key: cord-0744490-ptnhzpz6
authors: Aoud, Sahar EL; Morin, Clément; Boutin, Béatrice; Chouchane, Hajer; Soria, Didier; Rondeau, Paul; Thomas, Laurent
title: Ischemic cerebrovascular diseases in patients with COVID 19
date: 2020-07-19
journal: Rev Neurol (Paris)
DOI: 10.1016/j.neurol.2020.06.002
sha: 7ec55ad7532686f5cab41635fb03593dc76853a7
doc_id: 744490
cord_uid: ptnhzpz6

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J o u r n a l P r e -p r o o f echocardiography (TTE) revealed mitral endocarditis. So that, she was excluded from this study. . Here, we describe the other three cases in whom oropharyngeal swabs were positive for SARS-CoV-2 on reverse-transcriptase-polymerase-chain-reaction (RT-PCR) assay on admission. Their lung computed tomographic (CT) imaging showed typical features of COVID 19 with different degree of lesion extent. Their laboratory results showed increasing inflammatory parameters in the acute phase of stroke setting.

Further details are summarized in Table 1 .

Case -patient 1, a 65-year old man, with no medical history, was referred to our Department for major psychomotor slowing progressing within 9 days. His body temperature was 38°C and his oxygen saturation was 92 % on room air. His blood pressure was 120/85 mmHg, it was stable during hospitalization. He was well oriented in time and space. He had bradyphrenia but his verbal responses were appropriate. His spontaneous and organized movements in response to command were patently executed weakly and slowly highlighting cognitive and motor components impairment. Cerebrospinal fluid (CSF) examination was normal.

Electroencephalogram showed slow oscillations without epileptiform features. CT imaging of the brain was normal. Brain magnetic resonance imaging (MRI) disclosed multiple subcortical periventricular stroke with corona radiata damages. Ischemic stroke is considered as a rare complication of SARS CoV-2 infection. It is noted in 0.83 % in our cohort. Nevertheless, a more significant results were found in Italy [4] and China [1, 2] with a frequency of ischemic stroke assessed between 2.33 and 5 %.

Oxley TJ et al [5] reported five cases of large-vessel stroke in COVID 19 patients younger than 50 years of age with cardiovascular risk factors in three cases. Nevertheless, in a recent chinese study, eleven COVID-19 patients with new onset of ischemic stroke were significantly older [2] , the youngest patient was 57 years of age. They were more likely to have cardiovascular risk factors, including hypertension and diabetes [2] . Ischemic stroke was more common in Page 4 of 9 J o u r n a l P r e -p r o o f severely infected patients [1, 2] . Our three patients had a mean age of 73.66 years with cardiovascular risk factors in two cases. All patients required oxygen therapy.

In Helms et al report [3] , MRI brain was performed in 13 of 58 cases with COVID 19 revealing ischemic stroke in 3 asymptomatic patients. These findings suggest the possibility of underdiagnosed ICVD in affected patients due to subclinical presentation. In our report, patients with ischemic stroke had psychiatric, cognitive and/or focal signs as presenting features leading to MRI practice. Ischemic stroke was revealing SARS-COV2 in our case patient 1 and 3.

There is an increasing evidence that COVID 19 may predispose to brain thromboembolic events [4] . stroke onset [10] . Finally, ischemic stroke could be due to cardio embolism from virus-related cardiac injury . In our report, TTE and HE findings of all patients ruled out atrial fibrillation and morphological heart disease.

During COVID 19 infection, regular laboratory monitoring of inflammatory and hemostasis parameters including C-reactive protein, ferritin, platelet count, prothrombin time, and fibrinogen is crucial to detect early coagulation changes progression. Interestingly, high serum ferritin level was significantly correlated with COVID 19 infection severity in recent reports [11] . It may not only reflect acute symptomatic phase but also has a pro-inflammatory activity.

Colafrancesco S et al [11] suggested that COVID-19 systemic inflammation could be a part of the spectrum of hyerferritinemic syndromes due to several clinical, laboratory and autoptic similarities including hyperferritinemia , lymphopenia, reduced natural killers number and activity, abnormal liver function tests and coagulopathy. This finding supported the hypothesis of probable common pathogenic background. Thus, serum ferritin level might be considered as an important marker to predict coagulopathy disorders and stroke risk in COVID 19 critically ill patients. Prophylactic anticoagulation should be strictly applied to prevent thrombosis and improve patients outcome [6] .

In conclusion, the incidence of acute ICVD in patients with COVID 19 is probably underestimated due to the atypical clinicalsymptoms. Our report illustrates the heterogeneity 

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