Bihemispheric ischemic strokes in patients with COVID-19

Christeena Kurian; Stephan Mayer; Gurmeen Kaur; Ramandeep Sahni; Eric Feldstein; Mena Samaan; Divya Viswanathan; Tamarah Sami; Syed Faizan Ali; Hussein Al-Shammari; Jessica Bloomfield; Michelle Bravo; Rolla Nuoman; Edwin Gulko; Chirag D Gandhi; Fawaz Al-Mufti

doi:10.4103/bc.bc_65_21

Bihemispheric ischemic strokes in patients with COVID-19

Brain Circ. 2022 Mar 21;8(1):10-16. doi: 10.4103/bc.bc_65_21. eCollection 2022 Jan-Mar.

Authors

Christeena Kurian¹, Stephan Mayer¹, Gurmeen Kaur^{1

2}, Ramandeep Sahni¹, Eric Feldstein², Mena Samaan¹, Divya Viswanathan¹, Tamarah Sami³, Syed Faizan Ali¹, Hussein Al-Shammari¹, Jessica Bloomfield¹, Michelle Bravo¹, Rolla Nuoman⁴, Edwin Gulko⁵, Chirag D Gandhi², Fawaz Al-Mufti^{1

2}

Affiliations

¹ Department of Neurology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA.
² Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA.
³ Department of Neurology, New York Medical College, Valhalla, NY, USA.
⁴ Department of Pediatrics, Maria Fareri Children's Hospital, New York Medical College, Valhalla, NY, USA.
⁵ Department of Radiology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA.

Abstract

Background: There is emerging evidence that COVID-19 can trigger thrombosis because of a hypercoagulable state, including large-vessel occlusion ischemic strokes. Bihemispheric ischemic stroke is uncommon and is thought to indicate an embolic source. Here, we examine the findings and outcomes of patients with bihemispheric stroke in the setting of COVID-19.

Methods: We performed a retrospective cohort study at a quaternary academic medical center between March 1, 2020, and April 30, 2020. We identified all patients with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection who presented with simultaneous bihemispheric ischemic strokes.

Results: Of 637 COVID-19 admissions during the 2-month period, 13 had a diagnosis of acute ischemic stroke, including 5 who developed bihemispheric cerebral infarction. Three of those 5 (60%) were female, median age was 54 (range 41-67), and all five were being managed for severe COVID-19-related pneumonia complicated by acute kidney injury and liver failure before the diagnosis of cerebral infarction was established. Five presented with elevated ferritin, lactate dehydrogenase, and interleukin-6 (IL-6) levels, and four had lymphopenia and elevated D-dimer levels. All patients underwent neuroimaging with computed tomography for persistent depressed mentation, with or without a focal neurologic deficit, demonstrating multifocal ischemic strokes with bihemispheric involvement. Outcome was poor in all patients: two were discharged to a rehabilitation facility with moderate-to-severe disability and three (60%) patients died.

Conclusions: Stroke is implicated in SARS-CoV-2 infection. Although causality cannot be established, we present the imaging and clinical findings of patients with COVID-19 and simultaneous bihemispheric ischemic strokes. Multifocal ischemic strokes with bihemispheric involvement should be considered in COVID-19 patients with severe infection and poor neurologic status and may be associated with poor outcomes.

Keywords: Coronavirus disease 2019; embolism; ischemic stroke; neurologic complications; severe acute respiratory syndrome coronavirus 2.