

“… 5 Hypercoagulation during SARS-CoV-2 infection has been linked to cerebral embolism in several cases. (6) , (7) …”

Neuropsychiatric manifestations of COVID-19, potential neurotropic mechanisms, and therapeutic interventions

“…The prevalence and severity of these psychiatric symptoms, attention deficits, and hyperactivity symptoms increased the risk for problematic internet use during the COVID-19 pandemic [ 51 ]. Moreover, a case series reported that critically ill COVID-19 patients with multiple acute bilateral ischemic lesions exhibited alterations of mental status but no neurological deficits [ 52 ]. A group of experts convened by the UK Academy of Medical Sciences and the mental health research charity also advocate monitoring and evaluating brain function, and mental health issues such as anxiety, depression, insomnia, self-harm, and suicide in COVID-19 patients and related vulnerable populations [ 53 ].…”