Mediterranean BioMedical Journals

Integrative Journal of Medical Sciences

2020, Volume 7, ID 186
DOI: 10.15342/ijms.7.186

CASE REPORT

Acute Ischemic Stroke Induced by Covid-19

Disease - A Case Report
Ayşın Kısabay Ak, Güldeniz Çetin, Melike Batum
Department of Neurology, Celal Bayar University, Manisa, Turkey

ABSTRACT
Introduction: Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), which is the agent of Coronavirus disease
2019 (COVID-19), may attack the central nervous system in addition to the respiratory system because of its neuro-invasive
features. Increased inflammation, immobilization, hypoxia, and disseminated intravascular coagulation may predispose to the
cerebrovascular diseases.
Case Report: A 73 years old man presenting to the emergency service with complaints of dyspnea, cough, and high fever
was admitted to the hospital after being diagnosed as having COVID-19 upon findings of ground-glass densities and mild
parenchymal involvement which was more prominent in the mid- and lower lobes of the lungs on his computerized
tomography scan. His treatment was started with chloroquine, azithromycin, ceftriaxone and enoxaparin. On the neurological
exam performed for symptoms of dizziness, imbalance, speech disorder and deviation of angle of mouth; he was conscious,
cooperating, oriented limitedly and the right nasolabial groove was indistinct and he had dysarthria and ataxia. Acetyl
salicylic acid was added to the treatment because cerebral diffusion magnetic resonance imaging revealed limited diffusion
consistent with acute ischemia on the right posterolateral area of the bulbus. The patient whose respiratory distress worsened
and who was admitted to the intensive care unit developed cardiac and respiratory arrest and he died despite all efforts of
resuscitation.
Conclusion: It should be kept in mind that the elderly patients with Covid-19 with prothrombotic risk factors are also at risk
for cerebrovascular disease in addition to the infectious symptoms. In this case report, a patient infected with SARS-CoV-2
and diagnosed as acute ischemic stroke with anamnesis, clinical and radiological findings is presented.
KEYWORDS: SARS-CoV-2, COVID-19, Cerebrovascular Disease, Wallenberg Syndrome, Cytokine Storm.

Correspondence : Dr Melike Batum, Department of Neurology, Celal Bayar University, 45000, Manisa, Turkey. Email :
drmelikeyaman@hotmail.com
Copyright © 2020 Kısabay AkA et al.This is an open access article distributed under the Creative Commons Attribution 4.0
International, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.

HIGHLIGHTS
• SARS-CoV-2, causative agent of COVID-19, is a virus with neuro-invasive features.
• During the disease increased inflammation, immobilization, hypoxia and disseminated intravascular
coagulation contribute to development of cerebrovascular diseases.
• Inflammation may be monitored with levels of ferritin, CRP and d-dimer.
• Particularly the elderly patients with risk factors for development of atherosclerosis should be followed
closely.

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INTRODUCTION of the CNS include dizziness, vertigo, sleep disorders,

Severe acute respiratory syndrome coronavirus-2 (SARS- headaches, loss of conscious, ataxia, seizure, acute
CoV-2), which is the causative agent of Coronavirus cerebrovascular disease (ACD), meningitis, and
disease 2019 (COVID-19), was first detected in China in encephalitis [4].
December 2019 [1]. About 172.000 confirmed cases were In COVID-19 increased inflammation, immobilization,
detected so far and a total of 4729 patients died of the hypoxia and disseminated intravascular thrombosis
disease [2]. Remarkable symptoms of COVID-19 include increase predisposition to ACD [5]. This case report
high fever, cough, fatigue, hemoptysis and dyspnea. In reported that acute ischemic stroke accompanied the
the severe cases pneumonia, acute respiratory distress clinical presentation of COVID-19.
syndrome, sepsis, heart failure, alkalosis, hyperkalemia,
acute renal failure, hypoxic encephalopathy and multiple CASE REPORT
organ failure may occur [3]. Vital findings of the 73 years old man presenting to the
SARS-CoV-2 enters the cell by binding to the emergency service with symptoms of cough, high fever
angiotensin converting enzyme (ACE-2) receptors. ACE- starting about one week ago followed by dyspnea were as
2 receptors which are present on the type II alveolar follows: arterial blood pressure 145/95 mm/Hg,
epithelial cells of human lung are also expressed in the temperature 38.2°C, respiratory rate 18 per minute.
glial cells and in the neurons [4]. SARS-CoV-2 may Physical examination revealed widespread rales which
spread from the respiratory system to the central nervous were more remarkable in the middle and lower bilateral
system either by means of its neuro-invasive features or pulmonary lobes and pretibial edema on both lower
by altering the endothelial and epithelial cells making the limbs. Medical history of the patients included
blood-brain barrier or through retrograde axonal route. hypertension, chronic obstructive pulmonary disease,
Thus, neurological conditions are commonly observed in diabetes mellitus (DM) and smoking of 18 packs per year
the patients with COVID-19. Several neurological for 30 years. Thoracic computerized tomography (CT)
conditions including involvement of the central nervous revealed ground-glass densities which were more
system (CNS), peripheral nervous system and skeletal prominent on the middle and lower lobes and mild
muscles have been reported in more than one third of the parenchymal involvement (Figure 1) and the patient was
patients [3]. Signs and conditions indicating involvement admitted to the hospital with diagnosis of COVID-19.

Figure-1: Thoracic CT revealed widespread remarkable rough reticular markings and traction bronchiectasis in parenchymal areas of both
lungs. Ground-glass densities were observed which were more prominent in the middle and lower lobes.

His treatment was started with chloroquine at loading pCO2:2.34, SO2: 85 and HCO3:25 and oxygen treatment
dose of 800 mg daily, followed by maintenance dose of was started with nasal canula. Results of routine
400 mg daily, azithromycin at loading dose of 500 mg biochemistry and hemogram investigations and
daily followed by maintenance dose of 250 mg daily, polymerase chain reaction (PCR) results from the
ceftriaxone at daily dose of 0,5 mg/kg per 12 hours (40 nasotracheal smear samples for Covid-19 are given in
mg bid). Arterial blood gas parameters were pH:7.45, Table-1.

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Table-1: Characteristics of blood hemogram, biochemical and Covid-19 PCR tests of the patient after admission
27th 28th 30th
Covid-19 PCR
(Smear from the upper respiratory tract) Negative Negative Positive
Indicators (Normal range) Detection time (April-May)
27th 28th 29th 30th 01st 02nd 03th
White blood cell (4,5-11 x 10³. /µL) 6,15 4,83 6,26 8,80 8,6 9,20 15,2
Neutrophil (1,8 -6,4 x 10³. /µL) 4,91 4,23 5,16 7,91 5,10 7,19 13,37
Lymphocyte (1,2-3,6x 10³ /µL) 0,84 0,39 0,67 0,42 0,34 1,17 0,81
Eosinophils (0,1-0,5 x 10³ /µL) 0,07 0,07 0,01 0,02 0,14 0,13 0,01
Red blood cell (3,83-5,08 x 106/µL) 4,53 4,85 4,47 4,46 3,97 3,96 3,03
Monosit (0,3-0,8 x 10³ /µL) 0,32 0,19 0,36 0,91 0,32 0,66 0,91
Hemoglobin (11,7-15,5 g/dl) 11,8 12,7 11,6 11,4 11,2 9,4 8,7
Platelet (156-373 x10³ /µL) 226 228 250 252 258 403 425
PT (9,2-12,8 sn) 11,2 14,5 12,9 13,4 16,5 12,4 11,4
INR (0,8-1,2 INR) 1,20 1,12 1,09 1,01 1,43 1,07 1,01
APTT (25,1-38 sn) 28,8 27,4 25,9 27,1 23,6 26 22,1
C-Reactive Protein (0-0,5 mg/dl) 18,1 16,6 13,9 30,4 48,6 84,1 111,6
Ferritine (24-336 ng/mL) 311 335 320 716 945 526 726
Procalcitonin (0-0,065ng/mL) 0,1 0,1 0,1 0,9 0,9 0,9 0,7
Alanine aminotransferase (0-35 U/L) 34 46 33 27 38 29 20
Aspartate aminotransferase (0-35 U/L) 42 48 24 27 41 34 41
Serum total protein (6,6-8,3 g/dl) 6,2 6,0 5,6 5,2 5,1 6,65 6,48
Serum albümin (3,5-5,2 g/dl) 2,8 2,7 2,5 2,9 2,7 2,9 3
Creatine kinase (0-145 U/L) 18 21 16 24 36 30 32
Lactic dehydrogenase (0-247 U/L) 286 317 292 423 441 345 437
Fibrinogen (200-393 mg/dl) 1068 982 944 977 1054 1124 1245
D-dimer (<243 ng/ml) 1604 1921 1035 3035 3446 3657 4160
PT: protrobin time, aPTT: activated partial thromboplastin time, INR: International Normalized Ratio

On the neurological exam performed for symptoms of patient revealed that he had complaints of dizziness,
dizziness, imbalance, speech disorder and deviation of vertigo and speech disorder one day after his admission
angle of mouth he was conscious, cooperating, oriented to the hospital and these findings progressed in one day.
limitedly and the right nasolabial groove was indistinct Cerebral magnetic resonance imaging (MRI) revelaed
and he had dysarthria and ataxia. The right nasolabial hypo-intensity on the apparent diffusion co-efficient
groove was indistinct and the patient had dysarthria and sections and hyperintensity on the diffusion sections
ataxia. Other findings were normal on the neurological consistent with acute ischemia on the right posterolateral
exam. NIHSS score was 4. More detailed history of the area of the bulbus (Figure 2).

Figure-2: Cerebral magnetic resonance imaging (MRI) revealing hyperintensity on diffusion sections and hipointensity in apparent diffusion
co-efficient sections of the right posterolateral area of the bulbus. These findings were considered to be consistent with acute ischemia.

Acetyl salicylic acid at dose of 300 mg daily was added echocardiogram (ECO) revealed second degree
to treatment of the patient considered to have clinical of tricuspid regurgitation and intermediate
presentation consistent with ACD upon his history and pulmonary hypertension. Calcium canal blocker was
examination and imaging findings. In regard to the added to the treatment after the patient with medical
investigations for risk factors, electrocardiogram (ECG) history of hypertension was evaluated in the light of all
was in normal sinus rhythm and transthoracic investigations (ECG, ECO). In regard to DM, anti-

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diabetic treatment was scheduled and blood sugar was intravascular coagulation (DIC) through fulminant
regulated. CT-angiogram ordered for detailed activation of coagulation and results in widespread
investigation of both anterior and posterior circulatory microvascular thrombosis. The virus binds to ACE-2
system of our patient was within normal limits. On the receptors and decreases their expression, activating the
5th post-admission day, the patient was admitted to the reticuloendothelial activation system. Thus, risk of
intensive care unit (ICU) and entubated because of pulmonary embolism, pulmonary hypertension, and
development of unconsciousness and decrease in partial fibrosis increases as a consequence of platelet adhesion
oxygen tension (PO2: 48) and oxygen saturation (SO2: and aggregation. Additionally, risk of venous
81). The patient with general decline in health status thromboembolism also increases in these patients due to
during stay in ICU developed cardiac and respiratory prolonged immobilization. In brief, increased level of
arrest was resuscitated. However, he didn’t response to lactate dehydrogenase (LDH), ferritin, C-reactive protein
the resuscitation and died. (CRP), d-dimer, and Interleukins is considered as an
DISCUSSION indication of predisposition of the disease to the pro-
The patient presented here is of importance because he inflammatory and hypercoagulability [8]. In our patient,
had posterior system ischemic stroke considered to be levels of LDH, CRP, d-dimer and ferritin indicating
induced by confirmed COVID-19 infection. It has been predisposition to hypercoagulability were found to be
reported that 5.7% of the patients with severe infection high. Furthermore, timing of stroke in our patient (day 8)
[3] and about 5% of the patients with COVID-19 develop is consistent with the time at cytokine storm reported in
ischemic stroke during the course of the infection. Mean the literature (day 7-14).
age at the time of stroke in 71.6 years in COVID-19 In brief increased inflammation, immobilization, hypoxia,
disease [3, 6]. Most patients have such risk factors as and DIC contribute to occurrence of ACD. In conclusion,
hypertension, DM and coronary arterial disease [6]. Age predisposition to thrombosis increases remarkably in the
of the patient presented here was 73 years, similar to the presence of severe COVID-19 infection and risk factors
literature and the patient had risk factors of DM and for development of atherosclerosis. As can be understood
hypertension. from the findings of thoracic CT and inflammation
Severe viral infection leads to activation of complement markers, Wallenberg syndrome consistent with
and increased level of the proinflammatory cytokines involvement of the posterior circulatory system was
such as interleukin (IL)-2, IL6, IL-8, IL-10 and tumor considered in our patient due to severe nature of COVID-
necrosis factor alpha (TNF α) within 7 to 14 days after 19 infection and presence of accompanying
onset of the symptoms following viremia [6]. Endothelial atherosclerotic risk factors.
injury activates the coagulation system along with the
immune system response. In addition, endothelial injury COMPETING INTERESTS
creates hypercoagulability by cause excessive production The author declares no competing interests with this case.
of thrombin and inhibition of the fibrinolysis [7].
Hypoxia occurring in COVID-19, however, increases PATIENT CONSENT
blood viscosity as well as stimulates thrombosis via Written informed consent was obtained from the patient
signaling due to hypoxia-induced transcription factors. for publication of this case report.
Severe COVID-19 infection causes disseminated

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