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CASE PRESENTATION

A 35-year-old male patient with a medical history of well-controlled hypertension and diabetes mellitus presented to the emergency room with left sided weakness when he woke up from sleep that progressed to paralysis of the left side of his body. The symptoms started 12 hours prior to his arrival. The patient also reported feeling shortness of breath for the last few days. He denied any recent sick contact, headache, photophobia, recreational drug use, and family history of note. His medications included metformin and hydrochlorothiazide. Vitals signs were temperature 97.6°F, blood pressure 153/117 mmHg, heart rate of 117 beats/min, and oxygen saturation of 91% on nonrebreather mask. His finger stick glucose was 98 mg/dl. Physical examination revealed alert, oriented male in mild respiratory distress. Pupillary examination revealed anisocoria. Lungs were clear to auscultation except bibasilar crackles, and heart sounds were normal. On neurological examination, the patient had hemiplegia of the left side of the body but had good strength on the right side of the body. Abdomen was soft without any organomegaly. Initial labs revealed mild leukocytosis (white blood cell [WBC] of 11.0 k/μl), with normal hemoglobin, electrolytes, and renal function. D-dimers were elevated at 1088 ng/ml. His initial international normalized ratio (INR) was 1.06, prothrombin time (PT) was 12.5 seconds, and partial thromboplastin time (PTT) was 30.7 seconds. He was also noted to have an elevated lactate dehydrogenase (LDH) level at 254 unit/L and elevated C-reactive protein at 17.2 mg/L. The patient tested positive for SARS-CoV-2 RNA via polymerase chain reaction testing. Chest X-ray revealed bilateral pulmonary opacities. Computed tomography (CT) of the head showed no evidence of acute intracranial hemorrhage or injury. CT angiogram of the brain revealed abrupt occlusion of the right M2 middle cerebral artery (MCA) inferior branch with lack of visible perfusion in the posterior inferior right MCA territory. Subsequent CT head showed interval development of a large acute right MCA distribution territorial infarct, with findings suspicious for thrombus involving a branch of the right M2 segment. The patient was diagnosed with acute right MCA stroke in the setting of COVID-19 infection. Since he was not a candidate for tissue plasminogen activator (tPA) due to the late presentation, he was given aspirin and high-intensity statin. He also received conservative management for COVID-19 pneumonia. After 48 hours of stroke symptoms, he was initiated on low-molecular-weight heparin (LMWH) for venous thromboembolism (VTE) prophylaxis. His oxygenation and hemodynamic parameters started to improve. His D-dimer and LDH started to trend down. He was later discharged to rehabilitation center for physical therapy.

Epidemiology

According to observational data, the incidence of thromboembolic disorder such as pulmonary embolism (PE) in COVID-19 infection ranges from 1.5%-9%. (1-3) Similarly, the incidence of asymptomatic deep venous thrombosis (DVT) in hospitalized patients with COVID infection ranges from 18%-20%. (1-3) Cerebrovascular accident was observed in 1%-6% of the population with COVID infection. More younger ...

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