Case Report

Stroke and COVID19: Not only a large-vessel disease
Giovanni Frisullo, PhD, Simone Bellavia, MD, Irene Scala, MD, Carla Piano, PhD,
Roberta Morosetti, PhD, Valerio Brunetti, MD, Paolo Calabresi, PhD, and
Giacomo Della Marca, PhD

Recent evidence has underlined the association between large-vessel stroke and
COVID-19, probably due to a proinflammatory and prothrombotic microenvironment induced by SARS-CoV-2. Here, we report the case of a young fit woman
affected by COVID-19 without any flu-like symptom, who suffered from speech disorder and left hemiparesis. Brain magnetic resonance evidenced two small acute
brain infarctions in right perirolandic cortex without signs of previous ischemic
lesions and hemorrhagic infarction. Diagnostic workup excluded cardiac embolic
sources, acquired and inherited thrombophilia or autoimmune diseases. Two positive
nasopharyngeal swab tests and high titers of serum specific IgA/IgM confirmed
COVID-19 diagnosis. In our case stroke seems to be the only manifestation of SARSCOV-2 infection. Therefore the hypothesis of an underlying viral infection, as
COVID-19, should be investigated in all the cases of small vessel cryptogenic stroke.
Keywords: Stroke—COVID19—Small-vessel occlusion—SARS-COV-2
© 2020 Elsevier Inc. All rights reserved.

A 49-year-old women, scrub nurse in a COVID-19 hospital, was admitted to the Emergency Department for
sudden onset of speech disorder and left hemiparesis
with no fever, cough or wheezing. The neurological examination showed dysarthria, left facial weakness, left hemiparesis and hemianesthesia with National Institutes of
Health Stroke Scale score (NIHSS) of 7. Brain angiography
CT ruled out parenchymal lesions and large vessel occlusion (LVO). The patient received intravenous alteplase
with improvement of neurological symptoms (NIHSS=1).
Since she was positive for SARS-CoV-2 by RT-PCR from
nasopharyngeal swab, the patient was transferred to
COVID-19 subintensive Unit. Complete blood count
revealed lymphocytosis (4.09 £ 10^9/L) while systemic

From the IRCCS UOC Neurologia Dipartimento di Scienze dell’Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo,
Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A
Gemelli, 8 00168, Rome, Italy.
Received May 20, 2020; revision received June 9, 2020; accepted
June 14, 2020.
Corresponding author. E-mail:
giovanni.frisullo@policlinicogemelli.it.
1052-3057/$ - see front matter
© 2020 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jstrokecerebrovasdis.2020.105074

inflammatory and prothrombotic factors were normal.
Furthermore, an EEG registration evidenced no irritative
anomalies. Chest x-ray and CT did not show interstitial
lung involvement.
SARS-COV-2 infection was confirmed by high titers of
serum specific IgA/IgM and by the second positive nasopharyngeal swab sample.
Brain magnetic resonance imaging revealed two small
cortical acute ischemic lesions in the right pre and postcentral gyrus, without signs of previous ischemic lesions
and hemorrhagic infarction (Fig. 1). Cardiac workup consisting of electrocardiogram, cardiac telemetry monitoring, transthoracic and transesophageal echocardiography
excluded arrhythmias, cardiac source of emboli, or patent
foramen ovale. Serological testing for malignancy, thrombophilia and autoimmune diseases were negative.
After two consecutive negative swab she was discharged with a diagnosis of COVID-19 related cryptogenic stroke.
Our report describes the case of a young fit woman without cerebrovascular risk factors or family history of neurological diseases who developed a cryptogenic stroke.
Although the relationship between viral infection and
ischemic stroke is well-established, the pathogenic mechanism in the induction of cerebrovascular diseases is still

Journal of Stroke and Cerebrovascular Diseases, Vol. 29, No. 10 (October), 2020: 105074

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G. FRISULLO ET AL.

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LVO stroke.2,3 In our patient we did not detect any alteration of serum inflammation markers,3,4 such as Ddimer, fibrinogen, C-reactive protein, erythrocyte sedimentation rate. Therefore, it is possible to hypothesize
that SARS-COV-2 might penetrate the endothelial cells
of the arterioles in the cerebral cortex inducing direct or
immuno-mediated damage, without inducing a systemic
response. This hypothesis is supported by the absence,
in our patient, of flu or systemic symptoms, being stroke
the only manifestation of COVID-19. In conclusion, the
search for underlying viral infection such as COVID-19
should be investigated in all the cases of small vessel
cryptogenic stroke.

References
Fig. 1. An axial section of diffusion-weighted (Panel A), Apparent diffusion
coefficient (ADC) (Panel B), Fluid attenuation inversion recovery (FLAIR)
(Panel C) and Susceptibility-weighted Angiography (SWAN) (Panel D)
images of the brain shows two small acute brain infarctions (arrows) in right
perirolandic cortex without signs of previous ischemic lesions and hemorrhagic infarction.

debated.1 SARS-COV-2 seems to be able to create a proinflammatory microenvironment and to induce a prothrombotic state, predisposing to thrombogenesis and

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