ABSTRACT
Background: Paediatric Cov-2 infections have been less severe than in adults, however some have developed a newly defined syndrome, Paediatric Inflammatory Multisystem Syndrome associated with CoV-2 (PIMS -TS). Its presentation is variable and can cause multi-system involvement. It belongs to the common spectrum of pathogen-triggered hyperinflammatory states, including atypical Kawasaki disease. Case summary: 17 year old male of Ghanaian origin, with no significant past medical history, presented with a one-week history of general malaise, fevers and sore throat. He developed severe chest pain and cardiogenic shock, with a CRP of 200, raised troponin and global hypokinesia on echocardiogram with an ejection fraction of 20%. He was positive for SARS-CoV-2 antibodies (though PCR-antigen negative at admission) and fit the criteria for myocarditis secondary to PIMS-TS. He was treated for sepsis, commenced on IV methylprednisolone and needed intubation, sedation and cardiothoracic ICU level care. On weaning sedation after 3 days, he was found to have left middle cerebral artery syndrome with NIHSS 16. CT head and CT angiogram showed a left MCA ischaemic stroke, and a thrombus in the Sylvian MCA branch. This was treated with antiplatelets. His disease markers and motor deficits improved significantly, however he has cognitive impairment and low mood. Conclusion: PIMS-TS related LVO anterior circulation infarct is rare. It necessitates urgent recognition and multi-specialty involvement as currently management is not standardised. Axial DWI (A), ADC (B) MRI demonstrate large left MCA territory infarct. Axial MRA (C) shows occlusion of the left M2 branches, signal drop-out on SWI (D).
ABSTRACT
Introduction: There are reports of changes in the numbers of stroke admissions and time intervals to receiving emergency treatments during the COVID-19 pandemic. We examined the impact of the COVID-19 pandemic on the stroke thrombolysis rate and delay to thrombolysis treatment in a regional stroke centre in London, UK. Methods: COVID-19 testing began at our hospital on 3 March 2020. Clinical data for all acute stroke admissions were routinely collected as part of a national Sentinel Stroke National Audit Programme (SSNAP) and all thrombolysis data were entered into our local thrombolysis database. We retrospectively extracted the relevant patient data for the period of March to May 2020 (COVID group) and compared to the same period in 2019 (pre-COVID group). Results: Compared with pre-COVID, there was a 17.5% fall in total stroke admissions (from 315 to 260) during COVID;but there were no significant differences in the demographics, stroke severity, proportions with known time of onset, or median onset-to-arrival time. The thrombolysis rates amongst ischemic strokes were not significantly different between the two groups (59/260=23% pre- COVID vs. 41/228=18% COVID, p=.19). For thrombolysis patients, their stroke severity and demographics were similar between the two both groups. Median onset-to-needle time was significantly longer by 22 minutes during COVID [127 (IQR 94-160) vs. 149 (IQR 110-124) minutes, p=.045];this delay to treatment was almost entirely due to a longer median onset-to-arrival time by 16 minutes during COVID (p=.029). Favorable early neurological outcomes post-thrombolysis (defined as an improvement in NIHSS by ≥4 points at 24 hours) were similar (45% vs. 46%, p=.86). Conclusion: COVID-19 pandemic had a negative impact on prehospital delays which in turn significantly increased onset-to-needle time, but without affecting the chance of a favorable early neurological outcome. Our data highlight the need to maintain public awareness of taking immediate action when stroke symptoms occur during the COVID-19 pandemic.