In a recent study published in Radiology Case Reports, researchers described a case of a patient with acute respiratory failure and ischemic stroke.
Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was declared a pandemic by the World Health Organization in March 2020. Although primarily a respiratory disease, neurologic complications may occur in patients, increasing disease severity.
Ischemic stroke is an underrecognized neurologic complication of COVID-19, and the clinical presentation varies across patients. Studies have noted that most COVID-19 patients with ischemic stroke are older adults (aged 60 or above). Nonetheless, ischemic stroke has also been documented in younger COVID-19 patients. The pathogenesis and management of ischemic stroke in COVID-19 are unclear.
The study and findings
In the present study, researchers described a patient from Oujda, Morocco, with acute respiratory failure and ischemic stroke. The subject was a 44-year-old female, infected with the SARS-CoV-2 Delta variant and non-vaccinated. Twelve days before admission, the patient developed flu-like syndrome with fever, cough, myalgia, and asthenia.
Two days post-hospitalization, right hemiplegia was documented. Respiratory discomfort prompted a visit to the emergency department at the Mohamed VI University Hospital. Clinical examination revealed a blood pressure of 140/65 mm Hg, tachycardia, polypnea, and oxygen saturation at 60% (breathing room air).
Neurologic examination showed right hemiplegia, with a confusional syndrome, visual and auditory hallucinations, without any speech disorders. The patient was admitted to an intensive care unit (ICU). Cerebral magnetic resonance imaging (MRI) scan showed diffusion hyper signal with low apparent diffusion coefficient (ADC) in the left frontal, right frontal, and left temporal cortico-subcortical areas. It also revealed multiple bilateral sylvian ischemic strokes.
Thoracic computed tomography (CT) scan showed bilateral alveolar-interstitial lung disease, suggestive of COVID-19, classified as COVID-19 Reporting and Data System (CO-RADS) category 5. The CT scan also revealed segmental pulmonary embolism in the left upper and right lower lobes. Laboratory investigations showed lymphopenia and elevated D-Dimer levels.
The SARS-CoV-2 reverse-transcription polymerase chain reaction (RT-PCR) test returned positive, confirming the COVID-19 diagnosis. The electrocardiogram showed no conduction disorder or rhythm abnormalities. Transthoracic echocardiogram was normal.
The patient was started on oxygen therapy, azithromycin for seven days, ciprofloxacin, ceftriaxone, methylprednisolone, vitamin C, paracetamol (if febrile), nicardipine, and low molecular weight (LMW) heparin. The patient was also given levetiracetam and antiplatelet therapy.
The patient showed clinical improvement after 12 days in the ICU and was discharged with good respiratory progress and persistent sensory-motor deficit and, therefore, referred to a physical rehabilitation service. In summary, the study documented multiple ischemic strokes in a patient with pulmonary embolism, which was suggestive of COVID-19 pneumopathy.