Ischemic stroke in the setting of supratherapeutic International Normalized Ratio following coronavirus disease 2019 infection: a case report.

BACKGROUND: SARS-CoV-19 infection is associated with an increased risk of thrombotic events. We present a case of acute middle cerebral artery ischemic stroke in a patient with SARS-CoV-19 infection despite being on warfarin with supratherapeutic INR (International Normalized Ratio). CASE PRESENTATION: A 68-year-old Caucasian female with multiple comorbidities was admitted to the hospital with symptoms of upper respiratory tract infection. A rapid antigen test confirmed the diagnosis of COVID-19 pneumonia, and intravenous remdesivir was initiated. On the fifth day of admission, the patient experienced sudden onset confusion, slurred speech, left-sided hemiplegia, right-sided eye deviation, and left-sided facial droop. Imaging studies revealed an occlusion of the distal anterior M2 segment of the right middle cerebral artery, and an MRI of the brain confirmed an acute right MCA infarction. Notably, the patient was receiving warfarin therapy with a supratherapeutic INR of 3.2. CONCLUSIONS: This case report highlights the potential for thromboembolic events, including stroke, in patients with COVID-19 infection, even when receiving therapeutic anticoagulation therapy. Healthcare providers should be vigilant for signs of thrombosis in COVID-19 patients, particularly those with pre-existing risk factors. Further research is necessary to understand the pathophysiology and optimal management of thrombotic complications in COVID-19 patients.

A case report overlapped vaccine and COVID-19 in disseminated atherosclerosis.

Coronavirus disease 2019 (COVID-19) has become a part of our lives now and we have no more effective way of coping than a vaccine. COVID-19 is a disease that causes severe thrombosis outside the respiratory tract. Vaccines also protect us in this respect, but in some rare cases, thrombosis has been found to develop after vaccination (much less frequently than COVID-19). What was interesting in our case was that it showed how a disaster could happen under three factors that predispose to thrombosis. A 65-year-old female patient with disseminated atherosclerosis was admitted to the intensive care unit with complaints of dyspnea and dysphasia. In the evening of the day, the patient had the vaccination 2 weeks ago, she had active COVID-19. On examination, lower extremity pulses could not be detected. The patient's imaging and blood tests were performed. Multiple complications such as embolic stroke, venous and arterial thrombosis, pulmonary embolism, and pericarditis were observed in the patient. This case may give consideration to anticoagulant therapy studies. We give effective anticoagulant therapy in the presence of COVID-19 in patients at risk of thrombosis. Can anticoagulant therapy be considered after vaccination in patients at risk of thrombosis such as disseminated atherosclerosis?

Covid 19 presenting as stroke and MI

Its now a well known fact that covid 19 causes coagulopathy that has been associated with the inflammatory phase of coronavirus disease (COVID-19) and might be involved in this concurrency. Here we present a case of a 55y old female with no underlying comorbidity presented with the chief complaints of mild slurry speech and weakness over the right side of the body from last 8 h. Noncontrast brain computed tomography (CT) scan showed early signs of ischemia in left middle cerebral artery (MCA) territory, and a CT angiogram demonstrated a carotid atheromatous plaque with a superficial thrombus causing 40% stenosis in the left proximal internal carotid artery (ICA), however no intracranial artery occlusion was found. On ecg patient had ST segment depression in and depression in v5 and v6 leads with transthoracic echocardiogram showed lateral wall hypokinesia of the left ventricle, with qualitative troponin-T positive. There were no respiratory or other symptoms compatible with COVID-19 infection or chest pain. Chest CT ruled out inflammatory/infectious signs in the lung parenchyma, and Rapid antigen testing for covid 19 was negative on admission however RTPCR for SARS-CoV-2 was positive. Patient was initially loaded with dual anti platelets and lmw heparin and was subsequently managed with aspirin 150 mg, clopidogrel 75 mg and atorvastatin 40 mg with resolution of the chest pain and slurry speech.

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.

Mechanical thrombectomy for acute multivessel occlusions with duplicated middle cerebral artery: A case report.

Acute multivessel occlusions generally have multisite clot burden with lower successful reperfusion rates, and cerebrovascular anatomical variants increase the challenge of endovascular clot retrieval. We report a case of acute anterior multivessel occlusions patient with duplicated middle cerebral artery. Combined balloon guide catheter with stent retriever and aspiration approach has gained complete revascularization and good functional outcomes at 3 months follow-up.

Acute ischemic stroke due to floating thrombus of ascending aorta: An acute and subacute complication of SARS-CoV-2 infection

Objective: To describe ischemic stroke due to floating thrombus of ascending aorta occurring as acute and subacute complication of SARS-CoV-2 infection. Material(s) and Method(s): consecutive identification in clinical practice of ischemic strokes secondary to aortic arch thrombosis and history of acute or recent Covid-19 infection. Result(s): two patients had ischemic stroke with evidence of aortic arch thrombosis. The first case had concomitant acute Covid-19 infection, the second had recent Covid-19 infection. Both patients underwent intravenous thrombolysis, and subsequent anticoagulation. One patient died due to cerebral hemorrhage. Discussion and Conclusion(s): aortic arch thrombosis can be an incidental finding in acute ischemic stroke in patients with concomitant and recent COVID-19 disease. However, the infection may lead to thrombosis in non-atherosclerotic vessels and to cerebral embolism. Our findings support active radiological search for aortic thrombosis during acute stroke in patients with acute or recent COVID-19 disease.Copyright © 2022

Isolated arteritis misdiagnosed as bilateral orbital tumors in a patient with acute ischemic stroke.

Vasculitis is a heterogeneous group of disorders characterized by multifocal segmental inflammation of the small and medium vessels of the central nervous system. The predominant symptoms of cerebral vasculitis are stroke, headache, and encephalopathy. Additional symptoms include seizures, cranial nerve palsies, and myelopathy. Imaging techniques play a crucial role in identifying the diagnosis of vasculitis and demonstrating brain involvement. An 89-year-old woman with permanent atrial fibrillation developed an embolic stroke. In treatment, intravenous thrombolysis and thrombectomy with complete antegrade reperfusion of the left middle cerebral artery was used, without the clinical effectiveness. Brain MRI revealed bilateral oval lesions in medial parts of the orbits, which were initially misinterpreted as orbital tumors. Final diagnosis confirmed thickened arterial walls as orbital changes due to inflammatory arteritis. Ten days later, follow-up MRI was performed and showed complete regression of the orbital masses. Primary central nervous system vasculitis, manifesting as acute ischemic stroke, may be reversible with early systemic thrombolytic treatment.

PREVALENCE OF STROKE IN MUCORMYCOSIS PATIENTS WITH COVID-19 INFECTION IN INDIA

Background: During the second wave of COVID-19, India suffered from a catastrophic outburst of cases and rapid transmission of disease due to the highly infectious delta strain (B.1.617.2). Patients infected with this strain underwent prolonged hospitalisations, suffered from severe symptoms. A sudden surge of fungal infections, primarily Mucormycosis was observed. Methods: We conducted a case-control study to study various risk factors and form of intracranial involvement in cases of Mucormycosis. Results: Study included 121 patients in total;out of which 61 were Mucormycosis patients with prior COVID-19 infection. 30 out of 61 Mucormycosis patients had intracranial involvement with majority having stroke in the form of the either infarct (10 patients, 34%);or haemorrhage (3 patients, 10%) and thrombosis of artery involvement (8 patients, 29%). Other intracranial form of involvement was abscess (6 patients, 20%) and meningitis (2 patients, 7%). The most frequent type of infarcts were lacunar infarcts and the most common location of infarcts were middle cerebral artery (MCA) or anterior cerebral artery (ACA). Patients were treated with administration of Amphotericin B and Posaconazole. Telephonic follow-up was conducted after a time period of about 90 days and their health condition was recorded on basis of modified ranking scale (mRS). Out of the 30 Mucormycosis infection patients displaying the occurrence of stroke, 10 patients could not survive. q Conclusion: Intracranial Mucormycosis in COVID19 patients presenting with stroke were observed frequently and had mortality in about one-third cases.

LARGE VESSEL OCCLUSION STROKE IN A 17 YEAR OLD MALE WITH PAEDIATRIC INFLAMMATORY MULTI-SYSTEM SYNDROME ASSOCIATED WITH SARS-COV-2

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).

VACCINE-INDUCED IMMUNE THROMBOTIC THROMBOCYTOPENIA: A POSSIBLE PATHOGENETIC ROLE OF CHADOX1 NCOV- 19 VACCINE ENCODED SOLUBLE SARS-COV-2 SPIKE PROTEIN

Background and aims: Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a rare syndrome of unclear aetiology occurring after vaccinations against COVID-19. The aim of this study was to investigate the DNA vaccine-encoded Sars-cov-2 soluble spike protein (SP) as a potential trigger of platelet activation in VITT. Methods: We studied three VITT patients and seven healthy controls (HCs) within 3 weeks from the first dose of ChAdOx1 nCoV-19. Serum levels of SP, soluble angiotensin-converting enzyme 2 (sACE2), and platelet response to VITT serum stimulation were studied. A thrombus retrieved from middle cerebral artery during mechanical thrombectomy of one VITT patient, was analysed by immunohistochemistry for SP and ACE2. Neutrophil extracellular traps (NETs) markers and coagulation parameters were also measured. Results: We detected SP and sACE2 in all VITT patients, and in two and three out of 7 HCs, respectively. VITT sera markedly activated platelets and this activation was inhibited by both anti-SP and anti-FcγRIIA blocking antibodies. The retrieved thrombus showed positive immunohistochemical labelling of platelets using an anti-SP antibody with reduced ACE2 expression, compared to a thrombus from a pre-pandemic stroke patient. Markers of endothelial dysfunction, NETs and hypercoagulability state were present in VITT sera. Conclusions: The present data provide first evidence that DNA vaccineencoded Sars-cov-2 SP is detectable in VITT sera (up to several weeks post-vaccination) and in a platelet-rich thrombus, and suggest that SP may contribute to the initial platelet stimulation in VITT patients. Anti-PF4/ polyanion antibodies development could represent an epiphenomenon, which amplifies platelet aggregation, NETosis, and coagulation cascade.

POST-VACCINE-INDUCED IMMUNE THROMBOTIC THROMBOCYTOPENIA (VITT) STROKE: LITERATURE REVIEW AND PROPOSAL OF A THERAPEUTIC ALGORITHM FOR THE ACUTE PHASE

Background and aims: Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a rare but catastrophic syndrome characterized by venous and arterial thrombosis, with thrombocytopenia and antibodies against platelet factor-4 (PF4)/polyanion, typically 5-30 days from the first dose of a DNA viral vector vaccine. Very rarely, acute ischemic stroke (AIS) can be the result of VITT. The aim of this study was to define the clinical and radiological characteristics, outcome and therapeutic options of VITT patients with AIS. Methods: We carried out a systematic review of the literature till October 27, 2021 using MEDLINE, PUBMED and Google Scholar databases in order to collect all the published articles related to the development of AIS after vaccination against SARS-CoV-2. Results: We identified 16 patients from case reports or case series published in peer-reviewed journals affected by AIS and confirmed VITT. All patients had received the first dose of ChAdOx1 ncov19 vaccine within 10 days (median). 81% (n=13/16) of the patients had occlusion of the middle cerebral artery (MCA) or its branches, 43.7% (n=7/16) also had thrombotic occlusion of the intracranial internal carotid artery. 45.4% (n=5/16) of the patients with proximal MCA occlusion developed a malignant MCA infarct. Only one patient received intravenous thrombolysis, while three patients underwent mechanical thrombectomy. Conclusions: The management of AIS due to large vessel occlusion in VITT is challenging. Based on the available literature, we propose a therapeutic protocol for acute stroke patients presenting to the Emergency Department within the time window for reperfusion strategies.

Pediatric Cerebral Infarction associated with recent SARS-CoV-2 mild infection treated with intravenous thrombolysis and endovascular thrombectomy

Objective: N/A Background: Acute ischemic stroke is a major cause of disability worldwide in adults and children. It is a common disease after middle age but uncommon in the pediatric population. Disabling arterial ischemic strokes due to acute intracranial large vessel occlusion within 3-4 weeks of SARS-CoV-2 (COVID-19) infection have been described. Design/Methods: N/A Results: A 15-year-old boy presented with sudden onset right-sided weakness and expressive aphasia witnessed by mother. He presented within 50 minutes of symptom onset to the regional ER facility. Around 4 weeks ago, patient had mild SARS-Cov-2 infection with flu-like symptoms and mild chest pain that worsened with exertion lasting 3-4 days. Neurological examination revealed diminished fluency, anomia, and right upper extremity drift. Initial non contrast computed tomography (CT) demonstrated hyperdense left middle cerebral artery (MCA) sign with subtle loss of gray/white matter differentiation in the left anterior insula. Aphasia and right-sided weakness worsened as he was coming back from CT 2 hours after symptom onset. Intravenous Tenecteplase was administered. CT angiography of head/neck confirmed left proximal M2 occlusion with no arterial dissection. Patient underwent successful mechanical thrombectomy. Three days later his deficits completely resolved. Transthoracic echocardiography with contrast bubble study was unremarkable. Laboratory workup demonstrated mildly low ATIII, positive Factor V Leiden screen with negative genetic testing, positive SARS coronavirus-2 IgG, mildly low PTT. Remaining coagulopathy workup was unremarkable. Conclusions: To our knowledge this is the first case of large vessel occlusion in a pediatric patient treated successfully with both intravenous thrombolysis and mechanical thrombectomy associated with recent SARS-Cov-2 infection. The AIS etiology in our case remains uncertain as abnormal laboratory findings do not explain this presentation. There is high clinical suspicion of an embolic event as possible explanation, possibly related to SARS-CoV-2 postinfectious stage.

Thromboembolic clot perviousness in COVID-19: A case-control study

Background: Large vessel occlusion (LVO) is the most common stroke subtype for those patient's presenting with COVID-19. Clot perviousness, or a clot's permeability to iodinated contrast, provides insight to an individual's responsiveness of hyperacute revascularization, clot origin and functional post-stroke outcomes. We aimed to calculate LVO perviousness for those with and without COVID-19 and its association with revascularization and outcomes. Methods: This is a retrospective case-control study for individuals presenting with middle cerebral artery (MCA) LVO with and without COVID-19 positivity. Clot perviousness was calculated by a blinded experienced neuroradiologist. Perviousness scores were compared with demographic and comorbidity information as well as revascularization and functional outcomes. Results: 18 individuals with a MCA LVO (9 COVID-19 infected) were included. Those with COVID-19 were significantly more likely to have diabetes mellitus [67% (6/9) versus 11% (1/9), p = 0.05] and hypertension [89% (8/9) versus 22% (2/9), p = 0.02]. Clot perviousness trended lower in the COVID-19 group [11.0 (8.2 - 26.4) versus 31.7 (30.4 - 39.2), p = 0.10]. Those with COVID-19 infection tended to have a lower clot pervious score, [22% (2/9) versus 78% (7/9), p =0.057]. The majority of those presenting with COVID-19 died during the hospitalization. Conclusions: Our data suggests for those with COVID-19 and MCA LVO, clots tended to be more impermeable to iodinated contrast. This finding may be due to the underlying coagulopathy of COVID-19, namely alternations in fibrin homeostasis. (Figure Presented).

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.

Persistent impairment in peripheral but not cerebral vascular function in young healthy adults with long-term symptoms from covid-19

Vascular dysfunction and inflammation are precursors to cardiovascular disease (CVD). Notably, young adults who were symptomatic from COVID-19 during the acute phase of illness (within 4 weeks from diagnosis) have shown to exhibit peripheral vascular dysfunction. Importantly, many young adults report persistent symptoms from COVID-19 for several months, including cognitive difficulties. However, it remains unknown whether vascular dysfunction persists beyond the acute phase of COVID-19 in symptomatic young adults. We tested the hypothesis that peripheral and cerebral vascular function would be blunted in symptomatic (SYM) young adults who are beyond 4 weeks from a COVID-19 diagnosis, compared to asymptomatic adults (ASYM). Since COVID-19 causes inflammation that may negatively impact vascular function, we also hypothesized that serum hsCRP would be elevated in SYM compared to ASYM. We studied 15 otherwise healthy adults (age = 23 ± 1 years;mean ± SE) with a positive lab diagnosis of COVID-19. Eight were SYM (14 ± 1 weeks from diagnosis) while seven were ASYM (13 ± 2 weeks from diagnosis) at time of testing. Brachial artery flow-mediated dilation (FMD;duplex Doppler ultrasound) was performed, and macroand microvascular function were quantified as FMD% and peak blood velocity after cuff release, respectively. Cerebral vasomotor reactivity (CVMR) was quantified as percent increase in middle cerebral artery blood velocity (transcranial Doppler ultrasound) to rebreathing induced hypercapnia. Serum hsCRP level was measured. FMD was lower in SYM (3.81 ± 0.60%) compared to ASYM (7.10 ± 0.94%, P = 0.010). Likewise, peak blood velocity after cuff release was lower in SYM (47 ± 3 cm/s vs. ASYM: 65 ± 8 cm/s, P = 0.037). However, CVMR was not different between the two groups (P = 0.91). Serum hsCRP was higher in SYM (3.4 ± 1.0 mg/L vs. ASYM: 0.7 ± 0.1 mg/L, P = 0.036). These preliminary results indicate that peripheral macro-and microvascular function remain blunted beyond the acute phase in young adults with persistent symptoms from COVID-19, whereas cerebral vascular function appears unaffected. The extent to which this sustained vascular impairment and elevated hsCRP contributes to increased CVD risk in these otherwise healthy young adults remains to be determined.

Decompressive hemicraniectomy for acute ischemic stroke: A neurosurgical view in a pandemic COVID-19 time highlights of literature.

Background and purpose: The novel coronavirus, SARS-CoV-2, which was identified after the outbreak in Wuhan, China, in December 2019, has kept the whole world in tenterhooks due to its severe life-threatening nature of the infection. The World Health Organization (WHO) declared coronavirus disease (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 a pandemic in 2020, an unprecedented challenge, having a high contagious life-threatening condition with unprecedented impacts for worldwide societies and health care systems. Neurologic symptoms related to SARS-CoV-2 have been described recently in the literature, and acute cerebrovascular disease is one of the most serious complications. The occurrence of large-vessel occlusion in young patients with COVID-19 infection has been exceedingly rare. In this article, we describe the profile of patients undergoing decompressive craniectomy for the treatment of intracranial hypertension by stroke associated with COVID-19 published so far. A narrative review of the central issue in focus was designed: decompressive craniectomy in a pandemic time.

A severe case of bilateral COVID-19 pneumonia with concurrent ischemic stroke and myocardial infarction

Looking at the recent data provided in literature, we can see an association between cardiovascular and cerebrovascular accidents in COVID-19 thought to be related to severe inflammation and prothrombotic environment caused by the virus. This article reports a patient presenting with typical signs and symptoms of SARS-CoV-2 infection including flu like symptoms and respiratory distress. Initially a chest CT was performed that showed characteristic findings of atypical pneumonia caused by SARS-CoV-2 virus which was later confirmed with a nasopharyngeal PCR positive for COVID-19. During the course of admission patient developed unstable angina. Further testing confirmed an acute ST elevation myocardial infarction. While on anticoagulant treatment, patient showed signs of cerebrovascular accident. An emergency brain CT was ordered which did not yield any significant changes supporting our clinical diagnosis. Further diagnostic workup using magnetic resonance imaging disclosed evidence of cerebral ischemia in medial cerebral artery territory. Our study suggests that prophylactic anticoagulant regiment is not reassuring in COVID-19 patients and close observation and vigilance, can help clinicians to act timely and can improve patient survival.

Pediatrics COVID-19 and neurological manifestations: Single tertiary centre experience.

IMPORTANCE: Coronavirus disease 2019 (COVID-19) is a severe acute respiratory syndrome that is caused by a novel coronavirus 2 (SARS-CoV-2). It originated in China late December 2019 and was declared a global pandemic on March 12, 2020. Most reports of COVID-19 cases either presented with neurological manifestations or complications involve adults. Only few cases were reported in pediatric patients. OBJECTIVE: To report COVID-19 pediatric cases with neurological manifestations and identify the wide spectrum of its manifestations. DESIGN SETTING AND PARTICIPANTS: This was a retrospective, observational case series. Data of pediatric patients infected by SARS-CoV-2 presenting with neurological manifestations at King Abdullah Specialized Children Hospital in King Abdulaziz Medical City in Riyadh were collected from May 23 to June 30, 2020. RESULTS: We encountered 5 COVID-19 cases with neurological manifestations. Three patients who were previously healthy had new-onset neurological symptoms. Symptoms and signs included encephalopathy, ataxia, headache, seizure, papilledema, ophthalmoplegia, hyporeflexia, and different clinical spectra, such as Miller Fisher syndrome, meningoencephalitis, and idiopathic intracranial hypertension. Other patients attending our center were incidentally found to be SARS-CoV-2-positive, which caused a delay in the investigations required to reach diagnosis. CONCLUSIONS AND RELEVANCE: Our cases highlight the wide clinical spectrum of neurological manifestations in COVID-19 patients. Given the paucity of information about pediatric COVID-19 cases with neurological symptoms, we here reported these cases to shed light on the association between SARS-CoV-2 and neurological presentation. Moreover, our study indicates that many investigations are being delayed and could affect diagnosis and treatment.

Case Report: Decompressive Craniectomy for COVID-19 Malignant Cerebral Artery Infarction. Is Surgery a Good Option?

SARS-CoV2 infection can lead to a prothrombotic state. Large vessel occlusion, as well as malignant cerebral stroke have been described in COVID-19 patients. In the following months, given the increase in COVID-19 cases, an increase in malignant cerebral SARS-CoV2 associated strokes are expected. The baseline situation of the patients as well as the risk of evolution to a serious disease due to the virus, depict a unique scenario. Decompressive craniectomy is a life-saving procedure indicated in patients who suffer a malignant cerebral stroke; however, it is unclear whether the same eligibility criteria should be used for patients with COVID-19. To our knowledge seven cases of decompressive craniectomy and malignant cerebral stroke have been described to date. We report on a 39-year-old female with no major risk factors for cerebrovascular disease, apart from oral contraception, and mild COVID-19 symptoms who suffered from left hemispheric syndrome. The patient underwent endovascular treatment with stenting and afterward decompressive craniectomy due to a worsening neurological status with unilateral unreactive mydriasis. We present the case and provide a comprehensive review of the available literature related to the surgical treatment for COVID-19 associated malignant strokes, to establish whether the same eligibility criteria for non-COVID-19 associated strokes should be used. Eight patients, including our case, were surgically managed due to malignant cerebral stroke. Seven of these patients received decompressive craniectomy, and six of them met the eligibility criteria of the current stroke guidelines. The mortality rate was 33%, similar to that described in non-COVID-19 cases. Two patients had a left middle cerebral artery (MCA) and both survived after decompressive craniectomy. Our results support that decompressive craniectomy, using the current stroke guidelines, should be considered an effective life-saving treatment for COVID-19-related malignant cerebral strokes.