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.