UTTARA KOUL, MD
Fellow Physician
Rush University Medical Center, United States
Disclosure information not submitted.
Title: Stroke and Pulmonary Embolism as the First presentation of COVID-19 Infection.
Case Report Body:
Introduction: Coronavirus disease is associated with thrombotic complications including stroke, deep vein thrombosis and pulmonary embolism. We report a case of a COVID-19 patient who presented with concurrent stroke and pulmonary embolism.
Description: A 64-year-old male with a history of Hypertension and Coronary artery disease presented with sudden onset left-sided weakness, dysarthria and right-gaze preference to St. Louis University Hospital in September 2020. His Last known well was 18 hours prior to presentation. He was afebrile, in sinus rhythm, oxygenating well and had a BP of 184/78 mmHg on arrival. His NIH Stroke scale was 16. CT head ruled out bleeding and CT Angiogram (CTA) of the head did not show Intracranial Large Vessel Occlusion (LVO), so he was not a candidate for Alteplase or for Mechanical Thrombectomy. CTA of the neck did show a possible pulmonary embolism (PE) in the left upper lung, which was subsequently confirmed on CTA chest. Diffuse groundglass opacities were also noted in the lungs. This prompted a Nasopharyngeal swab for SARS-CoV-2 PCR, which was positive. An MRI brain showed multiple acute infarcts in both Fronto-parietal cortices, Periventricular white matter, Right Basal Ganglia and Right Thalamus concerning for an embolic etiology. Trans-thoracic Echocardiogram yielded an ejection fraction of 52%, normal Left Atrium and no evidence of a shunt. Due to his positive COVID-19 status, TEE and loop procedures were deferred to outpatient. The patient did not exhibit any respiratory symptoms throughout his admission and was discharged to a rehabilitation facility on Apixaban for anticoagulation.
Discussion: This case demonstrates the presence of multi-system arterial thrombotic complications in COVID-19 patients. Our patient did not have any risk factors such as Atrial Fibrillation or a hypercoagulable state. The patient’s thrombotic sequelae happened in the absence of respiratory symptoms and thus illustrates the need for physicians to have a low threshold for Neuroimaging in COVID-19 patients with Stroke-like symptoms.