Severe Acute Respiratory Syndrome Coronavirus 2 Infection and Ischemic Stroke

Abstract

A 52-year-old man with essential hypertension initially presented to a local emergency department with shortness of breath, cough, and fever.He was prescribed azithromycin and discharged home.On day 7, he represented to a primary stroke center emergency department with sudden onset of right hemiparesis and aphasia.Upon arrival, his blood pressure was 150/94 mm Hg, and his National Institutes of Health Stroke Scale score was 20 for global aphasia, left gaze preference, and right-sided partial hemianopia, facial weakness, severe hemiparesis, and hemianesthesia.He underwent a noncontrast computed tomography (CT) of the brain which was reported as negative for acute hemorrhage but showed a hyperdensity of the M1 segment of the left middle cerebral artery.He subsequently had a CT angiography that demonstrated a left intracranial internal carotid artery occlusion.He was within the intravenous thrombolysis window, and no contraindication for treatment was identified.He received intravenous alteplase and was then transferred to our comprehensive stroke center for consideration of mechanical thrombectomy.Upon arrival to the comprehensive stroke center, the patient's blood pressure was 146/98 mm Hg, and his neurological deficits were persistent.A chest radiograph was within normal and a noncontrast CT of the head was repeated which showed early infarct signs of in the left basal ganglia, internal capsule, caudate head, insular ribbon, operculum, and right posterior frontal lobe with an Alberta Stroke Program Early CT Score of 5. CT perfusion imaging of the brain was obtained to ensure that there was salvageable tissue and showed a favorable mismatch ratio of 4.1 (Figure 1).He underwent conventional angiography, which demonstrated a partially occlusive left terminal internal carotid artery thrombus extending into the left anterior cerebral artery and middle cerebral artery with occlusion of the proximal left middle cerebral artery.Mechanical thrombectomy was performed without the use of general anesthesia with restoration of flow from Thrombolysis in Cerebral Infarction 0 to Thrombolysis in Cerebral Infarction 2A (Figure 2).He was admitted to the stroke unit for further management.The reverse-transcriptase-polymerase-chainreaction assay of a nasopharyngeal sample was positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).He was empirically treated with hydroxychloroquine, and his cough gradually resolved.He did not develop complications of pneumonia, increased work of breathing, or fever.Additional workup revealed: BNP (B-type natriuretic peptide) 193 pg/mL, D-dimer >10 000 ng/mL, fibrinogen 235 mg/dL, ferritin 588 µg/L, CRP (C-reactive protein) 11 mg/L, erythrocyte sedimentation rate 37 mm/h, HIV nonreactive, and a urine drug screen on admission was negative.Hemoglobin A1c and LDL (low-density lipoprotein) levels were normal.Electrocardiogram and cardiac telemetry monitoring did not reveal any arrhythmias.Transthoracic echocardiography showed normal cavity size and wall thickness of the left ventricle, an ejection fraction of 63%, and no evidence of a cardiac source of emboli or patent foramen ovale.A follow-up CT showed a left MCA territory infarction with petechial hemorrhage (Figure 1).His stroke cause remained cryptogenic.Due to the potential risk of worsening hemorrhagic transformation with anticoagulation therapy, he was discharged to acute rehabilitation on aspirin and statin with plans for

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