Coronavirus Disease 2019-Related Acute Ischemic Stroke: A Case Report

Coronavirus disease 2019 (COVID-19) is an active worldwide pandemic with diverse presentations and complications. Most patients present with constitutional and respiratory symptoms. Acute ischemic stroke remains a medical emergency even during the COVID-19 pandemic. Here we present a case of a patient with COVID-19 who presented with acute ischemic stroke in the absence of common risk factors for cerebrovascular accidents. A 70-year-old male patient, with no prior comorbidities, presented to the emergency department (ED) with fever, cough, and shortness of breath for four days, and altered level of consciousness and right-sided weakness with the sensory loss for one day. On examination, the patient had a score of 8/15 on the Glasgow coma scale (GCS). There was a right-sided sensory loss and weakness in both upper and lower limbs with a positive Babinski's sign. The pulmonary examination was remarkable for bilateral crepitation. On blood workup, there was leukocytosis and raised c-reactive protein (CRP). D-dimer, ferritin, thyroid-stimulating hormone (TSH), vitamin B12, and hypercoagulability workup were normal. Transthoracic echocardiography was also normal. COVID-19 polymerase chain reaction (PCR) detected the virus. Chest x-ray showed infiltrations in the left middle and both lower zones of the lungs in the peripheral distribution. Computed tomography (CT) scan of the chest showed peripheral and mid to basal predominant multilobar ground-glass opacities. CT scan of the head showed a large hypodense area, with a loss of gray and white matter differentiation, in the left middle cerebral artery territory. Magnetic resonance imaging (MRI) of the head showed abnormal signal intensity area in the left parietal region. It appeared isointense on T1 image and hyperintense on T2 image. It also showed diffusion restriction on the diffusion-weighted 1 (DW1) image with corresponding low signals on the apparent diffusion coefficient (ADC) map. These findings were consistent with left middle cerebral artery territory infarct due to COVID-19. The patient was intubated in the ED. He was deemed unfit for thrombolysis and started on aspirin, anti-coagulation, and other supportive measures. Patients with COVID-19 should be evaluated early for neurological signs. Timely workup and interventions should be performed in any patient suspected of having a stroke to reduce morbidity and mortality.