Stroke, takotsubo and covid-19: A subtle relationship

ABSTRACT

In a WSO review the risk of stroke during Covid-19 infection is about 5%;in a significant percentage of cases the symptoms of infection are not present at the admission. A 76-year-old woman came to ED for neck pain, vertigo, balance instability for 48 hours. Cerebral CT Scan showed cerebellar ischemic hypodense area of 2 cm. On EKG sinus rhythm, elevation of the anterolateral ST segment. No chest pain or palpitation. Normal C-reactive protein, troponin 222 pg / ml, D-Dimer 1053 ng / ml. TE left ventricle of normal size, akinesia of the apex. Chest CT scan normal aorta, no thrombo-embolic defects, ground glass thickening in the lingula site. Molecular test for Covid-19 positive. EGA pO2 79 mmHg, Sat02 96% in air. Stroke unit consult no indication for revascularization therapy by time window, prescription therapy with 125 mg aspirin, no recommendation against use of anticoagulant if indicated for infectious therapy. Troponin in reduction in 3rd day. EKG evolution with negative T wave in the anterior area. After 48 hours stable brain ischemic injury, improvement of ventricular wall motion. Enoxaparin was added. Sat02 98% with O2 at low flows. Cerebral MRI paramedian cerebellar area with hemorrhagic infarction, regular intracranial arterial circulation. Cardiac MRI hypokinesia of the apical segments, edema of the ventricular myocardium in the mid-apical planes, increased image values in T1 and T2 mapping, no defects of perfusion. The clinical course was regular. Viral infections induce a pro-thrombotic state and can cause stroke by increasing the cardio-embolic risk or through the formation of arterial thrombi. D-dimer was elevated, no antiphospholipid antibodies were measured. We cannot exclude asymptomatic atrial fibrillation. The mechanism of stroke in the patient is unclear, no cardiac thrombotic formations were documented. Stress induced by stroke symptoms and the delayed access to treatment due to fear of going to hospital because of Covid-19 infection was probably the cause of stress cardiomyopathy. The incidence of Tako-Tsubo cardiomyopathy increased worldwide during the pandemic.