Ischemic Stroke in a SARS-CoV-2-Positive Octagenarian Without Cardiovascular Risk Factors: A Case Report

Abstract

Ischemic and hemorrhagic strokes are increasingly recognized as complications of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections. The absence of cardiovascular risk factors in SARS-CoV-2-infected patients who suffer a stroke supports a causal relationship as shown in the following report. The patient is an 86-year-old female who developed a mild, brachio-facial, right-sided hemi-symptomatic during a mild infection with SARS-CoV-2. Cerebral magnetic resonance imaging (MRI) showed a corresponding, small, subacute, ischemic lesion in the left periventricular white matter and a microbleed in the left thalamus. Under dual platelet aggregation inhibitor therapy, the neurological deficits regressed almost completely within three weeks. If one considers that classic cardiovascular risk factors were missing, a causal link between the SARS-CoV-2 infection and the stroke becomes likely. Vasculopathy, coagulopathy, and cardiac disease caused by the virus or the immune response against it serve as pathophysiological explanations for the cerebral lesions. It is concluded that ischemic stroke can occur during infection with SARS-CoV-2. There are more arguments for than against a causal relationship between the viral infection and ischemic stroke.

Cerebral small vessel disease pathology in COVID-19 patients: A systematic review

“… Case 1: 43 y/o; Case 2: 45 y/o Acute Case 1: Yes Case 2: Yes Case 1: No Case 2: No n/a MRI sequence: T1, T2, FLAIR, DWI, ADC, T2 * GRE For both cases: confluent diffuse supratentorial frontoparietal WMH with no MB. ( Finsterer, 2022 ) Case-report COVID-19 positive patient with bradykinesia and facial palsy on R side with symptoms of malaise, coughing, and fever. Patient had pre-existing microangiopathy.…”

“…Eighteen out of twenty-nine case reports presented patients who were admitted to the ICU due to respiratory failure/distress and required one or more of the following: intubation, mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) ( Ahmed et al, 2022 , Backman et al, 2022 , Cannac et al, 2020 , De Stefano et al, 2020 , Elshereye and Erdinc, 2020 , Gupta et al, 2020 , Hanafi et al, 2020 , Haroon et al, 2020 , Neppala et al, 2021 , Petersson et al, 2022 , Planinc et al, 2020 , Reichard et al, 2020 , Rudilosso et al, 2020 , Shoskes et al, 2020 , Toeback et al, 2021 , Tristán-Samaniego et al, 2022 , Vattoth et al, 2020 , Witvoet et al, 2021 ). MB were seen in 17/29 case reports ( Backman et al, 2022 , Cannac et al, 2020 , De Stefano et al, 2020 , Finsterer, 2022 , Fraiman et al, 2020 , Gupta et al, 2020 , Hanafi et al, 2020 , Haroon et al, 2020 , Liang et al, 2021 , Petersson et al, 2022 , Planinc et al, 2020 , Reichard et al, 2020 , Rudilosso et al, 2020 , Shoskes et al, 2020 , Toeback et al, 2021 , Tristán-Samaniego et al, 2022 , Vattoth et al, 2020 , Witvoet et al, 2021 ) with 14/17 being in patients with severe pulmonary/respiratory complications. Regarding the three MB cases in which patients did not require intubation, mechanical ventilation or ECMO, patients presented with early onset Alzheimer’s Disease ( Fraiman et al, 2020 ), CAA ( Liang et al, 2021 ), or pre-existing microangiopathy ( Finsterer, 2022 ), all of which are independent risk factors for cerebral MB ( Cordonnier and van der Flier, 2011 , Woerdeman et al, 2014 ).…”

“…MB were seen in 17/29 case reports ( Backman et al, 2022 , Cannac et al, 2020 , De Stefano et al, 2020 , Finsterer, 2022 , Fraiman et al, 2020 , Gupta et al, 2020 , Hanafi et al, 2020 , Haroon et al, 2020 , Liang et al, 2021 , Petersson et al, 2022 , Planinc et al, 2020 , Reichard et al, 2020 , Rudilosso et al, 2020 , Shoskes et al, 2020 , Toeback et al, 2021 , Tristán-Samaniego et al, 2022 , Vattoth et al, 2020 , Witvoet et al, 2021 ) with 14/17 being in patients with severe pulmonary/respiratory complications. Regarding the three MB cases in which patients did not require intubation, mechanical ventilation or ECMO, patients presented with early onset Alzheimer’s Disease ( Fraiman et al, 2020 ), CAA ( Liang et al, 2021 ), or pre-existing microangiopathy ( Finsterer, 2022 ), all of which are independent risk factors for cerebral MB ( Cordonnier and van der Flier, 2011 , Woerdeman et al, 2014 ). All but one report (7/8) presenting with both MB and ischemic lesions/infarctions required pulmonary/respiratory intervention in the ICU ( Hanafi et al, 2020 , Haroon et al, 2020 , Petersson et al, 2022 , Shoskes et al, 2020 , Toeback et al, 2021 , Tristán-Samaniego et al, 2022 , Witvoet et al, 2021 ).…”

“…Laboratory values were recorded for 21/29 case studies of COVID-19 patients presenting with MB or ischemic lesions/infarctions ( Abdi et al, 2020 , Backman et al, 2022 , De Stefano et al, 2020 , Elshereye and Erdinc, 2020 , Finsterer, 2022 , Fraiman et al, 2020 , Frisullo et al, 2020 , Gupta et al, 2020 , Hanafi et al, 2020 , Haroon et al, 2020 , Liang et al, 2021 , Petersson et al, 2022 , Piazza et al, 2021 , Pinzon et al, 2021 , Planinc et al, 2020 , Rajendran et al, 2021 , Reichard et al, 2020 , Shoskes et al, 2020 , Tristán-Samaniego et al, 2022 , Vattoth et al, 2020 , Witvoet et al, 2021 ). Elevated thromboinflammatory biomarkers (e.g., CRP, IL-6, ferritin, D -dimer) were present in 16/21 case reports.…”

“…In total, 32 patients were presented across the 29 studies. Past medical history was available for 26 patients ( Ahmed et al, 2022 , Backman et al, 2022 , De Stefano et al, 2020 , Elshereye and Erdinc, 2020 , Finsterer, 2022 , Fraiman et al, 2020 , Frisullo et al, 2020 , Haroon et al, 2020 , Liang et al, 2021 , Neppala et al, 2021 , Petersson et al, 2022 , Piazza et al, 2021 , Pinzon et al, 2021 , Planinc et al, 2020 , Reichard et al, 2020 , Rudilosso et al, 2020 , Shoskes et al, 2020 , Toeback et al, 2021 , Trifan et al, 2020 , Tristán-Samaniego et al, 2022 , Vattoth et al, 2020 , Williams et al, 2020 , Witvoet et al, 2021 , Zhang et al, 2021 ) and sex and age data were available from all reports. Thirteen out of twenty-six patients had cardiovascular risk factors (e.g., hypertension, type 2 diabetes, smoking), of whom 10/32 patients were female ( De Stefano et al, 2020 , Elshereye and Erdinc, 2020 , Finsterer, 2022 , Fraiman et al, 2020 , Frisullo et al, 2020 , Rajendran et al, 2021 , Trifan et al, 2020 , Vattoth et al, 2020 , Williams et al, 2020 , Zhang et al, 2021 ) and 12/32 patients were ≥ 60 years old (mean age of 12 patients = 70 years old, range = 60–86 years old) ( Cannac et al, 2020 , Elshereye and Erdinc, 2020 , Finsterer, 2022 , Hanafi et al, 2020 , Haroon et al, 2020 , Liang et al, 2021 , Reichard et al, 2020 , Shoskes et al, 2020 , Toeback et al, 2021 , Vattoth et al, 2020 , Witvoet et al, 2021 ).…”