Acutely altered mental status as the main clinical presentation of multiple strokes in critically ill patients with COVI
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COVID-19
Acutely altered mental status as the main clinical presentation of multiple strokes in critically ill patients with COVID-19 Carolina Díaz-Pérez 1 & Carmen Ramos 1 & Alberto López-Cruz 2 & José Muñoz Olmedo 3 & Jimena Lázaro González 4 & Enrique De Vega-Ríos 5 & Carmen González-Ávila 1 & Carlos Hervás 1 & Santiago Trillo 1 & José Vivancos 1 Received: 7 May 2020 / Accepted: 7 August 2020 # Fondazione Società Italiana di Neurologia 2020
Abstract Background and aims 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. Methods Clinical presentation and diagnostic work-up of the patients. Results 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. Conclusion 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. Keywords COVID-19 . Acutely altered mental status . Multiple strokes
Introduction Carolina Díaz-Pérez and Carmen Ramos contributed equally to this work. * Carolina Díaz-Pérez [email protected] 1
Department of Neurology, La Princesa University Hospital, Madrid, Spain
2
Department of Psychiatry, La Princesa University Hospital, Madrid, Spain
3
Neuroradiology Unit, Department of Radiology, La Princesa University Hospital, Madrid, Spain
4
Intensive Care Unit, La Princesa University Hospital, Madrid, Spain
5
Department of Internal Medicine, La Princesa University Hospital, Madrid, Spain
The COVID-19 caused by the novel coronavirus SARS-CoV2 usually manifests with fever, cough, and dyspnea,
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