Post COVID-19 ischemic stroke in a 15-Year-old patient

Patient information

A 15-year-old female patient without any previous medical history presented at Amiri Hospital, Kuwait, on March 6, 2021, with a one-day history of facial asymmetry and weakness in the right upper and lower limbs, accompanied by impaired sensation. She reported feeling unwell with fatigue and loss of appetite a few days prior to admission. She had a low-grade fever on the day of admission with no other infective/coryzal symptoms. She had not received vaccination against Covid-19 infection. Her temperature was 37.8°Celsius, her pulse rate was 90 per minute, her blood pressure was 100/60 mm Hg, and her oxygen saturation was 98 percent on room air.

Clinical findings

Neurological examination revealed normal cognition, mild dysarthria, right-sided upper motor neuron facial weakness, and monocular diplopia affecting the left eye. There was no ptosis or nystagmus, a full range of motion in the external ocular muscles, and normal swallowing. In the right upper and lower limbs, the muscle power was 0/5 according to the Medical Research Council (MRC) Scale for Muscle Strength, accompanied by hypertonia, hyperreflexia, and ankle clonus. Superficial sensations were impaired on the right side of the body, although deep sensation was preserved. She had no bladder or bowel incontinence.

Diagnostic assessment

She tested positive for nasopharyngeal COVID-19 real-time reverse transcription polymerase chain reaction (RT-PCR) test carried out on admission to the hospital.

Magnetic resonance imaging (MRI) of the patient’s brain revealed acute infarcts in the pons and left cerebellum (Figure 1). There were no definite features of demyelinating disease. A computed tomography (CT) angiogram of the cerebrovascular system and carotid doppler findings showed occluded left vertebral and basilar arteries (Figure 2). The MRI findings of the brain and neck (T1 with fat suppression) suggested a thrombotic etiology rather than dissection. A conventional angiogram was not performed, as the patient’s family did not want to take the risks involved with the procedure. The findings of the transthoracic echocardiogram bubble study were unremarkable.

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Figure 1

- MRI Brain sagittal view showing acute infarcts in (A) the Pons and (B) left Cerebellum.

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Figure 2

- CT angiogram showing occlusion of A) left vertebral artery and B) Basilar artery.

Laboratory investigations were normal except for mildly elevated D-dimer level, at 299 ng/ml (normal range: 0–250 ng/ml). Her coagulation profile was normal. Serum ferritin and lactate dehydrogenase (LDH) levels were not elevated. The patient’s thrombophilia and vasculitis screens were all negative. Tests for mycoplasma, herpes simplex virus, varicella-zoster virus, and cytomegalovirus antibodies were also negative.

Therapeutic intervention

On admission, a preliminary diagnosis of a demyelinating disease was considered, and she was empirically treated with intravenous Methylprednisolone. When investigations revealed cerebrovascular thrombosis, Methyl Prednisolone was discontinued. She was then started on dual antiplatelet therapy (Aspirin and Plavix). Five weeks later the patient was transferred to the Physical Medicine and Rehabilitation Hospital, Kuwait, for rehabilitation. By this time, she exhibited partial motor recovery. Superficial sensations were still impaired on the right side. The cerebellar signs could not be assessed at this time due to the patient’s muscle weakness. The functional assessment revealed that she could take a few steps with the assistance of one person. She needed assistance for the activities of daily living, and her functional independence measure (FIM) score was 82/126. The patient underwent a comprehensive rehabilitation program, which included physiotherapy, occupational therapy, and robotic hand therapy sessions, as an inpatient as well as an outpatient at the Physical Medicine and Rehabilitation Hospital and showed significant improvement.

Follow-up and Outcome

The muscle power in her right upper and lower limbs had improved to grade 4/5 according to the MRC Scale, except for the finger extensors, intrinsic muscles of the hand, and ankle dorsiflexion, which were all graded 3/5. The patient had difficulty with her fine motor skills, especially handwriting, due to intention tremors in the fingers. She was trained to write with her left hand because she found doing so easier and faster than writing with her right hand. She exhibited mild incoordination. After eight months of rehabilitation, she could walk independently with a mild circumduction gait pattern. She was independent in all the activities of daily living and was able to return to school. At the time of discharge, her FIM score had improved to 123/126 (Figure 3).

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Figure 3

- Timeline picture of the case report.