key: cord-0875347-vjnzbo6d authors: Khosravi, Bkhtiar; Moradvaesi, Borhan; Abedini, Masomeh; Behzadi, Shirin; Karimi, Awat title: Stroke in a child with SARS-CoV-2 infection: A case report date: 2021-04-28 journal: eNeurologicalSci DOI: 10.1016/j.ensci.2021.100345 sha: ff976b714e78c791b8fe1a680782de6e24d428a2 doc_id: 875347 cord_uid: vjnzbo6d Coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Some patients with COVID-19 show widely neurological manifestations including stroke. We report a child who was hospitalized due to seizures and was later diagnosed with COVID-19. Acute infarction was seen in the right putamen, globus pallidus, and the posterior part of the insula. A small focal dilatation within M1 segment of the left middle cerebral artery (MCA) was also observed. According to the present case report, COVID-19 infection may contribute to the occurrence and development of ischemic stroke. The novel coronavirus was first reported in Wuhan, China [1] . This virus is called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and has been called by the WHO as the coronavirus disease 2019 [2, 3] . The severity of COVID-19 in children is classified as mild, normal, severe, and critical [4, 5] . Although there are reports that children are less likely to develop COVID-19 infection, it is important to monitor the symptoms and the course of the disease carefully [6] . In addition to the usual symptoms including fever and cough, coronavirus also has neurological symptoms such as hyposmia, hypogeusia, and headache [7] . After a nasal infection, coronavirus enters the CNS through the nasal route, causing neurological manifestations ranging from ischemic stroke to acute demyelination and encephalitis [8, 9] . Stroke can be ischemic or hemorrhagic. Ischemic stroke is more frequently caused by arterial occlusion, however, it may also be caused by venous occlusion of cerebral veins or sinuses [10] . In children, multiple risk factors are involved in stroke including cardiac disease, sickle cell disease, prothrombotic disorders, arteriovenous malformations, syndromic and metabolic disorders, cerebral vasculitis, cancers, and trauma [10] [11] [12] . Besides such risk factors which can all contribute to stroke, viral infections can also lead to stroke [12] . The most common microorganisms which contribute to stroke include mycoplasma, chlamydia, enterovirus, influenza A, parvovirus 19, and coxsackie [13] . Virus infection triggers a cytokine cascade that aggravates ischemic brain damage [14] [15] [16] . There are reports that COVID-19 infection may contribute to the occurrence of ischemic stroke in adults [17] . In this article a pediatric case with the ischemic stroke subtypes related to the SARS-CoV-2 was reported. A 10-year-old girl was referred to Besat Hospital of Kurdistan University of Medical Sciences, Sanandaj, Iran. She suddenly had a severe headache in the right temporal area followed by facial distortion, tonic movements of the shoulders and the right leg, and loss of consciousness for 5 minutes. Body temperature at admission was 37.0 °C and blood pressure was 110/70 mmHg. The heart rate was 90 beats per minute and the number of breaths per minute was 20. The patient was fully J o u r n a l P r e -p r o o f Journal Pre-proof conscious and when she came to the hospital she only had dysarthria and left-sided hemiparesis. One week before, she had had a low grade fever and gastrointestinal manifestations such as vomiting and abdominal pain for two days. She had no previous history of cough, shortness of breath, skin rash, or recent trauma. No one in her family had a known history of COVID-19 infection. In the context of COVID-19 pandemic, SARS-CoV-2 reverse transcription-polymerase chain reaction (RT-PCR) was performed on a nasopharyngeal swab and the result was positive. In the neurological examinations, ipsilateral cranial nerve VII (facial nerve) dysfunction was observed, however, the other nerves were normal. The muscle stretch was 3.5 for the left limb Enoxaparin was prescribed until lack of thrombosis was confirmed (5 days) and then aspirin treatment was started. After a second echocardiogram and normal MRV results, treatment with anticoagulants was stopped and aspirin treatment with a dose of 3 mg/kg was started. The patient's clinical symptoms were relatively improved by the time of discharge. The patient is currently under our care and has been receiving aspirin for up to two years. Neurological signs have been observed in about 84% of the patients with COVID-19 [18] . Some COVID-19 patients develop stroke [19] [20] [21] .There are multiple, not mutually exclusive, possible mechanisms associating COVID-19 with ischemic stroke. Pulmonary angiopathy and thrombosis reported in severe COVID-19 pneumonia which can be related to stroke [22] . reported. In another case, a 78-year-old man with positive diagnosis of COVID-19 was presented with a strong clinical concern for stroke and venous thromboembolic event [24] . Yaghi et al. observed a low rate of imaging-confirmed ischemic stroke in hospitalized patients with COVID-19 infection. Most strokes were cryptogenic, possibly related to an acquired hypercoagulability [25] . In the present case report, D-dimer level was normal. In the case report of Mohammadifard et al. about a pediatric patient with ischemic stroke due to SARS-CoV2, the D-dimer level has not been reported [23] . Some studies have reported that lactate dehydrogenase is elevated in ischemic stroke [26] . In the current case, lactate dehydrogenase was elevated. Stroke rates have increased during the COVID-19 pandemic [27] . Evidence suggests that COVID-19 can also affect the cerebrovascular systems [28] . It has been stated that 5% of COVID-19 adult patients have had a concomitant stroke [27] . In strokes following COVID-19, inflammatory and hypercoagulable mechanisms may play a role through thrombotic events [27, 29] . The data of the current study can propose a causal relationship between SARS-CoV-2 and ischemic stroke since other risk factors were not present in this patient. Due to the absence of thrombotic events in this case, angiopathy caused by COVID-19 seems to have led to a stroke. Despite an increased incidence of pediatric stroke, there is often a delay in diagnosis, and cases may still remain under-or misdiagnosed. During the COVID-19 pandemic, neuroscientists should be vigilant about neurological symptoms especially in children. COVID-19 may play a J o u r n a l P r e -p r o o f Journal Pre-proof role in the prognosis of ischemic stroke. Therefore, ready-made programs are needed to deal with diseases such as stroke. These images are from patient with ischemic stroke in the setting of COVID-19. The MRI showed an acute infarction in the right putamen, globus pallidus, and the posterior part of the insula. We report a child who was hospitalized due to seizures and was later diagnosed with COVID-19. Acute infarction was seen in the right putamen, globus pallidus, and the posterior part of the insula. Right internal carotid artery (ICA) stenosis and a small focal dilatation within the middle cerebral artery (MCA) were also observed J o u r n a l P r e -p r o o f J o u r n a l P r e -p r o o f The neuroinvasive potential of SARS-CoV2 may play a role in the respiratory failure of COVID-19 patients A pneumonia outbreak associated with a new coronavirus of probable bat origin New Insights of Emerging SARS-CoV-2: Epidemiology, Etiology, Clinical Features, Clinical Treatment, and Prevention novel coronavirus disease in children: an insight and the next steps forward SARS-CoV-2 infection in children Clinical Characteristics of Coronavirus Disease 2019 in China Human coronaviruses and other respiratory viruses: underestimated opportunistic pathogens of the central nervous system? Neurologic alterations due to respiratory virus infections Guillain-Barre syndrome during COVID-19 pandemic: an overview of the reports Pediatric stroke: a review Risk Factors for Ischemic Stroke in Younger Adults Stroke Statistics Subcommittee: Heart disease and stroke statistics-2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee Stroke and Pediatric Human Immunodeficiency Virus Infection Influenza Virus Infection Aggravates Stroke Outcome Mitochondrial function in hypoxic ischemic injury and influence of aging Advances in Understanding the Pathophysiology of Lacunar Stroke: A Review The impact of COVID-19 on ischemic stroke: A case report Neurologic Features in Severe SARS-CoV-2 Infection A rampage through the body Large-Vessel Stroke as a Presenting Feature of Covid-19 in the Young Challenges and Potential Solutions of Stroke Care During the Coronavirus Disease 2019 (COVID-19) Outbreak Pulmonary Angiopathy in Severe COVID-19: Physiologic, Imaging, and Hematologic Observations Focal Cerebral Arteriopathy in a COVID-19 Pediatric Patient Neurological emergencies associated with COVID-19: stroke and beyond SARS-CoV-2 and Stroke in a New York Healthcare System Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease Potential Effects of Coronaviruses on the Cardiovascular System: A Review Coagulopathy and Antiphospholipid Antibodies in Patients with Covid-19 Normal range white blood cell 6.8×10 9 /L 5 to 11×10 9