Medicine

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Clinical Case Report

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Quadrantanopia as the only symptom of
post-COVID stroke in the occipital pole
Case report

∗

Katarzyna Baltaziak, MDa, , Agata Szpringer, MDa, Aleksandra Czarnek-Chudzik, MDa,
Maksymilian Onyszkiewicz, MD, PhDa, Mario Damiano Toro, MD, PhDa,b, Anna Pankowska, MScc,
Radoslaw Pietura, MD, PhDc, Robert Rejdak, MD, PhDa, Katarzyna Nowomiejska, MD, PhDa
Abstract
Rationale: This is a case report describing delayed complications of COVID-19 pneumonia, which evolved into the vascular-

ischemic complications leading to quadrantanopia and MRI findings consistent with recent ischemic event in the occipital pole of the
brain.
Patient concerns: We report a case of a 46-year-old woman with quadrantanopia due to stroke confirmed with brain MRI,
secondary to COVID-19 infection with chronically elevated D-dimers and treated with anticoagulation/antithrombotic modalities.
Quadrantanopia was the only symptom recognized by the patient of a stroke localized in the occipital pole of the brain.
Diagnosis: The patient was diagnosed with quadrantanopia due to stroke confirmed with brain MRI, secondary to COVID-19

infection.
Intervention: Patient underwent ophthalmological examination and MRI.
Outcomes: A thrombotic or ischemic risks in the chronic recovery from COVID-19 should be considered in patients with elevated

D-dimers.
Lessons: An MRI should be considered as a long term follow up for post-COVID-19 patients reporting ophthalmic or neurologic

complains.
Abbreviations: AIS = acute ischemic stroke, SARS-CoV-2 = severe acute respiratory syndrome coronavirus 2.
Keywords: COVID-19, D-dimers, neuro-ophthalmology, quadrantanopia, SARS-CoV-2, stroke, thrombosis, visual field defect

Province of China. Since then, the virus now known as SARSCoV-2 (severe acute respiratory syndrome coronavirus 2), has
spread to over 200 countries and it continues to be recognized as
a major world pandemic.[1] Coronaviruses are a family of
enveloped RNA viruses that are distributed widely among
mammals and birds, causing principally respiratory or enteric
disorders, and in some cases neurologic illness or hepatitis.[2]
SARS-CoV2 is known to initially bind to the angiotensinconverting enzyme 2 receptors of epithelial and endothelial cells where an
immediate immunological activation occurs that can, in severe
cases, eventually lead to hypercoagulability or thrombophilia and
increased tendency of clots forming in the blood and potentially
acute ischemic stroke (AIS).[3] In addition, non-respiratory
clinical manifestations of the CoV-related disease, mainly
ophthalmological and neuro-ophthalmological were also
reported but not fully described.[4] For example conjunctivitis
and keratoconjunctivitis[5] as well as retinal alterations[6] and
diplopia and ophthalmoparesis[7] have been described as case
reports or case series. We believe that this was at least in part due
to both technical and safety issues concerning the detailed
ophthalmological examinations in CoV patients and the
legitimate tendency to neglect eye complaints due to lifethreatening manifestations taking priority over the secondary
symptoms.[8]
It is assumed, that about one-third of patients hospitalized
due to severe COVID-19 develops macrovascular thrombotic
complications, including venous thromboembolism, myocardial

1. Introduction
In December 2019, a novel corona virus associated with a series
of acute, atypical cluster of pneumonia cases and respiratory
symptoms was first detected in Wuhan, a city in the Hubei
Editor: Maya Saranathan.
The patient has provided informed consent for publication of the case.
The authors have no funding and conflicts of interest to disclose.
All data generated or analyzed during this study are included in this published
article.
a

Chair and Department of General and Pediatric Ophthalmology, Medical
University of Lublin, Poland, b Faculty of Medicine, Collegium Medicum Cardinal
Stefan Wyszynski University, Warsaw, Poland, c Electroradiology Department,
Medical University of Lublin, Poland.
∗

Correspondence: Katarzyna Baltaziak, Chair and Department of General and
Pediatric Ophthalmology, Medical University of Lublin, Poland
(e-mail: k.baltaziak@gmail.com).

Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.
This is an open access article distributed under the Creative Commons
Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
How to cite this article: Baltaziak K, Szpringer A, Czarnek-Chudzik A,
Onyszkiewicz M, Toro MD, Pankowska A, Pietura R, Rejdak R, Nowomiejska K.
Quadrantanopia as the only symptom of post-COVID stroke in the occipital pole:
case report. Medicine 2021;100:44(e27542).
Received: 27 April 2021 / Received in final form: 9 September 2021 / Accepted:
1 October 2021
http://dx.doi.org/10.1097/MD.0000000000027542

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injury/infarction, and stroke.[9] Stroke is perhaps the most serious
non-pulmonary complication of COVID-19.
In some patients, COVID-19 infection can be severe, with
hypercoagulation being a common finding, with a vascular
endothelial damage and the consequent risk of venous and
arterial thrombotic complications. Coagulopathy secondary to
COVID-19 infection significantly worsens the prognosis and
increases overall mortality. Anosmia and dysgeusia have been
reported as common early symptoms of COVID-19 in absence of
nasal congestion or discharge, but severe neurologic presentations are rather rare with the exception of encephalopathy
secondary to hypoxemia in the course of SARS-CoV-2 acute
respiratory syndrome. Vascular and infectious encephalopathy
had been correlated with COVID-19 in critically ill patients.
However, whether COVID-19 may be considered a risk factor for
stroke is still not established.[10]
There are many publications regarding broad range of
respiratory-related COVID-19 manifestations, but there are very
limited sources of data related to neuro-ophthalmologic
complications of COVID-19.[11] The aim of this study was to
present a case of quadrantanopia as the only symptom of postCOVID stroke in the occipital pole.

all showed no abnormalities. At that time, the patient did
not undergo a polymerase chain reaction diagnostic test for
SARS-CoV-2 due to the pre-pandemic onset of illness. The
patient’s daughter had developed similar symptoms and virus
pneumonia after 2 weeks since the contact. According to the
official data at that time there were no known cases of COVID-19
in Poland.
On the July 3, 2020, the patient had D-dimers tested again due
to severe dizziness and the level was 1193 ng/mL, and she was
treated with acetylsalicylic acid (75 mg). In September 2020 the
D-dimers level was 600 ng/mL.
In October 2020 the patient presented at the Department of
General Ophthalmology in Lublin and the ophthalmological
tests have been completed due to bilateral visual deterioration
mentioned by the patient. Best-corrected visual acuity was 0.8
the right eye and 0.9 in the left eye. Anterior segment
examination and intraocular pressure were not remarkable.
Fundoscopic examination and photography was normal,
optical coherence tomography of the macula and peripapillary
retinal nerve fiber layer thickness – also normal (Figs. 1 and 2).
There was no pain on ocular movements and there was no
relative afferent pupillary defect. Based on the visual fields
examination (semi-automated kinetic perimetry using Octopus
900) the quadrantanopia was diagnosed in lower and right area
in both eyes (Fig. 3).
The patient was referred to neurologist for additional
evaluation. The neurological evaluation revealed isolated right
homonymous lower quadrantanopia, the National Institutes of
Health Stroke Scale score was 1 point. Routine computed
tomography scan of the head did not show any pathology.
The MRI examination was conducted using Magnetom-Avanto
1.5 T scanner (Siemens Healthcare, Erlangen, Germany). Study
protocol comprised turbo inversion recovery magnitude sequence,
diffusion-weighted imaging, and apparent diffusion coefficient
maps, T1- and T2-weighted sequences with and without
gadolinium enhancement obtained in coronal, sagittal, and axial
planes. Within the medial cortex of the left occipital lobe, a banded
high-signal area in turbo inversion recovery magnitude and T1weighted sequence with the presence of cortical laminar necrosis
areas and a slight enhancement after intravenous gadolinium
administration was visible. Diffusion-weighted imaging/apparent
diffusion coefficient imaging did not show diffusion restriction.
The image obtained in MRI examination corresponds to the
chronic vascular ischemic areas (Fig. 4).

2. Case description
A 46-year-old previously healthy woman without obesity
(BMI = 23 kg/m2) and cardiovascular risk factors and no
personal or family history of thromboembolic events reported
fever, cough, and myalgia in January 2020 after returning
from her trip to Andora. After computed tomography scan of the
chest with extensive multifocal dense ground-glass opacities
in the lungs she was diagnosed with pneumonia and was treated
in the hospital with 3 antibiotics and antiviral medication.
Her illness was lasting 4 weeks. She had no neurologic
signs during infection. D-dimer levels were as follows: 882 ng/
mL on February 3, 2020, 3412 ng/mL on February 8, 2020, and
421 ng/mL on February 13, 2020 and the anticoagulation
treatment was reinitiated with Clexane (enoxaparin sodium)
given subcutaneously. Her consecutive levels of D-dimers
were not normalizing during the course of the illness regardless
the continued treatment. Additional studies in the courses
of the hospitalization included ultrasound of the abdomen,
Doppler ultrasound of lower limbs’ venous system, Doppler
ultrasound of cervical/carotid and vertebral arteries, and

Figure 1. Optical coherence tomography of the macula of the right (A) and left (B) eye of the presented patient – normal appearance.

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Figure 2. Optical coherence tomography of the peripapillary retinal nerve fiber layer thickness and photography of the optic disc of both eyes of presented patient –
normal result.

3. Discussion

Patient was admitted to the stroke unit of the neurological
department to perform additional investigations. Duplex Doppler ultrasound assessing the cerebral arteries in the intracranial
segments showed an occlusion of the left posterior cerebral
artery.
In order to search for a cardioembolic origin of the embolus,
additional cardiological diagnostic examinations were carried
out. Echocardiography did not reveal any valvular defects or
myocardial contractility disorders; 24-hour Holter ECG monitoring did not disclose significant arrhythmias or conduction
disorders. Patient was monitored for blood pressure and blood
sugar.
To determine the etiology of cerebral stroke additional
laboratory tests towards rare blood diseases of increased
coagulability states were carried out but without findings
(homocysteine level, antiphospholipid antibodies, anticardiolipin
antibodies, antinuclear antibodies, antineutrophil cytoplasmic
antibodies, factor V Leiden mutation, protein C and S level,
antithrombin III level).
Considering the age of the patient and the absence of serious
concomitant cardiovascular diseases SARS-CoV-2 infection was
taken to be an independent cerebrovascular risk factor.
As the patients arrived beyond the time of the therapeutic
window for thrombolysis (4.5 hours) this intensive treatment of
AIS was not taken. As the secondary prevention of stroke
acetylsalicylic acid was given orally.
The patient was regularly followed-up by ophthalmologist and
neurologist, but the visual acuity and neurological state were
both stable. Visual acuity was 0.9 in both eyes after 6 months, the
quadrantanopia was still present.

To date, neurologic comorbidities and complications of COVID19 infections were broadly described including dysosmia,
dysgeusia, Guillain-Barre syndrome, anosmia, and AIS. Rarely,
neuro-ophthalmology complications of COVID-19 have been
reported.[12,13]
This is a case report describing complications of COVID-19
pneumonia, which evolved into the vascular-ischemic complications leading to quadrantanopia few months later and MRI
findings consistent with recent ischemic or thrombotic event in
the occipital pole of the brain. Neuroimaging abnormalities had
been described in patients with COVID-19-related encephalopathy, stroke, encephalitis, and other complications. The incidence
of ischemic stroke associated with COVID-19 in hospitalized
patients has been under 3%[14] and focal lesions leading to
quadrantanopia has not been described, yet. Reviews of COVID19 publications, reported clinically and autopsy-determined rates
of acute brain infarction range from 0.4% to 8.1% while rates of
acute brain hemorrhage range from 0.13% to 9.5%.[10] Based on
large meta-analysis, 1.4% of patients with COVID-19 suffer
from cerebrovascular disease.[10]
It has already been observed that patients with COVID-19 and
stroke are younger than patients with stroke without infection[15]
and majority of post-COVID patients (87.4%) develop AIS
rather than intracerebral hemorrhage (11.6%).[10] Moreover,
people with COVID-19 developing a stroke were older than
infected patients without stroke.[10] None of the studies
reported visual field results in patients with stroke. In a study
of Mao et al, visual symptoms, not specified, were found in 4 of
214 patients with neurological symptoms accompanying
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Figure 3. MRI study, axial brain slices of the occipital pole showing ischemic stroke obtained using following sequences: (A) Turbo inversion recovery magnitude
(TIRM), (B) T1-weighted turbo spin echo (TSE), (C) T1-weighted TSE after gadolinium contrast administration, and (D) diffusion-weighted imaging (DWI).

Reports on visual disturbances during or post-COVID
infection are scarce[14] and not described in details, only as
accompanying neurological disturbances.
Recently developed treatments, such as intravenous thrombolysis and mechanical thrombectomy, can significantly improve the
outcomes of AIS. However, the effects of these treatments are
highly time-dependent. After the end of a therapeutic time
window (4.5 hours) according to recommendations we can use
antiplatelet drugs, hypotensive drugs and statins. In our case it is
not possible to determine precisely when the thromboembolic
event occurred. The present case of stroke delayed after COVID19-related pneumonia seems to confirm that COVID-19 is an
independent risk factor for AIS.
In addition to the potential ischemic event, we have considered
thrombotic risks and we have used anticoagulating and antithrombotic therapy (low-molecular-weight-heparins) in responses to
elevated D-dimers keeping in mind a prevention of the acute visual
loss due to ophthalmic artery occlusion. Fortunately, it was a low
risk patient since the carotid and intracerebral circulation was
normal based on the U/S and CTA, respectively.
Nevertheless, the optimal treatment to prevent ischemic event
(ischemic stroke) or vascular thrombosis in presence of D-dimer
elevation in COVID-19 neuro-ophthalmic complications continue to be unclear and require attention to multimodalities in
diagnostic evaluations and multispecialty team’s collaboration in
diagnostic evaluations of such patients.

COVID-19 infection. In our case report of post-Covid stroke we
have shown documentation with the peripheral visual field results
and localization of ischemic area in the occipital pole of the brain.
A recent vascular/thrombotic event on MRI in studied patient
was consistent with AISs in patients with COVID-19 reported in
several case series and several mechanisms for AIS in COVID-19
were proposed including hypercoagulability, vasculitis, new
onset atrial fibrillation, and the infection by the SARS-CoV-2
itself.[16]
Connors and Levy,[17] recommended that D-dimer, PT, aPTT,
fibrinogen, and platelet count testing could be prognostic at
admission. A coagulation panel is not typically ordered in
ophthalmology services, but we are convinced now that the rising
D-dimer and the rapid drop in fibrinogen and platelet count could
be associated with neuro-ophthalmologic comorbidities leading
to complications in vision impairment or loss. In COVID-19, Ddimer elevation appears to be an important prognostic marker
and has been observed in initial COVID-19 stroke patients, as in
our patient.
The American Stroke Association has indicated that the risk of
stroke doubles every 10 years after age 55, so far more elderly
people are affected by stroke.[18]
Due to the increase in COVID-19 infections, the literature
reports an increasing number of premature strokes also in the
younger generation.[19]
Early reports from China described cerebrovascular disease in
about 5% of patients with severe COVID-19 disease, with
strokes occurring almost 2 weeks after initial diagnosis. In our
study, the stroke occurred probably few weeks after COVID-19
infection, the precise moment is not known, as the neurological
signs were limited to quadrantanopia.

Author contributions
Conceptualization: Mario Damiano Toro.
Funding acquisition: Robert Rejdak.
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[10] Nannoni S, de Groot R, Bell S, Markus HS. Stroke in COVID-19:
a systematic review and meta-analysis. Int J Stroke 2021;16:
137–49.
[11] Gold DM, Galetta SL. Neuro-ophthalmologic complications of coronavirus disease 2019 (COVID-19). Neurosci Lett 2021; 742:135531.
doi:10.1016/j.neulet.2020.135531.
[12] Cyr DG, Vicidomini CM, Siu NY, Elmann SE. Severe bilateral vision loss
in 2 patients with coronavirus Disease 2019. J Neuroophthalmol
2020;40:403–5.
[13] Selvaraj V, Sacchetti D, Finn A, Dapaah-Afriyie K. Acute vision loss in a
patient with COVID-19. R I Med J (2013) 2020;103:37–8.
[14] Mao L, Jin H, Wang M, et al. Neurologic manifestations of hospitalized
patients with coronavirus disease 2019 in Wuhan, China. JAMA Neurol
2020;77:683–90.
[15] 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:e60.
doi:10.1056/NEJMc2009787.
[16] Elkhider H, Ibrahim F, Sharma R, et al. COVID-19 and stroke, a case
series and review of literature. Brain Behav Immun Health
2020;9:100172. doi:10.1016/j.bbih.2020.100172.
[17] Connors JM, Levy JH. COVID-19 and its implications for thrombosis
and anticoagulation. Blood 2020;135:2033–40.
[18] Sacco RL, Adams R, Albers G, et al. Guidelines for prevention of stroke
in patients with ischemic stroke or transient ischemic attack: a statement
for healthcare professionals from the American Heart Association/
American Stroke Association Council on Stroke: co-sponsored by the
Council on Cardiovascular Radiology and Intervention: the American
Academy of Neurology affirms the value of this guideline. Stroke
2006;37:577–617.
[19] Hurley D. Sharp increase in large-vessel stroke risk seen in young, healthy
COVID-19 patients. Neurol Today 2020;20:36–7.
[20] Avula A, Nalleballe K, Narula N, et al. COVID-19 presenting as stroke.
Brain Behav Immun 2020;87:115–9.

Methodology: Maksymilian Onyszkiewicz.
Resources: Anna Pankowska, Radoslaw Pietura.
Visualization: Agata Szpringer, Aleksandra Czarnek-Chudzik.
Writing – original draft: Katarzyna Baltaziak.
Writing – review & editing: Katarzyna Nowomiejska.

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