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1.
J Stroke Cerebrovasc Dis ; 30(11): 106072, 2021 Nov.
Article in English | MEDLINE | ID: covidwho-1377775

ABSTRACT

Recently cases of vaccine-induced immune thrombotic thrombocytopenia (VITT) and thrombosis following the adenoviral vector vaccine against the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) were reported. A mechanism similar to heparin-induced thrombocytopenia was proposed with antibodies to platelet factor 4 (PF4). Vaccine related arterial thrombosis in the brain is rare but life-threatening and optimal treatment is not established. We report clinical, laboratory, imaging findings and treatment in a 51-year-old female presenting with acute left middle cerebral artery (MCA) occlusion 7 days after the first dose of ChAdOx1 nCoV-19 vaccine. Due to low platelet count and suspicion of VITT she was not eligible for intravenous thrombolysis (IVT) and proceeded to mechanical thrombectomy (MER) with successful recanalization four hours after onset of symptoms. Treatment with intravenous immunoglobulin (IVIG) and heparin pentasaccharide fondaparinux was initiated. Presence of anti-PF4 antibodies was confirmed. The patient improved clinically with normalization of platelet count. Clinicians should be alert of VITT in patients with acute ischemic stroke after ChAdOx1 nCov-19 vaccination and low platelet counts. MER showed to be feasible and effective. We propose considering MER in patients with VITT and large vessel occlusion despite thrombocytopenia. High-dose IVIG should be started immediately. Alternative anticoagulation to heparin should be started 24 hours after stroke onset unless significant hemorrhagic transformation occurred. Platelet transfusion is contraindicated and should be considered only in severe hemorrhagic complications. Restenosis or reocclusion of the revascularized artery is possible due to the hypercoagulable state in VITT and angiographic surveillance after the procedure is reasonable.


Subject(s)
COVID-19 Vaccines/adverse effects , COVID-19/prevention & control , Infarction, Middle Cerebral Artery/chemically induced , Ischemic Stroke/chemically induced , Purpura, Thrombocytopenic, Idiopathic/chemically induced , Anticoagulants/therapeutic use , COVID-19/immunology , COVID-19/virology , Female , Humans , Immunoglobulins, Intravenous/therapeutic use , Infarction, Middle Cerebral Artery/diagnostic imaging , Infarction, Middle Cerebral Artery/immunology , Infarction, Middle Cerebral Artery/therapy , Ischemic Stroke/diagnostic imaging , Ischemic Stroke/immunology , Ischemic Stroke/therapy , Middle Aged , Purpura, Thrombocytopenic, Idiopathic/diagnosis , Purpura, Thrombocytopenic, Idiopathic/immunology , Purpura, Thrombocytopenic, Idiopathic/therapy , Thrombectomy , Treatment Outcome
3.
Am J Forensic Med Pathol ; 42(2): 160-163, 2021 Jun 01.
Article in English | MEDLINE | ID: covidwho-1045797

ABSTRACT

ABSTRACT: The SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) pandemic has revealed diverse neurological manifestations of coronavirus disease 2019 (COVID-19). This case report begins with a background review of the neurological effects of COVID-19, focusing on stroke, neuroinflammation, and coagulopathy. It then describes the clinical course and autopsy findings of a young patient presenting with COVID-19-associated stroke. The formal neuropathological examination is presented, along with the systemic and brain histological features. Interesting aspects include multiterritory hemorrhagic infarctions, microinfarcts throughout the cortex and white matter, and prominent mixed inflammatory cell cuffing of intracerebral blood vessels distant from the infarcts.


Subject(s)
COVID-19/complications , Infarction, Middle Cerebral Artery/pathology , Stroke/etiology , Stroke/pathology , Adult , Brain/pathology , Brain Death , Female , Humans , Infarction, Middle Cerebral Artery/diagnostic imaging , Lung/pathology , Lymphocytes/pathology , Macrophages/pathology , Monocytes/pathology , Pulmonary Edema/pathology , Tomography, X-Ray Computed
4.
J Stroke Cerebrovasc Dis ; 30(3): 105609, 2021 Mar.
Article in English | MEDLINE | ID: covidwho-1012468

ABSTRACT

The case of a 70-year-old male presenting an ischemic stroke related to COVID-19 infection is described. He was initially admitted to the hospital with respiratory insufficiency syndrome secondary to pneumonia caused by SARS Co2. In the next days, he developed rapid neurological deterioration characterized by drowsiness which progressed to deep coma. D-dimer was elevated. Brain CT scan showed bilateral massive ischemic stroke located in the anterior circulation, CT angiogram showed occlusion in the left internal carotid artery and the right middle cerebral artery. The deterioration of the patient continued and he subsequently died. Large vessel occlusion has been reported in COVID-19 patients, but this clinical presentation is usually unilateral. Cases of bilateral occlusion of large vessels have not been previously reported in COVID-19 patients. This report shows that bilateral massive stroke may occur in COVID-19 cases and it should be suspected in patients who show rapid neurological deterioration without focal deficits.


Subject(s)
Arterial Occlusive Diseases/etiology , COVID-19/complications , Ischemic Stroke/etiology , Aged , Brain/diagnostic imaging , COVID-19/diagnostic imaging , Carotid Stenosis/diagnostic imaging , Carotid Stenosis/etiology , Coma/etiology , Computed Tomography Angiography , Fibrin Fibrinogen Degradation Products/analysis , Humans , Infarction, Middle Cerebral Artery/diagnostic imaging , Infarction, Middle Cerebral Artery/etiology , Ischemic Stroke/diagnostic imaging , Male , Nervous System Diseases/etiology , Respiratory Insufficiency/etiology , Respiratory Insufficiency/therapy , Thrombectomy
5.
World Neurosurg ; 144: 140-142, 2020 12.
Article in English | MEDLINE | ID: covidwho-800521

ABSTRACT

BACKGROUND: The occurrence of large-vessel occlusion in young patients with coronavirus disease 2019 (COVID-19) infection has been exceedingly rare. An extensive review of reported studies revealed a few reported cases. In the present report, we have described the clinical presentation, radiological findings, and outcome of large-vessel occlusion in a young patient with COVID-19 and reviewed the pertinent reported data on this condition. CASE DESCRIPTION: A 31-year-old woman was in her usual state of health until she had presented with a 3-day history of right-sided weakness, slurred speech, and decreased vision. The patient had been taken to several hospitals where she had been treated conservatively with analgesics and discharged. Shortly thereafter, her weakness had become progressive. She had become severely dysarthric and unresponsive. On arrival to the emergency department, her physical examination revealed that she was stuporous, with a Glasgow coma scale of 10 (eye response, 3; verbal response, 2; motor response, 5). The National Institutes of Health Stroke Scale score was 19 on presentation. Brain computed tomography and computed tomography venography revealed an occluded left internal carotid artery and left middle cerebral artery with subacute left middle cerebral artery territory infarction and midline shift. Computed tomography angiography revealed complete occlusion of the left common carotid artery. An emergent decompressive craniectomy was successfully performed. The patient was shifted to the intensive care unit. She was later found to be positive for COVID-19. CONCLUSIONS: Although rare, patients with COVID-19 can present with large-vessel occlusion. Prompt identification of COVID-19-related coagulopathy is essential to assess young patients with clinical manifestations of infarction.


Subject(s)
COVID-19/complications , Carotid Artery Thrombosis/etiology , Infarction, Middle Cerebral Artery/etiology , Adult , COVID-19/diagnosis , Carotid Artery Thrombosis/diagnostic imaging , Carotid Artery Thrombosis/surgery , Carotid Artery, Common , Computed Tomography Angiography , Decompressive Craniectomy , Dysarthria/etiology , Epilepsy/complications , Female , Hemiplegia/etiology , Humans , Hypertension/complications , Infarction, Middle Cerebral Artery/diagnostic imaging , Infarction, Middle Cerebral Artery/surgery , Stupor/etiology , Tomography, X-Ray Computed
6.
BMC Neurol ; 20(1): 358, 2020 Sep 24.
Article in English | MEDLINE | ID: covidwho-792799

ABSTRACT

BACKGROUND: The novel coronavirus (COVID-19) global pandemic is associated with an increased incidence of acute ischemic stroke (AIS) secondary to large vessel occlusion (LVO). The treatment of these patients poses unique and significant challenges to health care providers requiring changes in existing protocols. CASE PRESENTATION: A 54-year-old COVID-19 positive patient developed sudden onset left hemiparesis secondary to an acute right middle cerebral artery occlusion (National Institutes of Health Stroke Scale (NIHSS) score = 11). Mechanical thrombectomy (MT) was performed under a new protocol specifically designed to maximize protective measures for the team involved in the care of the patient. Mechanical Thrombectomy was performed successfully under general anesthesia resulting in TICI 3 recanalization. With regards to time metrics, time from door to reperfusion was 60 mins. The 24-h NIHSS score decreased to 2. Patient was discharged after 19 days after improvement of her pulmonary status with modified Rankin Scale = 1. CONCLUSION: Patients infected by COVID-19 can develop LVO that is multifactorial in etiology. Mechanical thrombectomy in a COVID-19 confirmed patient presenting with AIS due to LVO is feasible with current mechanical thrombectomy devices. A change in stroke workflow and protocols is now necessary in order to deliver the appropriate life-saving therapy for COVID-19 positive patients while protecting medical providers.


Subject(s)
Coronavirus Infections/complications , Endovascular Procedures/methods , Infarction, Middle Cerebral Artery/surgery , Personal Protective Equipment , Pneumonia, Viral/complications , Thrombectomy/methods , Betacoronavirus , Brain Ischemia/complications , Brain Ischemia/diagnostic imaging , Brain Ischemia/surgery , COVID-19 , Cerebral Angiography , Computed Tomography Angiography , Emergency Medical Services , Female , Humans , Infarction, Middle Cerebral Artery/complications , Infarction, Middle Cerebral Artery/diagnostic imaging , Intubation, Intratracheal , Middle Aged , Pandemics , Reperfusion , SARS-CoV-2 , Stroke/complications , Stroke/diagnostic imaging , Stroke/surgery , Time-to-Treatment , Treatment Outcome
7.
J Stroke Cerebrovasc Dis ; 29(12): 105307, 2020 Dec.
Article in English | MEDLINE | ID: covidwho-753198

ABSTRACT

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) initially most appreciated for its pulmonary symptoms, is now increasingly recognized for causing multi-organ disease and stroke in the setting of a hypercoagulable state. We report a case of 33-year-old African American woman with COVID-19 who developed acute malignant middle cerebral artery infarction due to thromboembolic occlusion of the left terminal internal carotid artery and middle cerebral artery stem. Mechanical thrombectomy was challenging and ultimately unsuccessful resulting in limited reperfusion of <67% of the affected vascular territory, and thrombectomized clot was over 50 mm in length, at least three times the average clot length. The final stroke size was estimated at 224 cubic centimeters. On admission her D-dimer level was 94,589 ng/mL (normal 0-500 ng/ml). Throughout the hospitalization D-dimer decreased but never reached normal values while fibrinogen trended upward. Hypercoagulability panel was remarkable for mildly elevated anticardiolipin IgM of 16.3 MPL/mL (normal: 0-11.0 MPL/mL). With respect to remaining stroke workup, there was no evidence of clinically significant stenosis or dissection in the proximal internal carotid artery or significant cardioembolic source including cardiomyopathy, atrial fibrillation, cardiac thrombus, cardiac tumor, valvular abnormality, aortic arch atheroma, or patent foramen ovale. She developed malignant cytotoxic cerebral edema and succumbed to complications. This case underscores the importance of recognizing hypercoagulability as a cause of severe stroke and poor outcome in young patients with COVID-19 and highlights the need for further studies to define correlation between markers of coagulopathy in patients with COVID-19 infection and outcome post stroke.


Subject(s)
Blood Coagulation , COVID-19/complications , Carotid Stenosis/etiology , Infarction, Middle Cerebral Artery/etiology , Thrombophilia/etiology , Adult , Biomarkers/blood , Brain Edema/etiology , COVID-19/blood , COVID-19/diagnosis , COVID-19/therapy , Carotid Stenosis/blood , Carotid Stenosis/diagnostic imaging , Carotid Stenosis/therapy , Disease Progression , Fatal Outcome , Female , Fibrin Fibrinogen Degradation Products/metabolism , Humans , Infarction, Middle Cerebral Artery/blood , Infarction, Middle Cerebral Artery/diagnostic imaging , Infarction, Middle Cerebral Artery/therapy , Thrombectomy , Thrombophilia/complications , Thrombophilia/diagnosis , Treatment Outcome
8.
Stroke ; 51(11): 3366-3370, 2020 11.
Article in English | MEDLINE | ID: covidwho-722391

ABSTRACT

BACKGROUND AND PURPOSE: Reports are emerging regarding the association of acute ischemic strokes with large vessel occlusion and coronavirus disease 2019 (COVID-19). While a higher severity of these patients could be expected from the addition of both respiratory and neurological injury, COVID-19 patients with strokes can present with mild or none respiratory symptoms. We aimed to compare anterior circulation large vessel occlusion strokes severity between patients with and without COVID-19. METHODS: We performed a comparative cohort study between patients with COVID-19 who had anterior circulation large vessel occlusion and early brain imaging within 3 hours from onset, in our institution during the 6 first weeks of the COVID-19 outbreak and a control group admitted during the same calendar period in 2019. RESULTS: Twelve COVID-19 patients with anterior circulation large vessel occlusion and early brain imaging were included during the study period and compared with 34 control patients with anterior circulation large vessel occlusion and early brain imaging in 2019. Patients in the COVID-19 group were younger (P=0.032) and had a history of diabetes mellitus more frequently (P=0.039). Patients did not significantly differ on initial National Institutes of Health Stroke Scale nor time from onset to imaging (P=0.18 and P=0.6, respectively). Patients with COVID-19 had more severe strokes than patients without COVID-19, with a significantly lower clot burden score (median: 6.5 versus 8, P=0.016), higher rate of multivessel occlusion (50% versus 8.8%, P=0.005), lower DWI-ASPECTS (Diffusion-Weighted Imaging-Alberta Stroke Program Early CT Scores; median: 5 versus 8, P=0.006), and higher infarct core volume (median: 58 versus 6 mL, P=0.004). Successful recanalization rate was similar in both groups (P=0.767). In-hospital mortality was higher in the COVID-19 patients' group (41.7% versus 11.8%, P=0.025). CONCLUSIONS: Early brain imaging showed higher severity large vessel occlusion strokes in patients with COVID-19. Given the massive number of infected patients, concerns should be raised about the coming neurovascular impact of the pandemic worldwide.


Subject(s)
Coronavirus Infections/complications , Pneumonia, Viral/complications , Stroke/diagnostic imaging , Aged , Aged, 80 and over , Betacoronavirus , COVID-19 , Case-Control Studies , Cerebral Angiography , Computed Tomography Angiography , Diffusion Magnetic Resonance Imaging , Female , Hospital Mortality , Humans , Infarction, Anterior Cerebral Artery/complications , Infarction, Anterior Cerebral Artery/diagnostic imaging , Infarction, Anterior Cerebral Artery/physiopathology , Infarction, Anterior Cerebral Artery/therapy , Infarction, Middle Cerebral Artery/complications , Infarction, Middle Cerebral Artery/diagnostic imaging , Infarction, Middle Cerebral Artery/physiopathology , Infarction, Middle Cerebral Artery/therapy , Infarction, Posterior Cerebral Artery/complications , Infarction, Posterior Cerebral Artery/diagnostic imaging , Infarction, Posterior Cerebral Artery/physiopathology , Infarction, Posterior Cerebral Artery/therapy , Magnetic Resonance Angiography , Male , Middle Aged , Pandemics , SARS-CoV-2 , Severity of Illness Index , Stroke/complications , Stroke/physiopathology , Stroke/therapy , Thrombectomy , Thrombolytic Therapy
9.
J Thromb Haemost ; 18(8): 2031-2033, 2020 Aug.
Article in English | MEDLINE | ID: covidwho-401717

ABSTRACT

Coronavirus disease 2019 (COVID-19) is a pandemic disease currently affecting millions of people worldwide. Its neurological implications are poorly understood, and further study is urgently required. A hypercoagulable state has been reported in patients with severe COVID-19, but nothing is known about coagulopathy in patients with milder disease. We describe cases of patients in New York City presenting with stroke secondary to large vessel thrombosis without occlusion, incidentally found to have COVID-19 with only mild respiratory symptoms. This is in contrast to the venous thrombosis and microangiopathy that has been reported in patients with severe COVID-19. Our cases suggest that even in the absence of severe disease, patients with COVID-19 may be at increased risk of thrombus formation leading to stroke, perhaps resulting from viral involvement of the endothelium. Further systematic study is needed because this may have implications for primary and secondary stroke prevention in patients with COVID-19.


Subject(s)
Betacoronavirus , Carotid Artery Thrombosis/etiology , Coronavirus Infections/complications , Infarction, Middle Cerebral Artery/etiology , Pandemics , Pneumonia, Viral/complications , Adult , Aged , Anticoagulants/therapeutic use , Betacoronavirus/isolation & purification , Biomarkers , C-Reactive Protein/analysis , COVID-19 , Carotid Artery Thrombosis/blood , Carotid Artery Thrombosis/diagnostic imaging , Carotid Artery Thrombosis/drug therapy , Cerebral Angiography , Computed Tomography Angiography , Coronavirus Infections/blood , Coronavirus Infections/diagnosis , Coronavirus Infections/epidemiology , Emergencies , Female , Fibrin Fibrinogen Degradation Products/analysis , Hemiplegia/etiology , Humans , Infarction, Middle Cerebral Artery/blood , Infarction, Middle Cerebral Artery/diagnostic imaging , Infarction, Middle Cerebral Artery/drug therapy , Magnetic Resonance Angiography , Male , Middle Aged , New York City/epidemiology , Pneumonia, Viral/blood , Pneumonia, Viral/diagnosis , Pneumonia, Viral/epidemiology , SARS-CoV-2 , Thrombophlebitis/complications
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