Between a Clot and a Hard Place: Ischaemic Stroke and COVID-19

Coronavirus disease (COVID-19) emerged in late December 2019 and resulted in a rapidly spreading acute respiratory disease epidemic originating in Wuhan, China. As the coronavirus pandemic progressed, it quickly became clear that acute ischaemic stroke (AIS) is the most frequently reported neurological complication of COVID-19 with an incidence varying from 0.9% to 2.7%. We describe the clinical, radiological and laboratory characteristics of a 64-year-old man who presented in the beginning of the pandemic with severe COVID-19 symptoms. On day 15 after COVID-19 onset, he developed transient dense left-sided weakness, paraesthesia and difficulty swallowing. MRI brain confirmed intradural left vertebral artery occlusion and acute left posterior-inferior cerebellar artery territory infarction with petechial haemorrhage. He received aspirin and clopidogrel. D-dimer was >80 000 μg/L. On day 19, he developed bilateral pulmonary embolism, treated with therapeutic low molecular weight heparin (LMWH). On day 22, he developed acute bilateral incoordination and right homonymous hemianopia; MRI brain showed extensive acute posterior cerebral artery territory infarction. He received high-intensity LMWH anticoagulation. Thrombophilia testing showed persistently positive antiphospholipid-antibodies. Our case highlights distinct characteristics of AIS associated with COVID-19 which occurs in the context of highly prothrombotic state with predominance of large vessel occlusion and multiple vascular territories involvement. Early prophylactic or therapeutic anticoagulation with LMWH often guided by D-dimer levels could be beneficial to reduce thromboembolism in patients with COVID-19, including those with AIS but must be balanced against the risk of haemorrhagic transformation.