Focal intracranial vasculopathy as a manifestation of COVID-19-associated acute ischemic stroke

ABSTRACT

Introduction COVID-19 infection has been associated with an increased risk of thrombotic events, including cerebrovascular accidents, presumed to be secondary to a systemic hypercoagulable state. These events have been reported even in young patients, without other significant vascular risk factors. We present a different, atypical case of a large-vessel occlusion (LVO) acute ischemic stroke secondary to a focal vasculopathy in a young patient with COVID-19 infection, requiring mechanical thrombectomy and emergent intracranial stenting, and we also review available literature. Methods Case analysis and literature review. Results A patient in their early 20's with mild obesity presented to the emergency department (ED) one hour after acute onset of left hemiplegia (NIHSS 11). Emergent imaging revealed multifocal right middle cerebral artery territory acute ischemic infarcts with small petechial hemorrhage. CT angiography showed a right M1 segment occlusion. He was not a candidate for intravenous thrombolysis. Patient underwent mechanical thrombectomy with contact aspiration. The occluded right M1 segment was successfully recanalized, but follow-up angiography revealed re-stenosis. Balloon angioplasty was performed, but repeat angiography again demonstrated critical re-stenosis. A balloon-mounted stent was placed in the R M1 segment, with successful recanalization and no further restenosis. The patient was acutely loaded with intravenous tirofiban, followed by oral aspirin and clopidogrel. Notably, the patient tested positive for COVID-19, but remained otherwise asymptomatic. Laboratory investigation, including hypercoagulabe and autoimmune workup for typical and atypical stroke etiologies, did not reveal any significant abnormalities, but the patient did have mildly elevated d-Dimer, and a minimally elevated homocysteine levels. Lower extremity ultrasound was negative for deep venous thrombosis, and echocardiogram was negative for significant abnormalities or intracardiac shunts. No cardiac arrhythmia was found. Patient was discharged home on hospital day five with NIHSS 1 (mild left facial droop) on aspirin and clopidogrel. At a two-month follow-up, patient remained without any objective residual deficits. Transcranial Doppler ultrasound at follow-up revealed full patency of the intracranial stent. Our literature search revealed a large body of evidence for acute stroke, LVO and secondary hypercoagulable state in COVID patients. However, focal vasculopathy, occasionally described with other viral infections such as VZV, has not been reported in association with COVID infection. Conclusion To our knowledge, our case is the first to illustrate the potential for COVID-19 infection to present as a focal intracranial vasculopathy in an otherwise healthy youngpatient, resulting in acute ischemic stroke without an underlying hypercoagulable state. Rescue intracranial stenting was necessary to maintain vessel patency and restore intracranial flow.