Bihemispheric ischemic strokes in patients with COVID-19
Christeena Kurian1, Stephan Mayer1, Gurmeen Kaur2, Ramandeep Sahni1, Eric Feldstein3, Mena Samaan1, Divya Viswanathan1, Tamarah Sami4, Syed Faizan Ali1, Hussein Al-Shammari1, Jessica Bloomfield1, Michelle Bravo1, Rolla Nuoman5, Edwin Gulko6, Chirag D Gandhi3, Fawaz Al-Mufti2
1 Department of Neurology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
2 Department of Neurology; Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
3 Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
4 Department of Neurology, New York Medical College, Valhalla, NY, USA
5 Department of Pediatrics, Maria Fareri Children's Hospital, New York Medical College, Valhalla, NY, USA
6 Department of Radiology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
Department of Neurology; Department of Neurosurgery, Westchester Medical Center, New York Medical College, 100 Woods Road, Macy Pavilion 1331, Valhalla, NY 10595
Source of Support: None, Conflict of Interest: None
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.