A 51 year old man presented to the Emergency Department (ED) with acute onset left sided peripheral facial palsy and a complete right sided homonymous hemianopsia.\nThe patient was a Caucasian male of normal BMI with no prior history of hypertension, hypercholesterolemia, diabetes, smoking and or heart disease. He had been in good health until March 2020 when he returned from a group holiday to Austria. The patient started feeling unwell with a fever and was diagnosed with coronavirus disease (COVID-19) along with several members of the group that he had travelled with. A nasopharyngeal PCR swab confirmed the presence of SARS-CoV-2 RNA on the 22nd of March 2020. The patient was admitted the hospital on the 29th of March 2020 after increasing shortness of breath and onset of diarrhea and vomiting. The patient was febrile but had no oxygen requirement and was therefore diagnosed with mild COVID-19. He was admitted for observation, managed conservatively, and was discharged home 3 days later on the 1st of April 2020 after showing clinical improvement.\nThe patient was readmitted 2 days later on the 3rd of April 2020 with increasing shortness of breath. Clinically, pulmonary embolism (PE) was suspected with no signs of hemodynamic compromise. The diagnosis was confirmed by a CT Pulmonary Angiography (CTPA) (Fig. ) which demonstrated multiple bilateral subsegmental PE with no signs of right sided heart strain. The CTPA also demonstrated bilateral ground glass and consolidation in the lungs in keeping with COVID-19 infection (Fig. ). The CT examination was performed using the Siemens® Somatom Definition Flash using GE Healthcare® Omnipaque intravenous contrast and a standardized CTPA protocol. The patient had a D-dimer > 4.0 mg/L (normal range 0.2–0.6 mg/L). The Chest CT performed during the CTPA also shows the radiological extent of the COVID-19 illness in the lungs (Fig. ). The patient was started on Low Molecular Weight Heparin (LMWH) with bridging to direct oral anticoagulation (DOAC) on a dose of 20 mg Rivaroxaban OD. The patient continued DOAC treatment for a total of three months until the beginning of July 2020.\nOn the 26th of February 2021, approximately 11 months after being diagnosed with COVID-19, the patient contacted the emergency medical services due to acute onset visual field disturbances. The ambulance arrived on scene minutes after the onset of symptoms. A preliminary examination by the paramedics revealed as right sided visual field defect and a left sided facial palsy. The patient had a heart rate of 70 beats per minute and blood pressure of 147/89 mm Hg. The prehospital oxygen saturation was 98 % whilst breathing room air. Based on their initial findings, the paramedics suspected a stroke, and the patient was blue lighted to the ED.\nOn admission to the ED the patient was taken directly to the CT lab. The patient had a temperature of 35.5 ℃, ECG showing normal sinus rhythm, blood glucose of 5.8 mmol/L, a blood pressure of 157/99 mmHg and an oxygen saturation of 99 % on room air. A rapid neurological examination revealed a left sided peripheral facial palsy, right sided homonymous upper quadrantopia. A National Institutes of Health Stroke Scale (NIHSS) exam revealed a score of 3.\nA CT scan was performed including a pre- and intra- cerebral angiography. A subsequent cerebral perfusion scan was also performed. The CT examination was performed using the Siemens® Somatom Definition Flash using GE Healthcare® Omnipaque intravenous contrast and standardized protocols for angiography and perfusion.\nThe plain CT showed no signs of hemorrhage and based on the clinical suspicion of stroke the decision to treat with intravenous thrombolysis was made. Alteplase was administered at a dose of 0.9 mg/kg as per guidelines. The CT angiography three occluded intracerebral vessels, occlusions of the P2 and P3 segments of the left posterior cerebral artery (Fig. ) and an occlusion of the left superior cerebellar artery. The CT perfusion scan show increased time to drain (TTD) and reduced cerebral blood flow (CBF) in the afore mentioned occluded vascular territories (Fig. ).\nThe patient was admitted to the stroke unit and showed neurological improvement after Alteplase administration. The following day the patient had a NIHSS of 0.\nDuring hospital admission examinations were performed to determine ischemic stroke etiology. Ultrasound of the pre- and intra- cerebral vessels showed no significant stenoses or occlusions. Five day in-hospital cardiac rhythm monitoring showed sinus rhythm without any signs of atrial fibrillation and or other arrythmia. The patient underwent a Trans- Thoracic Echocardiography (TTE) which was normal and a Trans- Esophageal Echocardiography (TEE) where a patent foramen ovale was detected (PFO). The right to left shunting was visualized on color doppler and whilst using contrast (Fig. ). A blood work up during admission showed a normal ESR, normal levels of Immunoglobulin G and M, normal levels of Protein C and S and normal Factor Xa activity. Immunological assays did not detect the presence of rheumatoid factor, ANCA, ANA, anti-CCP antibodies. Furthermore, no factor V Leiden mutation was detected nor the presence of Lupus anticoagulant. The only abnormal finding was an elevated D-dimer of 1.2 mg/L (normal range 0.2–0.6 mg/L). A full body CT was performed including a CTPA and a CT venography of the lower extremities. The full body CT showed no signs of malignancy. The CTPA showed no evidence of pulmonary embolus and the CT venography of the lower extremities ruled out deep vein thrombosis (DVT).\nThe patient was discharged with a NIHSS of 0 following an Embolic Stroke of Unknown Source (ESUS). The patient is currently being treated with 20 mg Rivaroxaban OD, and atranscatheter closure of his PFO has been scheduled.
A 38-year-old man was referred to our clinic with generalized jerks in his hands (see Supplementary video-). A week before, he had been discharged from the hospital after four days of hospitalization due to a positive nasopharyngeal RT-PCR test and evident involvement of his lungs. Four days after discharge, he developed fine jerks in his hands and could not write; three days later, he was referred to our clinic with progression and generalization of jerks. He had generalized myoclonus in upper and lower limbs and bizarre abnormal movements that diminished with distraction; he was also restless and seemed anxious. The rest of the neurological examinations were normal. Lab tests were unremarkable. Laboratory investigations and brain MRI scans were normal. CSF analyses, including cell count, protein, and autoimmune panel, were normal. Clonazepam (2 mg/day), levetiracetam (1000 mg/day), and IV methylprednisolone for 5 days (1 g/day) were started, resulting in partial improvement. After two weeks, myoclonus was resolved; functional movements improved with some residual deficits, but he was still suffering from anxiety.