Abstract
BackgroundRecent studies have reported that COVID-19 infected patients with stroke, who were often in the older age group, had a higher incidence of vascular risk factors, and more severe infection related respiratory symptoms. These observations provided little evidence to suggest that COVID-19 infection is a potential causative factor for stroke. This report describes a young patient with a cerebellar stroke secondary to COVID-19 infection.Case presentation A 45-year old male presented at a hospital, reporting a two-day history of headache, vertigo, persistent vomiting, and unsteady gait. Physical examination revealed gaze-evoked nystagmus on extraocular movement testing, left-sided dysmetria and dysdiadochokinesia. He was diagnosed with a left cerebellar stroke. An external ventricular drain was inserted, and sub-occipital craniectomy was performed to manage the effects of elevated intracranial pressure due to the extent of oedema secondary to the infarct. He also underwent screening for the COVID-19 infection, which was positive on SARS-COV-2 polymerase chain reaction testing of his endotracheal aspirate. Blood and cerebrospinal fluid samples were negative. After the surgery, the patient developed atrial fibrillation and had prolonged vomiting symptoms, but these resolved eventually with symptomatic treatment. He was started on aspirin and statin therapy, but anticoagulation was withheld due to bleeding concerns. The external ventricular drain was removed nine days after the surgery. He continued with active rehabilitation.Conclusions Young patients with COVID-19 infection may be more susceptible to stroke, even in the absence of risk factors. Standard treatment with aspirin and statins remains essential in the management of COVID-19 related stroke. Anticoagulation for secondary prevention in those with atrial fibrillation should not be routine and has to be carefully evaluated for its benefits compared to the potential harms of increased bleeding associated with COVID-19 infection.
Highlights
Recent studies have reported that COVID-19 infected patients with stroke, who were often in the older age group, had a higher incidence of vascular risk factors, and more severe infection related respiratory symptoms
Such observations suggest that the same risk factors for stroke may be associated with more severe COVID-19 infection, but provide little evidence to support the infection as a direct causative factor for stroke
COVID-19 related stroke is thought to be due to multiple factors including coagulopathy and endothelial dysfunction, features that are increasingly seen as hallmarks of the COVID-19 infection
Summary
Neurological manifestations in COVID-19 infection have been well documented in recent observational studies, ranging from mild symptoms of dizziness to more severe stroke and seizures complications. Subsequent case series reported that COVID-19 patients with stroke were often in the older age group, had a higher incidence of vascular risk factors or more severe respiratory symptoms from COVID-19 infection [2, 3]. A 45-year-old Bangladeshi male presented at the Emergency Department of Singapore General Hospital, Singapore, giving a two-day history of moderately severe throbbing headache, associated with vertigo, multiple vomiting episodes aggravated by head movements, and unsteady gait He negated having any visual symptoms, dysarthria, dysphagia, anosmia, and ageusia. Two days after the craniectomy, the patient became drowsier again, recording a GCS=9, E2V1 (intubated) M6, and had weakness in his left upper and lower limbs. The following investigations were performed on Day 8 post-admission to evaluate potential causes of stroke. At the time of writing, he remained well and was actively participating in rehabilitation before eventual discharge to a community recovery facility
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