Department of Neurology, La Princesa University Hospital, Madrid, Spain.
Department of Psychiatry, La Princesa University Hospital, Madrid, Spain.
Neurol Sci. 2020 Oct;41(10):2681-2684. doi: 10.1007/s10072-020-04679-w. Epub 2020 Aug 17.
Cerebral infarction in COVID-19 patients might be associated with a hypercoagulable state related to a systemic inflammatory response. Its diagnosis might be challenging. We present two critically ill patients with COVID-19 who presented acutely altered mental status as the main manifestation of multiple strokes.
Clinical presentation and diagnostic work-up of the patients.
Two patients in their sixties were hospitalized with a bilateral pneumonia COVID-19. They developed respiratory failure and were admitted to ICU for mechanical ventilation and intense medical treatment. They were started on low-molecular-weight heparin since admission. Their laboratory results showed lymphopenia and increased levels of C-reactive protein and D-dimer. Case 1 developed hypofibrinogenemia and presented several cutaneous lesions with biopsy features of thrombotic vasculopathy. Case 2 was performed a CT pulmonary angiogram at ICU showing a bilateral pulmonary embolism. When waking up, both patients were conscious but with a remarkable global altered mental status without focal neurological deficits. A brain MRI revealed multiple acute bilateral ischemic lesions with areas of hemorrhagic transformation in both patients (case 1: affecting the left frontal and temporal lobes and both occipital lobes; case 2: affecting both frontal and left occipital lobes). Cardioembolic source and acquired antiphospholipid syndrome were ruled out. COVID-19-associated coagulopathy was suspected as the possible main etiology of the strokes.
Acutely altered mental status might be the main manifestation of multiple brain infarctions in critically ill COVID-19 patients. It should be specially considered in those with suspected COVID-19-associated coagulopathy. Full-dose anticoagulation and clinical-radiological monitoring might reduce their neurological consequences.
COVID-19 患者的脑梗死可能与全身性炎症反应相关的高凝状态有关。其诊断可能具有挑战性。我们报告了两例 COVID-19 重症患者，他们以多发性中风的主要表现为急性改变的精神状态。
患者的临床表现和诊断检查。
两名六十多岁的患者因双侧肺炎 COVID-19 住院。他们出现呼吸衰竭，并因机械通气和强化治疗而入住 ICU。他们入院后开始使用低分子肝素。他们的实验室结果显示淋巴细胞减少，C 反应蛋白和 D-二聚体水平升高。病例 1 出现低纤维蛋白原血症，并出现了几处皮肤病变，活检特征为血栓性血管病变。病例 2 在 ICU 进行了 CT 肺动脉造影，显示双侧肺栓塞。当他们醒来时，两名患者均有意识，但整体精神状态明显改变，无局灶性神经功能缺损。脑部 MRI 显示两名患者均有多发性急性双侧缺血性病变，伴有出血性转化（病例 1：影响左额颞叶和双侧枕叶；病例 2：影响双侧额叶和左枕叶）。排除了心源性栓塞源和获得性抗磷脂综合征。怀疑 COVID-19 相关凝血病是中风的可能主要病因。
急性改变的精神状态可能是 COVID-19 重症患者多发性脑梗死的主要表现。在怀疑 COVID-19 相关凝血病的患者中应特别考虑这一点。全剂量抗凝和临床影像学监测可能会降低其神经后果。
