Stroke as Presenting Feature of COVID-19 in a Pediatric Patient

Abstract

Neurologic manifestations of severe acute respiratory syndrome coronavirus 2, the virus responsible for novel coronavirus 2019 (COVID-19) infection, have been frequently reported in the adult population but remain relatively rare in pediatric patients, specifically in regard to cerebrovascular accidents (CVAs). We present the case of a previously healthy 16-year-old adolescent boy with no preceding infectious symptoms who developed acute onset of left-sided weakness and slurred speech subsequently diagnosed with acute ischemic stroke (AIS). After performing a thorough diagnostic work-up, no clear etiology for AIS was identified. He was found to be COVID-19 positive by reverse transcription polymerase chain reaction upon admission. Accumulating evidence supports a link between COVID-19 and a systemic prothrombotic state suggesting pediatric patients who present with AIS and no other risk factors should be screened for this novel virus and potentially for extracranial sources of thrombi. As the rates of positive COVID-19 infection increase in the pediatric population, pediatricians and other pediatric subspecialists should be aware of the potential neurological and cerebrovascular complications of this novel virus to avoid delays in evaluation and intervention.

Keywords

pediatric - stroke - COVID-19

Authors' Contributions

S.S. conceptualized the case report, drafted the initial manuscript, and reviewed and revised the manuscript. A.C.E. conceptualized the case report, and reviewed and revised the manuscript. G.R.N. conceptualized the case report, critically reviewed the manuscript for important intellectual content, and revised the manuscript. All the authors approve the final manuscript as submitted and agree to be accountable for all aspects of the work.

Publikationsverlauf

Eingereicht: 14. März 2021

Angenommen: 14. Mai 2021

Artikel online veröffentlicht:
26. Juni 2021

• References

• 1 Cagnazzo F, Arquizan C, Derraz I. et al. Neurological manifestations of patients infected with the SARS-CoV-2: a systematic review of the literature. J Neurol 2020; 1-10
• 2 Ellul MA, Benjamin L, Singh B. et al. Neurological associations of COVID-19. Lancet Neurol 2020; 19 (09) 767-783
• 3 Kim Y, Walser SA, Asghar SJ, Jain R, Mainali G, Kumar A. A comprehensive review of neurologic manifestations of COVID-19 and management of pre-existing neurologic disorders in children. J Child Neurol 2021; 36 (04) 324-330
• 4 Tiwari L, Shekhar S, Bansal A, Kumar S. COVID-19 associated arterial ischaemic stroke and multisystem inflammatory syndrome in children: a case report. Lancet Child Adolesc Health 2021; 5 (01) 88-90
• 5 Schupper AJ, Yaeger KA, Morgenstern PF. Neurological manifestations of pediatric multi-system inflammatory syndrome potentially associated with COVID-19. Childs Nerv Syst 2020; 36 (08) 1579-1580
• 6 Bhatta S, Sayed A, Ranabhat B, Bhatta RK, Acharya Y. New-onset seizure as the only presentation in a child with COVID-19. Cureus 2020; 12 (06) e8820
• 7 Mirzaee SMM, Gonçalves FG, Mohammadifard M, Tavakoli SM, Vossough A. Focal cerebral arteriopathy in a pediatric patient with COVID-19. Radiology 2020; 297 (02) E274-E275
• 8 Beyrouti R, Adams ME, Benjamin L. et al. Characteristics of ischaemic stroke associated with COVID-19. J Neurol Neurosurg Psychiatry 2020; 91 (08) 889-891
• 9 TunÇ A, ÜnlÜbaŞ Y, Alemdar M, AkyÜz E. Coexistence of COVID-19 and acute ischemic stroke report of four cases. J Clin Neurosci 2020; 77: 227-229
• 10 Oxley TJ, Mocco J, Majidi S. et al. Large-vessel stroke as a presenting feature of COVID-19 in the young. N Engl J Med 2020; 382 (20) e60
• 11 Abdel-Mannan O, Eyre M, Löbel U. et al. Neurologic and radiographic findings associated with COVID-19 infection in children. JAMA Neurol 2020; 77 (11) 1440-1445
• 12 Miesbach W, Makris M. COVID-19: coagulopathy, risk of thrombosis, and the rationale for anticoagulation. Clin Appl Thromb Hemost 2020; 26: 1076029620938149
• 13 Cui S, Chen S, Li X, Liu S, Wang F. Prevalence of venous thromboembolism in patients with severe novel coronavirus pneumonia. J Thromb Haemost 2020; 18 (06) 1421-1424
• 14 Escalard S, Maïer B, Redjem H. et al. Treatment of acute ischemic stroke due to large vessel occlusion with COVID-19: experience from Paris. Stroke 2020; 51 (08) 2540-2543
• 15 Spence JD, de Freitas GR, Pettigrew LC. et al. Mechanisms of stroke in COVID-19. Cerebrovasc Dis 2020; 49 (04) 451-458
• 16 Middeldorp S, Coppens M, van Haaps TF. et al. Incidence of venous thromboembolism in hospitalized patients with COVID-19. J Thromb Haemost 2020; 18 (08) 1995-2002
• 17 Klok FA, Kruip MJHA, van der Meer NJM. et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res 2020; 191: 145-147
• 18 Klok FA, Kruip MJHA, van der Meer NJM. et al. Confirmation of the high cumulative incidence of thrombotic complications in critically ill ICU patients with COVID-19: an updated analysis. Thromb Res 2020; 191: 148-150
• 19 Llitjos JF, Leclerc M, Chochois C. et al. High incidence of venous thromboembolic events in anticoagulated severe COVID-19 patients. J Thromb Haemost 2020; 18 (07) 1743-1746
• 20 Le Jeune S, Suhl J, Benainous R. et al. High prevalence of early asymptomatic venous thromboembolism in anticoagulated COVID-19 patients hospitalized in general wards. J Thromb Thrombolysis 2020;1–5;
• 21 Tang N, Li D, Wang X, Sun Z. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. J Thromb Haemost 2020; 18 (04) 844-847
• 22 Thachil J, Tang N, Gando S. et al. ISTH interim guidance on recognition and management of coagulopathy in COVID-19. J Thromb Haemost 2020; 18 (05) 1023-1026
• 23 Hayıroğlu Mİ, Çınar T, Tekkeşin Aİ. Fibrinogen and D-dimer variances and anticoagulation recommendations in COVID-19: current literature review. Rev Assoc Med Bras (1992) 2020; 66 (06) 842-848
• 24 Musoke N, Lo KB, Albano J. et al. Anticoagulation and bleeding risk in patients with COVID-19. Thromb Res 2020; 196: 227-230
• 25 Khan R, Chan AK, Mondal TK, Paes BA. Thrombosis and Hemostasis in Newborns (THIN) Group. Patent foramen ovale and stroke in childhood: a systematic review of the literature. Eur J Paediatr Neurol 2016; 20 (04) 500-511
• 26 Mas JL, Derumeaux G, Guillon B. et al; CLOSE Investigators. Patent foramen ovale closure or anticoagulation vs. antiplatelets after stroke. N Engl J Med 2017; 377 (11) 1011-1021
• 27 Søndergaard L, Kasner SE, Rhodes JF. et al; Gore REDUCE Clinical Study Investigators. Patent foramen ovale closure or antiplatelet therapy for cryptogenic stroke. N Engl J Med 2017; 377 (11) 1033-1042 Erratum in: N Engl J Med 2020;382(10):978
• 28 Gerstl L, Weinberger R, Heinen F. et al. Arterial ischemic stroke in infants, children, and adolescents: results of a Germany-wide surveillance study 2015-2017. J Neurol 2019; 266 (12) 2929-2941
• 29 Castelli GP, Pognani C, Sozzi C, Franchini M, Vivona L. Cerebral venous sinus thrombosis associated with thrombocytopenia post-vaccination for COVID-19. Crit Care 2021; 25 (01) 137
• 30 Schultz NH, Sørvoll IH, Michelsen AE, Holme PA. et al. Thrombosis and Thrombocytopenia after ChAdOx1 nCoV-19 Vaccination. N Engl J Med 2021; 384 (22) 2124-2130