Stroke in patients with SARS-CoV-2 infection: case series

• Published in: Journal of neurology 2020-08, Vol.267 (8), p.2185-2192
• Main Authors: Morassi, Mauro, Bagatto, Daniele, Cobelli, Milena, D’Agostini, Serena, Gigli, Gian Luigi, Bnà, Claudio, Vogrig, Alberto
• Format: Article
• Language: English
• Subjects: Aged; Aged, 80 and over; Asymptomatic infection; Betacoronavirus; Coronaviridae; Coronavirus Infections - complications; Coronavirus Infections - diagnostic imaging; Coronavirus Infections - therapy; Coronaviruses; COVID-19; Encephalopathy; Fatal Outcome; Female; Hemorrhage; Humans; Infections; Ischemia; L-Lactate dehydrogenase; Lactic acid; Liver diseases; Male; Medicine; Medicine & Public Health; Middle Aged; Neuroimaging; Neurology; Neuroradiology; Neurosciences; Original Communication; Pandemics; Pneumonia; Pneumonia, Viral - complications; Pneumonia, Viral - diagnostic imaging; Pneumonia, Viral - therapy; Polymerase chain reaction; Renal failure; Retrospective Studies; Risk factors; SARS-CoV-2; Seizures; Severe acute respiratory syndrome coronavirus 2; Stroke; Stroke - diagnostic imaging; Stroke - etiology; Stroke - therapy
• ISSN: 0340-5354; 1432-1459
• DOI: 10.1007/s00415-020-09885-2

Background Italy is one of the most affected countries by the coronavirus disease 2019 (COVID-19). The responsible pathogen is named severe acute respiratory syndrome coronavirus (SARS-CoV-2). The clinical spectrum ranges from asymptomatic infection to severe pneumonia, leading to intensive care unit admission. Evidence of cerebrovascular complications associated with SARS-CoV-2 is limited. We herein report six patients who developed acute stroke during COVID-19 infection. Methods A retrospective case series of patients diagnosed with COVID-19 using reverse-transcriptase polymerase chain reaction (RT-PCR) on nasopharyngeal swabs, who developed clinical and neuroimaging evidence of acute stroke during SARS-CoV-2 infection. Results Six patients were identified (5 men); median age was 69 years (range 57–82). Stroke subtypes were ischemic (4, 67%) and hemorrhagic (2, 33%). All patients but one had pre-existing vascular risk factors. One patient developed encephalopathy prior to stroke, characterized by focal seizures and behavioral abnormalities. COVID-19-related pneumonia was severe (i.e., requiring critical care support) in 5/6 cases (83%). Liver enzyme alteration and lactate dehydrogenase (LDH) elevation were registered in all cases. Four patients (67%) manifested acute kidney failure prior to stroke. Four patients (67%) had abnormal coagulation tests. The outcome was poor in the majority of the patients: five died (83%) and the remaining one (17%) remained severely neurologically affected (mRS: 4). Conclusions Both ischemic and hemorrhagic stroke can complicate the course of COVI-19 infection. In our series, stroke developed mostly in patients with severe pneumonia and multiorgan failure, liver enzymes and LDH were markedly increased in all cases, and the outcome was poor.