Cerebrovascular Disease in Patients with COVID-19: A Review of the Literature and Case Series

Sujan T Reddy; Tanu Garg; Chintan Shah; Fábio A Nascimento; Rajeel Imran; Peter Kan; Ritvij Bowry; Nicole Gonzales; Andrew Barreto; Abhay Kumar; John Volpi; Vivek Misra; David Chiu; Rajan Gadhia; Sean I Savitz

doi:10.1159/000508958

Cerebrovascular Disease in Patients with COVID-19: A Review of the Literature and Case Series

Case Rep Neurol. 2020 Jun 11;12(2):199-209. doi: 10.1159/000508958. eCollection 2020 May-Aug.

Authors

Sujan T Reddy^{1

2}, Tanu Garg³, Chintan Shah⁴, Fábio A Nascimento⁴, Rajeel Imran³, Peter Kan⁵, Ritvij Bowry^{2

6}, Nicole Gonzales^{1

2}, Andrew Barreto^{1

2}, Abhay Kumar⁶, John Volpi³, Vivek Misra³, David Chiu³, Rajan Gadhia³, Sean I Savitz^{1

2}

Affiliations

¹ Department of Neurology, University of Texas Health Science Center at Houston, Houston, Texas, USA.
² Institute for Stroke and Cerebrovascular Disease, University of Texas Health Science Center at Houston, Houston, Texas, USA.
³ Department of Neurology, Houston Methodist Neurological Institute, Houston, Texas, USA.
⁴ Department of Neurology, Baylor College of Medicine, Houston, Texas, USA.
⁵ Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA.
⁶ Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, Texas, USA.

Abstract

COVID-19 has been associated with a hypercoagulable state causing cardiovascular and neurovascular complications. To further characterize cerebrovascular disease (CVD) in COVID-19, we review the current literature of published cases and additionally report the clinical presentation, laboratory and diagnostic testing results of 12 cases with COVID-19 infection and concurrent CVD from two academic medical centers in Houston, TX, USA, between March 1 and May 10, 2020. To date, there are 12 case studies reporting 47 cases of CVD in COVID-19. However, only 4 small case series have described the clinical and laboratory findings in patients with COVID-19 and concurrent stroke. Viral neurotropism, endothelial dysfunction, coagulopathy and inflammation are plausible proposed mechanisms of CVD in COVID-19 patients. In our case series of 12 patients, 10 patients had an ischemic stroke, of which 1 suffered hemorrhagic transformation and two had intracerebral hemorrhage. Etiology was determined to be embolic without a clear cause identified in 6 ischemic stroke patients, while the remaining had an identifiable source of stroke. The majority of the patients had elevated inflammatory markers such as D-dimer and interleukin-6. In patients with embolic stroke of unclear etiology, COVID-19 may have played a direct or indirect role in the processes that eventually led to the strokes while in the remaining cases, it is unclear if infection contributed partially or was an incidental finding.

Keywords: APLS; COVID-19; Cerebrovascular disease; Coronavirus; SARS-CoV-2; Stroke.

Publication types

Case Reports