Background:
The novel severe acute respiratory syndrome coronavirus (SARS-COV-2) is a viral respiratory illness of the coronavirus family. It was first discovered in Wuhan, China, in December 2019 and rapidly became a global pandemic of SARS-COV-2. It is transmitted primarily through respiratory droplets, but airborne transmission concerns have been raised by the World Health Organization (WHO). COVID-19 presents with widely variable clinical manifestations such as cough, fever, shortness of breath, and its complications, like pneumonia with adult respiratory distress syndrome (ARDS), circulatory shock, severe inflammatory reaction, in addition to coagulopathy and thromboembolism [1].
COVID-19-associated coagulopathy ranges from mild thrombocytopenia to severe coagulopathy, meeting the International Society on Thrombosis and Hemostasis (ISTH) criteria for disseminated intravascular coagulation (DIC). One of the most commonly observed coagulation abnormalities of COVID-19 is the raised D-Dimer and the reduction in serum fibrinogen levels [19] , which are considered a marker of disease severity and therefore have been used to monitor disease activity. The underlying pathophysiology of venous thromboembolism (VTE) is related to endothelial injury by the SARS-COV-2’s direct effect on the vascular endothelium, particularly in those with well-established secondary sepsis, venous stasis [7,13] and coagulopathy, especially in critically-ill patients. [12]
Another key role in developing hypercoagulability in COVID-19 patients is the hyper-inflammatory response to the SARS-COV-2 (cytokine storm syndrome), resembling the CAR-T associated cytokine release syndrome, mainly a serial cytokine rush particularly IL1, IL6 [1,4,9,14], TNF-alpha and IL8. These inflammatory mediators directly affect the vascular endothelium concurrently with the viral insult. They together activate the coagulation cascade resulting in arterial and venous thrombosis manifested as VTE, pulmonary embolism, arterial events such as ischemic strokes [2,3] , and peripheral limbs ischemia.
Herein, we report five cases of confirmed COVID-19 who developed an ischemic stroke of varying severity during their COVID-19 disease course.