Table 1.
Recent evidence about COVID-19 and stroke incidence
| Case demographics | Involved arterio-venous | General sign and symptoms | Medical history | CT/CTA scan of head | MRI/MRA of head | Laboratory testing and other imagings | CNS and PNS involvement | NIHSS | Treatment | Results | Ref. | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | A 73-year-old male | A large acute infarct of the left MCA vessels due to an acute thrombus | Fever, respiratory distress, dyspepsia, nausea, vomiting, and decreased appetite | Hypertension, dyslipidemia, and carotid stenosis | Loss of gray-white differentiation at the left occipital and parietal lobes | N. P | Leukocytosis with lymphopenia, elevated C-reactive protein, and positive COVID-19 PCR | Altered mental status | N. R | Aspirin and supportive measures | Died | [33] |
| 2 | A 83-year-old female | Right MCA stenosis | Fever, decreased appetite | Frequent urinary tract infections, hypertension, hyperlipidemia, diabetes mellitus type 2, and neuropathy | A focal moderate right MCA stenosis worsened to a new moderate hypodensity in the right frontal lobe | N. P | Leukopenia with lymphopenia, normal urine analysis, and positive COVID-19 PCR | Unilateral left facial drop, slurred speech, left-sided hemineglect, and left hemiparesis | At first was 2 then progressed to 16 | Integrellin | Died | [33] |
| 3 | A 80-year-old female | Occlusion of the right internal carotid artery at origin | Frequent falling since last week | Hypertension | Acute right MCA stroke | N. P | Leukocytosis with lymphopenia, elevated D-dimer and C-reactive protein, and positive COVID-19 PCR | Altered mental status, left-sided weakness, and left hemiplegia and aphasia | 36 | N. R | Complicated by acute kidney injury and extubed with comfort measures | [33] |
| 4 | A 88-year-old female | Mild stenosis of right M1 segment | Mild shortness of breath and dry cough | Hypertension, chronic kidney disease, and hyperlipidemia | No evidence of any acute findings | Acute infarct in the left medial temporal lobe and mild stenosis of the right M1 segment | D-dimer and other inflammatory markers elevated, positive COVID-19 PCR | Transient right arm weakness and numbness for 15 min | N. R | Aspirin, statins | Discharged to a rehab facility | [33] |
| 5 | A 59-year-old male | Thrombosis in right sigmoid and transverse sinus involving the torcula | Fever, No respiratory sign and symptoms | Hypertension, diabetes mellitus | CT-venogram filling defect and CT scan hyperdensity within the superior sagittal sinus, right transverse sinus, sigmoid sinus and upper right internal jugular vein | N. P | Elevated ESR, CRP and fibrinogen level, positive COVID-19 PCR | Gradual onset and progressive constant right-sided fronto-temporal headache, later right hemiparesis, slurred speech and expressive dysphasia | 10 | Low molecular weight heparin (LMWH), Apixaban | NIHSS improvement to 4 then discharged to recover at home | [34] |
| 6 | A 36-year-old female | Occlusion of the left internal carotid artery, MCA and the left anterior cerebral artery with a free-floating thrombus in the ascending aorta | Altered level of consciousness | Smoker, no other previous medical history was known | Established infarct in the territory of the left MCA with mild deviation of the midline, | N. P | Elevated CRP and creatine kinase and D-dimer level, leukocytosis, and positive COVID-19 PCR | Altered level of consciousness, global aphasia, right hemiplegia | 21 | The clinical status was not suitable for further measures | Died | [35] |
| 7 | A 31-year-old male | Right-sided ruptured dissecting posterior-inferior cerebellar artery (PICA) aneurysm | Malaise, mild fever, cough and arthralgia for about a week | No medical history | SAH centered in the posterior fossa, including the fourth ventricle, hydrocephalus | N. P | Positive COVID-19 PCR, 2 times negative CSF qualitative real-time PCR for COVID-19 | Sudden onset headache, loss of consciousness, lethargy | N. R | External ventricular drain | Discharged to rehabilitation | [36] |
| 8 | A 62-year-old female | Left middle cerebral artery occlusion | No overt respiratory and general symptoms | N. R | Left middle cerebral artery occlusion in CT-angiogram, 10 days later had hemorrhagic conversion with midline shift and obstructive hydrocephalus | N. P | Positive COVID-19 PCR, 2 times negative CSF qualitative real-time PCR for COVID-19 | Acute onset right hemiparesis and aphasia, later change in mental status | N. R | Decompressive hemicraniectomy, external ventricular drain | Recovered | [36] |
| 9 | A 73-year-old male | A large floating thrombus in the left common carotid artery | A week history of fever and dry cough | No specific medical history | Subtle cortical left frontal hypoattenuation with more extended surrounding hypoperfusion and distal occlusion of branch, large intraluminal thrombus appended to left common carotid artery non-stenosing plaque | Confirmation the presence of a large thrombus adherent to a thin atheromatous plaque in the left common carotid artery | Positive COVID-19 PCR, lymphopenia, elevated CRP, D-dimer, ferritin, fibrinogen and collagen activation | Acute onset of right hemiparesis and persistent moderate aphasia | 10 | Enoxaparin | Discharged after 7 days | [37] |
| 10 | A 33-year-old female | Right internal carotid artery | A week history of headache, chills, cough | No medical history and risk factors | Partial infarction of right middle cerebral artery territory, with partial occlusive thrombus in the right carotid artery | No source of thrombus | Elevated fibrinogen level, positive COVID-19 PCR | One-week headache, left-sided hemiplegia, facial drop, gaze preference, homonymous hemianopia, dysarthria, sensory deficit | 19 on admission, 13 at follow-up | Initial antiplatelet therapy with Apixaban (5 mg twice daily) | Discharged to rehabilitation facility | [38] |
| 11 | A 37-year-old male | Left middle cerebral artery | No overt respiratory and general symptoms | None | N. R | N. R | Positive COVID-19 PCR, elevated activated partial thromboplastin time | Altered level of consciousness, dysphasia, right-sided hemiplegia, dysarthria, sensory deficit | 13 on admission, 5 after 10 days | Apixaban (5 mg twice daily) | Discharged home | [38] |
| 12 | A 39-year-old male | Right posterior cerebral artery | None | Hyperlipidemia, hypertension | N. R | N. R | Positive COVID-19 PCR, thrombocytopenia, elevated fibrinogen, D-dimer and ferritin level | Altered level of consciousness, gaze preference to the right, left homonymous hemianopia, ataxia, left-sided hemiplegia | 16 on admission, then intubated with multiorgan failure | Aspirin (81 mg daily) | Intensive care unit | [38] |
| 13 | A 44-year-old male | Left middle cerebral artery | None | Undiagnosed diabetes | N. R | N. R | Positive COVID-19 PCR, elevated D-dimer and ferritin level | Lethargy | 23 on admission, 19 at follow-up | Intravenous t-PA, hemicraniectomy, aspirin (81 mg daily) | Stroke unit | [38] |
| 14 | A 49-year-old male | Right middle cerebral artery | Fever and cough | Mild stroke, diabetes mellitus | N. R | N. R | Positive COVID-19 PCR, leukopenia, elevated prothrombin time, activated partial thromboplastin time, fibrinogen, D-dimer and ferritin level | Altered level of consciousness, left-sided hemiplegia | Discharged | [38] | ||
| 15 | A 49-year-old female | Right carotid artery | Fever, fatigue, progressive shortness of breath | Diabetes, hypertension | Normal CT scan, CT angiography showed a thrombus in the right middle cerebral artery, filling defect in the left carotid bulb, CT perfusion showed a mismatch between cerebral blood volume and mean transit time in the territory of the right middle cerebral artery | N. P | Elevated CRP, lactate dehydrogenase, procalcitonin, ferritin | Sudden left-sided hemiparesis, sensory neglect, left hemianopsia, right gaze deviation | 14, reduced to 5 immediately after thrombectomy and 0 at discharge | Hydroxychloroquine, azithromycin, alteplase 69 min after symptoms recognition, mechanical thrombectomy, retrievable stent appliance in the right cerebral artery, 6-month course of oral anticoagulation (apixaban) | Fully improvement | [39] |
| 16 | A 64-year-old male | Left vertebral artery thrombus and bilateral posterior-inferior cerebellar artery occlusion | Cough, shortness of breath, fever, myalgia, loss of appetite | None | N. R | Acute left vertebral artery thrombus and acute left posterior-inferior cerebellar artery territory infarction with petechial hemorrhagic transformation. 7 days later, bilateral acute posterior cerebral artery territory infarcts despite therapeutic anticoagulation was seen | Reduced hemoglobin and albumin, lymphopenia, elevated alanine aminotransferase, lactate dehydrogenase, PT, fibrinogen, D-dimer, and ferritin, positive lupus anticoagulant / Lower limb Doppler Ultrasound reported occlusive DVT in the left posterior tibial vein and the left peroneal vein | Word-finding difficulties, bilateral incoordination, right homonymous hemianopia | N. R | Clarithromycin, oxygen therapy, high-intensity LMWH anticoagulation | Discharged after stabilization | [32] |
| 17 | A 53-year-old female | Right middle cerebral and left cerebellar artery occlusion | Malaise, dry cough, shortness of breath, fever | Hypertension, diabetes mellitus, mitral valve replacement, atrial fibrillation, heart failure with permanent pacemaker | Acute right parietal cortical and left cerebellar infarct with mass effect and hydrocephalus | N. R | Reduced hemoglobin and albumin, leukocytosis (high neutrophils and monocytes), elevated bilirubin, lactate dehydrogenase, cardiac troponin I, PT, INR, aPTT, D-dimer, ferritin, CRP, positive lupus anticoagulant | Acute confusion, incoordination, reduced consciousness (GCS 13/15) | N. R | Supportive, therapeutic LMWH | Died | [32] |
| 18 | An 85-year-old male | Thrombus in the left posterior cerebral artery occlusion | Cough | Hypertension, hypercholesterolemia, atrial fibrillation, ischemic heart disease, prostate cancer (Gleason score 4 + 5) | Hyperdensity consistent with thrombus in the left posterior cerebral artery and acute infarction in the left temporal stem and cerebral peduncle | N. R | Reduced hemoglobin and albumin, lymphopenia, elevated lactate dehydrogenase, cardiac troponin I, fibrinogen, D-dimer, ferritin, CRP | Dysarthria, right facial droop and right-sided weakness | Supportive, apixaban | Discharged | [32] | |
| 19 | A 61-year-old male | Transient occlusion of the M1 segment of the right middle cerebral artery | Fever, cough, shortness of breath, tachypnoea | Hypertension, stroke, chronic leg ulcers | Acute infarction in the right corpus striatum, recovery MRI showed an established infarct in the same region with moderate background cerebral small vessel disease | Reduced aPTT, hemoglobin and albumin, elevated lactate dehydrogenase, cardiac troponin I, fibrinogen, D-dimer, ferritin, positive lupus anticoagulant | Dysarthria, left facial droop and left-sided weakness | Antibiotics, therapeutic LMWH | Discharged | [32] | ||
| 20 | An 83-year-old male | Proximal M2 branch of the right middle cerebral artery occlusion | Fever, cough, shortness of breath, fatigue | Hypertension, Diabetes mellitus, ischemic heart disease, smoking and alcohol consumption | Thrombotic occlusion of a proximal M2 branch of the right middle cerebral artery; a repeat CT at 24 h showed a focus of parenchymal low density involving the right insular cortex in keeping with an evolving right middle cerebral artery territory infarct | Reduced hemoglobin and albumin, leukocytosis, elevated lactate dehydrogenase, cardiac troponin I, fibrinogen, D-dimer, positive lupus anticoagulant | Dysarthria, left facial droop, left-sided weakness and left-sided sensory inattention | Antibiotics, oxygen therapy, intravenous thrombolysis | Discharged | [32] | ||
| 21 | A 73-year-old male | Thrombotic material in the basilar artery and bilateral mild-to-moderate P2 segment stenosis | Shortness of breath, tachypnoea | Resected gastric carcinoma, benign essential tremor | Acute infarction in the right thalamus, left pons, right occipital lobe and right cerebellar hemisphere. At discharge images showed thrombotic material in the basilar artery and bilateral mild-to-moderate P2 segment stenosis | Reduced albumin, lymphopenia, thrombocytosis, elevated alanine transferase, lactate dehydrogenase, PT, D-dimer, ferritin, CRP, positive lupus anticoagulant | Aphasia, right facial droop and right-sided weakness | Antibiotics, oxygen therapy, intravenous thrombolysis | Discharged | [32] |
N. R, not reported; N. P, not performed; MCA, middle cerebral artery; ESR, erythrocyte sedimentation rate; CRP, C-reactive protein; SAH, sub arachnoid hemorrhage