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Ischemic stroke and cerebral vasospasm in a COVID-19 patient

Authors: DOMINGUEZ-WISCOVITCH Andrea , EIMAN Matthew N. , HINGORANY Sneha , MCDOUGAL Mackenzie , NAYDIN Stanislav, BINNING Mandy J., LIEBMAN Kenneth

Find out how this team from the Drexel University College of Medicine Philadelphia (United States) treated a COVID-19 positive 62-year-old male patient suffering from an ischemic stroke.

Monday 14 March 2022
  • Case

    BACKGROUND

    • COVID-19 has presented with a plethora of wide-ranging complications
    • Neurological complications1
      • Stroke
      • Cerebral or subarachnoid hemorrhage
      • Central nervous system (CNS) vasculitis
      • Cerebral vasospasm
      • Guillain-Barré Syndrome
      • Ageusia and/or anosmia
    • Paramount to anticipate and report complications for better patient outcomes

     

    • Possible mechanisms leading to cerebral vasospasm (CV) in COVID-19 patients have been described
      • Cerebral vasculitis describes endothelial damage and vasoconstriction leading to CV2
      • Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by a reversible, multifocal narrowing of cerebral arteries with or without neurological deficits3
      • Hypothesized that SARS-CoV-2 may induce vasoconstriction due to downregulation of the ACE2 receptor4

     

    THE CASE

    • A 62-year-old man with a history of hypertension, smoking, and alcohol abuse and noncompliant with medication presented to the hospital after being found unconscious in his car by EMS. 
      • Per family history, the patient had been complaining of headaches for several days
      • Intubated due to low GCS score and vomiting/concern for airway
      • Given levetiracetam, mannitol, and furosemide to be stabilized to transfer from OSH
    • The patient was found to be in hypertensive crisis with his BP being 240/140
      • Controlled with clevidipine
    • Lab findings: hyperglycemia, hyperlipidemia, polycythemia, normal coagulation studies, blood alcohol test negative, arterial blood gasses within normal limits
    • Home 81mg aspirin reversed on arrival with desmopressin
    • Neuro exam: intubated, minimal sedation, no eye-opening, pupils 2mm round and reactive, +cough/gag/corneal reflexes, bilateral upper extremity localization right > left, bilateral lower extremity withdrawal, not following commands
    • Found to be COVID positive on nasopharyngeal swab RT-PCR assay

     

    • Presenting non-contrast head CT showing an intraventricular hemorrhage.

     

    Ischemic stroke

     

    • Presenting MRI acute lacunar infarct in the left caudate body, with adjacent casted hematoma within the left lateral ventricle. 

     

    Ischemic stroke

     

    HOSPITAL COURSE

    • Patient was admitted to the NeuroICU 
      • Right external ventricular drain (EVD) was placed emergently
    • Increased FiO2 demands with COVID, started on prednisone 
    • Physical exam began to improve however required oxazepam for high CIWA* scores consistent with history of significant alcohol abuse
    • Patient became agitated
      • Self-extubated, transition to O2 via nasal cannula
      • Was also pulling at EVD
    • Marked improvement – patient was following commands and conversational
    • EVD self-removed day 12 
      • Neuro exam: drowsy but arousable, moves all extremities to commands, mild left paresis
      • Patient was saturating well on room air

     

    • Sudden onset decline and somnolence on day 13 requiring intubation
      • Sudden change in mental status, not verbalizing, not following commands with extremely decreased response to deep tactile stimuli, pupils reactive
      • Neuro exam: unequal pupils, left pupil 5mm and irregular, right pupil 2mm and regular; patient nonverbal and gargling
      • Intubated due to unresponsiveness
      • Non-contrast head CT demonstrating stability with mildly enlarged ventricles
      • EVD replaced emergently; normal opening pressure
    • Further imaging was obtained due to worsening exam – CT, MRI, MRA

     

    • Non-contrast head CT obtained demonstrating diffuse hypodensities

     

    Ischemic stroke

     

    • Brain MRI DWI with diffuse ischemic changes in multiple vascular territories - bilateral MCA distributions, bilateral ACA distributions, and to a lesser degree PCA distributions and posterior circulation.

       

    Ischemic stroke

     

    • MRI ADC map correlating ischemia.

       

    Ischemic stroke

     

    • MRA of Head demonstrating diffuse vascular spasm and no evidence of large vessel occlusion or high-grade stenosis.

       

    Ischemic stroke

     

     

    HOSPITAL COURSE

    • Day 15 – Family had made decision to pursue palliative care and comfort measures only
      • Family declined autopsy
    • Work-up:
      • Venous duplex of bilateral lower extremities on days 1 & 11 showed no deep venous thrombosis
      • No cardiac structural abnormalities on echocardiogram; Ejection Fraction of 55% 
      • Vasculitis panel negative – ANA, ANCA, SS-A/SS-B, RPR, C3, C4

     

    CONCLUSION

    • COVID-19 associated with a myriad of neurological complications
    • Patient's intracerebral hemorrhage (ICH) solely intraventricular, extremely unusual, and unlikely for ICH to cause cerebral vasospasm
    • CNS vasculitis appears to be a rare complication of COVID-19 and could potentially be responsible for this patient's presentation
    • RCVS remains another possible explanation

     

    • Vasculitis
      • Symptoms frequently include stroke, encephalopathy, and seizures
      • No known CNS-specific vasculitis markers
      • Possible increased inflammatory markers in CSF
    • Reversible cerebral vasoconstriction syndrome (RCVS)
      • RCVS frequently presents with thunderclap headache and neurological deficits after exposure to a trigger
      • RCVS in rare cases can cause massive strokes and severe morbidity
      • Typically develops over the course of weeks to days and not suddenly
    • More research needed to compare the correlation between neurological deficits and COVID-19

     

    RESOURCES

    • Al-Ramadan A, Rabab'h O, Shah J, Gharaibeh A. Acute and Post-Acute Neurological Complications of COVID-19. Neurol Int. 2021;13(1):102-119. Published 2021 Mar 9. doi:10.3390/neurolint13010010
    • Berlit P. Diagnosis and treatment of cerebral vasculitis. Ther Adv Neurol Disord. 2010 3(1):29-42. Doi: 10.1177/1756285609347123
    • Chen SP, Fuh JL, Wang SJ. Reversible cerebral vasoconstriction syndrome: an under-recognized clinical emergency. Ther Adv Neurol Disord. 2010;3(3):161-171. doi:10.1177/1756285610361795
    • Eleuteri D, Montini L, Cutuli SL, Rossi C, Alcaro F, Antonelli M. Renin-angiotensin system dysregulation in critically ill patients with acute respiratory distress syndrome due to COVID-19: A preliminary report. Crit Care. 2021;25(1):91. Doi: 10.1186/s13054-021-03507-7.
    • Singhal A, et al. Reversible cerebral vasoconstriction syndromes: analysis of 139 cases. Arch Neurosci. 2011;68(8):1005-12
    • Sommer B, Maurer C, Berlis A, Shiban E. Spontaneous Intracerebral Hemorrhage and Delayed Cerebral Vasospasm in a Patient with COVID-19 Infection. Arch Neurosci. 2021;8(3):e116184.doi: 10.5812/ans.116184
    • Spudich S. and Nath A. “Nervous system consequences of COVID-19” Science. January 21, 2022

     

    SOURCES

    1. Al-Ramadan A, Rabab'h O, Shah J, Gharaibeh A. Acute and Post-Acute Neurological Complications of COVID-19. Neurol Int. 2021;13(1):102-119. Published 2021 Mar 9. doi:10.3390/neurolint13010010
    2. Berlit P. Diagnosis and treatment of cerebral vasculitis. Ther Adv Neurol Disord. 2010 3(1):29-42. Doi: 10.1177/1756285609347123
    3. Chen SP, Fuh JL, Wang SJ. Reversible cerebral vasoconstriction syndrome: an under-recognized clinical emergency. Ther Adv Neurol Disord. 2010;3(3):161-171. doi:10.1177/1756285610361795
    4. Eleuteri D, Montini L, Cutuli SL, Rossi C, Alcaro F, Antonelli M. Renin-angiotensin system dysregulation in critically ill patients with acute respiratory distress syndrome due to COVID-19: A preliminary report. Crit Care. 2021;25(1):91. Doi: 10.1186/s13054-021-03507-7
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