Large Middle Cerebral Artery Ischemic Stroke in a Therapeutically Anticoagulated Patient With Severe SARS-CoV-2 Infection

Abstract

Introduction: Coronavirus disease 2019 caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is associated with hypercoagulability which can predispose infected patients to both arterial and venous thromboembolic complications. Despite therapeutic anticoagulation, there remains a risk of ischemic strokes, which may lead to adverse patient outcomes. Only a few cases are described in the literature regarding SARS-CoV-2 positive patients developing thrombotic ischemic strokes despite therapeutic anticoagulation. Case Report:The following is a case discussion regarding a 71-yearold female with past medical history of hypertension, diabetes mellitus type 2, hyperlipidemia, and hypothyroidism who was admitted with severe SARS-CoV-2 infection to the intensive care unit and later developed acute left upper extremity weakness on the 5th day of her admission. Initial National Institutes of Health stroke scale (NIHSS) was 15. Subsequent brain imaging was significant for right middle cerebral artery ischemic stroke. The patient was therapeutically anticoagulated with 1.5 mg/kg subcutaneous dose of Enoxaparin since day 1 of her admission. D-dimer upon admission was 1.84 mg/L (< 0.59) and fibrinogen 783.1 mg/dL (200 to 450). Other than past medical comorbidities, our patient had no other known stroke risk factors. Unfortunately, despite early transcatheter thrombectomy, the patient remained comatose and eventually expired after withdrawal of ventilatory support and compassionate extubation. Conclusion:Because of the severity of inflammation and coagulopathic sequelae of coronavirus disease 2019, anticoagulation failure may occur and lead to adverse patient outcomes. Our case report is one of the few discussions in the current literature regarding large vessel thromboembolic ischemic strokes despite therapeutic anticoagulation.

Cerebral microvascular complications associated with SARS-CoV-2 infection: How did it occur and how should it be treated?

“…Those patients with a history of stroke had higher neutrophil levels, cardiac troponin I, D-dimers levels, NT pro-brain natriuretic peptide, IL-6, and lower lymphocyte and platelet counts in contrast to those without a history of stroke [157] . On the other hand, it has been demonstrated that the majority of patients with ischemic strokes have a hypercoagulability state induced by SARS-CoV-2 infection [157] , [158] . Other markers that indicate coagulopathy in patients with COVID-19 infection, in addition to D-dimer levels, include a slight increase in prothrombin-time (PT) activity, international normalized ratio (INR), partial thromboplastin time (PTT), platelet counts, thrombocytopenia, elevated lactate dehydrogenase (LDH), and fibrinogen [159] , [160] , [161] .…”

An Atypical Case of Aphasia: Transitory Ischemic Attack in a 13-Year-Old Patient with Asymptomatic SARS-CoV-2 Infection

“…The main mechanism underlying the neurological complications of the virus is likely attributable to the state of systemic inflammation and hypercoagulability [ 3 , 4 ]. Moreover, according to recently reported cases, in patients with polymorbidity, standard anticoagulation may be insufficient to meet SARS-CoV-2-associated severe hypercoagulability syndrome and prevent the occurrence of cerebrovascular events [ 5 , 6 ]. In the pediatric field this topic is less discussed but published data have been growing recently.…”