Fulminant Extra- And Intracranial Arteriovenous Thrombosis And Non-aneurysmal Subarachnoid Hemorrhage Following COVID-19 Infection.

PURPOSE: Coronavirus disease of 2019 (COVID-19) is associated with increased risk of stroke and intracranial hemorrhage. This first report of fulminant panvascular arteriovenous thrombosis with subarachnoid hemorrhage (SAH) in a post-COVID-19 infection is attributed to extensive arteriovenous inflammation leading to arterial rupture following vasculitis. CASE REPORT: We report a rare case of extensive extra- and intra-cranial cerebral arteriovenous thrombosis following COVID-19 infection, presenting as fatal non-aneurysmal subarachnoid hemorrhage. The clinical course, biochemical and radiological evaluation is discussed. The other possible etiological differentials which were analysed and ruled out during case management are also detailed. CONCLUSION: A high degree of suspicion for COVID-19 induced coagulopathy leading to extensive non- aneurysmal, non-hemispheric SAH and malignant intracranial hypertension should be entertained. Our experience and previous reports on non-aneurysmal SAH in such patients show a poor prognosis.

Superior Cerebellar Artery Dissection in a Patient Diagnosed with Reversible Cerebral Vasoconstriction Syndrome: A Case Report

Arterial dissection is an uncommon complication of reversible cerebral vasocon-striction syndrome (RCVS). We describe the case of a 35-year-old woman with a migraine history who presented with recurrent thunderclap headache and focal neurological signs, including right hemiataxia. She had been diagnosed with COVID-19 disease two weeks earlier. Neuroimaging revealed multifocal stenosis of the posterior circulation arteries and dissection of the right superior cerebellar artery. She improved significantly throughout her one-week hospitalization and maintained only mild ataxia. The interplay between COVID-19 disease, RCVS, and arterial dissection requires further investigation.Copyright © Author(s) (or their employer(s)) and Sinapse 2022.

Endovascular Treatment of Basilar Artery Occlusion: What Can We Learn from the Results?

Background and Objectives: Current guidelines lack specific endovascular treatment (EVT) recommendations for posterior circulation stroke (PCS). The results of earlier studies are controversial. We aimed to compare early hospital outcomes of stroke caused by large-vessel occlusion (LVO) treated with EVT or bridging therapy (BT) in anterior circulation stroke (ACS) versus PCS (middle cerebral artery occlusion (MCAO) and basilar artery occlusion (BAO), and establish the risk factors for poor outcome. Materials and Methods: we analyzed the data of 279 subjects treated with EVT due to LVO-caused stroke in a comprehensive stroke centre in 2015−2021. The primary outcome was hospital mortality, secondary outcomes were National Institutes of Health Stroke Scale (NIHSS) after 24 h, early neurological deterioration, futile recanalization (FR), the ambulatory outcome at discharge, and complications. Results: BAO presented with higher baseline NIHSS scores (19 vs. 14, p < 0.001), and longer door-to-puncture time (93 vs. 82 min, p = 0.034), compared to MCAO. Hospital mortality and the percentage of FR were the same in BAO and almost two times higher than in MCAO (20.0% vs. 10.3%, p = 0.048), other outcomes did not differ. In BAO, unsuccessful recanalization was the only significant predictor of the lethal outcome, though there were trends for PAD and RF predicting lethal outcome. A trend for higher risk of symptomatic intracranial hemorrhage (sICH) was observed in the BAO group when BT was applied. Nevertheless, neither BT nor sICH predicted lethal outcomes in the BAO group. Conclusions: Compared to the modern gold standard of EVT in the ACS, early outcomes in BAO remain poor, there is a substantial amount of FR. Nevertheless, unsuccessful recanalization remains the strongest predictor of lethal outcomes. BT in PCS might pose a higher risk for sICH, but not the lethal outcome, although this finding requires further investigation in larger trials.

A catastrophic case of ischemic stroke and acute myocarditis in a young patient following mRNA COVID-19 vaccination: Coincidence or consequence?

A healthy 32-years-old man was admitted in emergency department after cardiac arrest at home. He had complaints of fatigue and general malaise after Pfizer-BioNTech Coronavirus disease-2019 (COVID-19) first dose vaccine 48 hours earlier. Upon hospital admission, patient scored 3 points in Glasgow Coma Scale. Electrocardiogram showed atrial fibrillation with rapid ventricular response and a point-of-care ultrasound demonstrated severe left ventricular dysfunction with global hypokinesia. Blood tests were remarkable for elevation of high-sensitivity cardiac troponin-T and inflammatory parameters, normal platelet and fibrinogen levels and slightly increased D-dimer. A computed tomography (CT) with angiography of the cerebral arteries revealed acute ischemic posterior circulation stroke with total occlusion of the basilar artery and partial occlusion of the left vertebral artery. Life-saving systemic thrombolysis was performed but there was no clinical benefit. Pulmonary embolism was excluded. Transesophageal echocardiography showed severe left ventricular dysfunction (LVEF 30%), global hypokinesia and an apical thrombus with no other significant abnormalities. De novo multiple ischemic injuries were shown in 24h control brain CT. Once autoimmunity, thrombophilia study, PCR and serologic tests for viral infections including SARS-CoV-2 were negative, cardioembolic stroke following post-vaccinal myocarditis was suspected. Brain stem death was verified 72h later and a post-mortem endomyocardial biopsy was performed, although no signal of myocarditis was found. COVID-19 mRNA vaccination is associated with increased risk of myocarditis. We report the first known case of cardioembolic stroke and probable myocarditis after BNT162b2 first dose. This highlights that, although rare and with a predominantly favorable course, vaccine-related myocarditis can have life-threatening complications. (Figure Presented).

Quadriparesis after COVID-19 Vaccination: Two Cases with Different Diagnosis

Aim and objective: During the recent COVID-19 pandemic various vaccines have been developed and approved for emergency use, including adenovirus vector-based ChAdOx1 nCov-19. There are few reports of serious adverse events following immunization (AEFI). Materials and methods: Here, we report two cases of serious AEFI who required ICU admission. Results: Case 1: A 55-y-m hospitalized with complaints of giddiness for 4 days and onset of weakness of all four limbs with altered sensorium for 1 day. He had no history of any comorbidity, non-smoker and non-alcoholic, and no previous episodes of transient ischemic attacks. He was vaccinated with a second dose of adenoviral vector-based ChAdOx1 nCov-19 vaccine (8 days before the onset of first symptoms). After hospitalization, immediate intubation was done for airway protection. His neurological examination revealed blinking of eyes spontaneously, motor power of 0/5 in all four limbs, deep tendon reflex of +2, and mute plantar. MRI Brain was done on the next day (day of illness, DOI-4), which revealed acute infarct in the pons and bilateral cerebellar hemisphere. He was referred to our ICU on DOI-12. Repeat MRI Brain on DOI-16 showed subacute infarcts in the pons, bilateral middle cerebellar peduncles, and left cerebral hemisphere with thrombosed basilar artery. Lipid profile, homocysteine levels, auto-immune work-up were normal. Echocardiography showed normal LV function with no evidence of LA clot. Carotid Doppler showed normal carotid vessels. In view of ischemic stroke and basilar artery thrombosis anti-platelet agent and therapeutic anticoagulation continued. Over the next 3 weeks, he showed gradual improvement in motor power (3/5 in upper limbs and 2/5 in lower limbs) and weaned off from mechanical ventilation. Case 2: A 19-y-m hospitalized with complaints of acute onset paraesthesia and progressive weakness in both lower limbs for 4 days and difficulty in speech and swallowing for 1 day. He had no history of any comorbidity, and no history of preceding viral/bacterial infection except that he had received the first dose of the adenoviral vector-based ChAdOx1 nCov-19 vaccine (16 days before the onset of first symptoms). After hospitalization, he required intubation in view of pooling of oral secretions and respiratory distress. Clinical examination revealed bifacial weakness, severe neck muscle weakness, and flaccid areflexic quadriparesis with prominent proximal upper and lower limb weakness. Pin-prick sensation was distally reduced in both lower limbs with associated autonomic instability in the form of tachycardia and hypertension. MRI Brain was normal in the study. In further work, Guillain-Barré syndrome (GBS) was diagnosed. CSF showed albumin-cytologic dissociation (protein 1.14 g/L and nil cell), and bilateral motor nerve axonal neuropathy on nerve conduction study. Immunoglobulin (IVIG) therapy was started on DOI-6. He did not show significant improvement and was referred to our ICU for further management. During the 5th week of illness, the IVIG dose was repeated without any improvement and continuing requirement of mechanical ventilation. Conclusion: Though vaccination is one of the important public health interventions implemented to tackle the COVID-19 pandemic, there are known and unknown serious AEFI being reported. Both cases presented quadriparesis with different diagnoses, who received vaccination for COVID-19.

PULSERIDER-ASSISTED TREATMENT OF INTRACRANIAL ANEURYSMS IN THE STERLING REGISTRY

Introduction PulseRider (Cerenovus, Irvine, CA) is an adjunctive neck bridging device designed to aid in coiling of wide neck bifurcation intracranial aneurysms. We present outcomes of PulseRider assisted coil embolization of brain aneurysms in routine clinical practice included in the STERLING registry. Materials and Methods STERLING (NCT03642639) is a prospective, global registry of endovascular treatment of intracranial aneurysms with Galaxy and MicrusFrame coils (Cerenovus, Irvine, CA). PulseRider cases from STERLING were included in this interim analysis. Primary outcome measures were core-lab assessed modified Raymond-Roy (mRR) occlusion at final procedural angiogram, and where available, at 6 months (+/-3 months) or 1 year (COVID allowed window: -3 months/+1.5 years). Safety outcomes were procedureand device-related adverse events. Results Seventeen subjects (mean age 64.4 ± 8.69 years, 12 female) were treated with the PulseRider device. All cases were unruptured and two were retreatments of previously coiled aneurysms. All aneurysms had saccular morphology, 14/ 15 (93.3%) were wide neck and 13/15 (86.7%) were at a bifurcation. Target aneurysm locations included basilar artery (6/15, 40.0%), MCA bifurcation (4/15, 26.7%), ACA (3/15, 20%), ICA terminus (1/15, 6.7%), and M2 (distal to bifurcation, 1/15, 6.7%), with a mean parent vessel diameter of 2.65 ± 0.440mm. PulseRider was successfully implanted with the ability to retain the coil mass in all cases. Mean packing density was 29.7 ± 11.32%. Adequate occlusion (mRR I or II) was achieved in 86.7% (13/15) cases immediately post procedure, 100% (3/3) at 6 moths, and 75% (3/4) at 1 year. There were no intraprocedural ruptures, no symptomatic thromboembolic events, and no device related SAEs through the maximum follow up. 87.5% (7/8) subjects had mRS 0-2 at 1 year. There were no aneurysm retreatments. Conclusion In this interim analysis of the ongoing STERLING registry, treatment of intracranial aneurysms with the PulseRider device in conjunction with embolization using Galaxy and MicrusFrame coils showed excellent safety outcomes and high rates of adequate occlusion and good clinical outcome.

A peculiar presentation of stroke in young patients

Introduction: Young patients presenting with stroke to the emergency department (ED) is more uncommon. Atypical presentations of stroke in young patients presenting to ED include loss of consciousness, headache, vomiting, and blurring of vision. Young patients may present with stroke of infective causes which include bacterial, viral, fungal, and parasitic origin. Case discussion: A 24-year-old male presented to the ED in semiconscious state with decreased responsiveness along with complaints of fever since 2days and giddiness since 2days, followed by two episodes of vomiting and loss of consciousness. His vital data are blood pressure of 90/60mm Hg, and on examination, Glasgow Coma Scale (GCS) was E3V2M2, pupils are 1mm sluggishly reacting to light and showing upbeat and downbeat nystagmus on both sides, horizontal gaze palsy was present on the right side, all four limbs are in paraplegia and hyperreflexive to deep tendon reflexes, and ankle clonus is present. In view of poor GCS, the patient was intubated in the ED. The patient had a history of right maxillary fungal sinusitis 7 years back for which Functional Endoscopic Sinus Surgery (FESS) was done. The patient denied COVID infection and immunization. Neuroimaging and magnetic resonance imaging (MRI) brain plain with contrast revealed right maxillary fungal sinusitis extending up to the base of the skull with bilateral pontine and cerebellar infarcts, and there was complete occlusion of basilar artery occlusion. The patient was shifted to the intensive care unit (ICU);on further evaluation, the patient's serum homocysteine, protein C, and protein S were normal. Carotid Doppler was normal. Infective workup was done for TB and herpes simplex virus (HSV), bacterial workup was done, and then fungal workup was done for KOH mount, and tissue fungal smear revealed Aspergillus which was managed with antifungals like liposomal amphotericin B and voriconazole;FESS was done during hospitalization. The patient improved clinically and was discharged to the rehabilitation center. Conclusion: In this case, the cause of stroke was an improperly treated fungal sinusitis which invaded the basilar artery. Being an emergency physician, we should have high index of suspicion in the case of young patients presenting with stroke to ED;we need to consider their past history which gives clue toward the diagnosis of infective causes besides routine workup.

Basilar Artery Thrombosis in the Postpartum Period During COVID – 19 Pandemic: A Lethal But Avoidable Complication

Purpose: To highlight the factors leading to the delayed diagnosis of basilar artery occlusion and poor outcome in the postpartum period during the prevailing Corona Virus Disease-2019 (COVID-19) pandemic. Case report: We here report a case of a 34-year female who presented with a headache localized to the occipital region after cesarean section under spinal anesthesia. Her headache severity increased over time, and she developed a generalized seizure episode and became unconscious. Subsequently, basilar artery thrombosis was diagnosed. Despite all efforts, she succumbed to death. We believe that we might have saved the patient's life if we could have made the diagnosis beforehand. Conclusion: We recommend that unless shown otherwise, postpartum headache and neck discomfort, even in individuals with no known risk factors, should have a low index of suspicion, early diagnosis using non-invasive radiological study such MRI to rule out this uncommon but deadly illness quickly. © 2022, Neurological Society R.O.C (Taiwan). All rights reserved.

Basilar Artery Thrombosis in the Postpartum Period During COVID - 19 Pandemic: A Lethal But Avoidable Complication.

PURPOSE: To highlight the factors leading to the delayed diagnosis of basilar artery occlusion and poor outcome in the postpartum period during the prevailing Corona Virus Disease-2019 (COVID-19) pandemic. CASE REPORT: We here report a case of a 34-year female who presented with a headache localized to the occipital region after cesarean section under spinal anesthesia. Her headache severity increased over time, and she developed a generalized seizure episode and became unconscious. Subsequently, basilar artery thrombosis was diagnosed. Despite all efforts, she succumbed to death. We believe that we might have saved the patient's life if we could have made the diagnosis beforehand. CONCLUSION: We recommend that unless shown otherwise, postpartum headache and neck discomfort, even in individuals with no known risk factors, should have a low index of suspicion, early diagnosis using non-invasive radiological study such MRI to rule out this uncommon but deadly illness quickly.

Endovascular Reperfusion of Acute Large Vessel Occlusion Stroke

Acute stroke treatment continues to evolve with optimization of systemic intravenous thrombolysis and endovascular mechanical thrombectomy (MT) for intracranial large vessel occlusion (LVO). Neurointerventional techniques to achieve reperfusion in acute LVO stroke initially involved local intra-arterial infusion of thrombolytic agents. The subsequent development of MT devices has resulted in more complete and faster arterial recanalization while maintaining patient safety. Today, MT is standard of care for LVO stroke up to 24 h from last known well. In this chapter, we discuss various endovascular recanalization techniques for LVO stroke with illustrative cases.

Thrombotic Sequela of Asymptomatic COVID-19 Infection.

Severe coronavirus disease 2019 (COVID-19) is known to be associated with thrombotic events like ischemic stroke. However, in the case of mild or asymptomatic disease, a thrombotic event like ischemic stroke is rare and has never been reported in our country. We present the case of a 28-year-old male patient with no co-morbidities who was diagnosed to have ischemic stroke involving the basilar artery. No risk factors for ischemic stroke could be found except for post-COVID-19 status, evident by the presence of antibodies against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

Right Internal Carotid Artery and Basilar Artery Aneurysms after New Coronavirus Infection COVID-19 in Adolescent: Clinical Case

The number of people infected with the SARS-CoV-2 virus causing COVID-19 is steadily growing around the world. Given the fact that the disease is new, it is necessary to study the characteristics of its spreading and clinical course, including pediatric population. The article presents clinical case of COVID-19 in 15-year-old child with the development of thrombosed basilar artery aneurysm that compressed the brain stem in the pons and subarachnoid hemorrhage, the development of a fusiform aneurysm of the right internal carotid artery. These pathologies were later complicated by right-sided hemiparesis. The importance of inter-clinical interaction of physicians of all specialties and the need for early rehabilitation at the outpatient stage of treatment in the context of the COVID-19 pandemic were shown.

Stroke and pulmonary embolism in moderate CoViD-19

Background: Venous thromboembolism, arterial thrombosis and thrombotic microangiopathy substantially contribute to increased morbidity and mortality in CoViD-19. We report a case of 56-year old man that presented with stroke and was found to have CoViD- 19 pneumonia complicated by pulmonary embolism (PE). Description of the case: A 55-year-old man with history of hypertension presented to the emergency department after a transient loss of consciousness. He was found to have left lateral hemianopia and lower right quadrantanopsia and head CT confirmed bilateral stroke in the posterior cerebral artery territory. MR angiography excluded atherosclerosis/dissection of the vertebral and basilar artery and a positive nasopharingeal swab PCR test revealed SARS-CoV-2 infection. The patient was admitted and ASA 100 mg and enoxaparin 40 mg per day were started. He experienced dry cough and fever and 10 days after admission presented atypical chest pain. CT Angiography revealed multiple confined ground glass opacities with segmental bilateral PE. Therapeutic dose of enoxaparin was started and after 5 days switched to edoxaban 60 mg per day. The patient progressively recovered and a complete work up excluded patent foramen ovale and any other cause predisponing to combined presence of venous and arterial thrombosis Conclusions: CoViD-19 has presented many diagnostic challanges in patients with neurologic and respiratory findings: thromboembolic disease may even be the initial or unique presentation. The early recognition of these phenotipes of the disease play a dramatic role in the CoViD-19 management.

Acute Ischemic Stroke Due to Basilar Artery Occlusion with Coronavirus Disease 2019: A Case Report.

Although it is increasingly recognized that coronavirus disease 2019 (COVID-19) can cause multi-organ disease, including acute ischemic stroke, the incidence of coagulation disorder is reported to be lower in Asian countries. We report a case of a 47-year-old Asian man with mild COVID-19 respiratory symptoms who had acute basilar artery occlusion. Despite successful recanalization with mechanical thrombectomy, the patient developed extensive cerebral infarction in the posterior circulation, necessitating decompressive craniotomy. Our findings suggest that severe large vessel occlusion (LVO) can occur even in young Asian patients with mild COVID-19 respiratory symptoms and that its outcome can be extremely severe despite successful recanalization. The management of COVID-19-related LVO can be very challenging, as both the prevention of possible nosocomial infection and early recanalization are required simultaneously.