Kerala Journal of Ophthalmology

CASE REPORT
Year
: 2022  |  Volume : 34  |  Issue : 2  |  Page : 154--156

A case of cerebellar stroke/Wallenberg syndrome postx-COVID-19 infection


Roopashri Lakkundi, Himani Manral, Manasi More, Harsha Sameer Pagad 
 Department of Ophthalmology, Padmashree Dr. D Y Patil Medical College and Hospital, Nerul, Navi Mumbai, Maharashtra, India

Correspondence Address:
Dr. Himani Manral
Department of Ophthalmology, Padmashree Dr. D Y Patil Medical College and Hospital, Nerul, Navi Mumbai - 400 706, Maharashtra
India

Abstract

Stroke has been reported as one of the several deadliest complications noted in COVID-19 infection. Stroke in COVID-19 is multifactorial and has propensity to involve large vessels and multiple territories. The most appealing mechanisms for strokes in COVID infection are the cytokine-induced coagulopathy and the endotheliopathy triggered by the infection. Stroke in young patients has been particularly observed. The treatment is also challenging in terms of judicious use of antithrombotic/anticoagulation agents concomitant to oral or intravenous steroids administration. We report a case of cerebellar stroke/ Wallenberg syndrome in a diagnosed COVID-19 patient with deranged coagulation profile and elevated interleukin-6. She presented with binocular diplopia, oscillopsia and had a very well documented skew deviation with torsional nystagmus. She also had impaired cerebellar functions. We also highlight the characteristic features of COVID stroke, its management, and shed light on the diagnosis of skew deviation and its management.



How to cite this article:
Lakkundi R, Manral H, More M, Pagad HS. A case of cerebellar stroke/Wallenberg syndrome postx-COVID-19 infection.Kerala J Ophthalmol 2022;34:154-156


How to cite this URL:
Lakkundi R, Manral H, More M, Pagad HS. A case of cerebellar stroke/Wallenberg syndrome postx-COVID-19 infection. Kerala J Ophthalmol [serial online] 2022 [cited 2022 Dec 2 ];34:154-156
Available from: http://www.kjophthal.com/text.asp?2022/34/2/154/355029


Full Text



 Introduction



There are multiple mechanisms implicated in the pathogenesis of stroke in COVID-19 infection. The diverse factors involved in stroke are hyper coagulable state, disseminated intravascular coagulation (DIC), cardiac dysfunction, vasculitis, cardiomyopathy, necrotizing encephalopathy.[1],[2] The usual causes like hypertension, atherosclerosis and atrial fibrillation may also contribute. Since there are multiple mechanisms underlying stroke, the treatment is also a combination of anti-coagulation, anti-inflammatory and antiviral therapies. We report a case of stroke in a young female patient who had typical features of Wallenberg syndrome post COVID-19 infection.

 Case Report



A 40-year-old female with a history of cough, breathlessness, and recent diagnosis of COVID-19 infection presented to us with a history of loss of balance, inability to walk, swaying to the left side associated with giddiness, nausea, vomiting, and headache. She complained of binocular vertical diplopia associated with oscillopsia. She also gave a history of hematuria and menorrhagia. She was admitted to the COVID care center before presenting to us, and details of the medications administered were unavailable. Her hemogram showed low hemoglobin of 8.3 gm%. Platelets were adequate with normal morphology. Peripheral smear revealed microcytic hypochromic anemia with anisopoikilocytosis. Coagulation profile was found to be normal. C-reactive protein was mildly elevated at 15.7 mg/l (<10 being normal). Procalcitonin was in the normal range. Interleukin-6 (IL-6) was elevated at 149.9 (normal being 0–50 pg/ml). D-dimer was deranged at 2630 (0–500 ng/ml is normal range). Lactate dehydrogenase was 569.2 (normal range of 140–280 U/L). She had a chest computed tomography (CT) score of CORAD 5. She was maintaining a saturation of 96% with 6 l of oxygen. Antinuclear antibodies were negative. Echocardiography showed left ventricular hypertrophy. CT scan of the brain was reported to have a nonhemorrhagic infarct in the left cerebellum [Figure 1]a. Magnetic resonance (MR) imaging of the brain and orbit areas, done a week later, featured gliotic area in the left cerebellar hemisphere and a tiny subcentimeter-sized area in the left dorsolateral medulla. MR angiography, in addition, showed constricted left vertebral artery with poor flow, suggesting a thrombo-occlusive disease process [Figure 1]b.{Figure 1}

On ocular examination, she had best-corrected visual acuity of 6/6 in both eyes. Intraocular pressure by applanation tonometer was 14 mmHg in both eyes. Fundus examination was done, and the images were captured on a fundus camera [Figure 2]. The patient had a left head tilt of around 10°. There was right hypertropia of around 18 prism Diopters which remained same in the right and left gazes and also with the head tilts, i.e., Parks' three-step test was inconclusive. In supine position, the hypertropia reduced significantly. There was no obvious under/overaction of any extraocular muscles [Figure 3]. The patient also had torsional nystagmus in both eyes [Video 1]. With the above findings, we came to a diagnosis of skew deviation secondary to a left-sided cerebellar infarct due to involvement of the left utriculosaccular pathways. Tests of cerebellar dysfunctions such as the finger nose nest, dysdiadochokinesia, and ataxia were positive on the left side. There were no signs of other cranial nerves involvement on either side. No focal neurological deficits were noted. The patient was treated with antiplatelet agents, intravenous methyl prednisolone, antihypertensives, antihistamines, iron, and multivitamin supplements. The patient was prescribed occlusion of one eye to alleviate the diplopia. Three months follow-up of the patient showed complete resolution of the skew deviation and the nystagmus. The patient had no complaints of diplopia, and there was even a marked improvement in her gait.{Figure 2}{Figure 3}

 Discussion



There are multiple mechanisms implicated in the pathogenesis of stroke in COVID-19 infection. The diverse factors involved in stroke are hypercoagulable state, disseminated intravascular coagulation, cardiac dysfunction, vasculitis, cardiomyopathy, and necrotizing encephalopathy.[1],[2] The usual causes such as hypertension, atherosclerosis, and atrial fibrillation may also contribute. Since there are multiple mechanisms underlying stroke, the treatment is also a combination of anticoagulation, anti-inflammatory, and antiviral therapies.

World Stroke Organization reported that the risk of ischemic stroke during COVID-19 is around 5%.[3] COVID-19–related hemorrhagic strokes are far less common than ischemic strokes, but a few cases have been reported.[4],[5],[6],[7] The median time from the first COVID-19 symptoms to the identification of stroke was 10 (5–16.5) days in one small single-center study.[8] Patients with COVID-19 who had strokes were more likely to be older and have hypertension with higher levels of D-dimer.[1]

Similarly, among 50 patients with ischemic stroke admitted in Wuhan, China, there was more comorbidity, with lower platelet and lymphocyte counts. These patients also had markedly higher levels of D-dimers, cardiac troponin I, NT pro-brain natriuretic peptide, and IL-6.[9]

Patients with COVID-19 fare worse in terms of clinical outcomes than patients with stroke who do not have COVID-19.[10],[11] On the contrary, our patient had complete resolution of diplopia, skew deviation, and nystagmus at 3 months of follow-up.

Our case report is a unique one with characteristic features of cerebellar stroke/Wallenberg syndrome, secondary to COVID-19 infection in a young individual with emphasis on complete recovery seen over a period of time. The patient demonstrated typical features of skew deviation observed in cerebellar strokes. She had classic triad of ocular tilt reaction, skew deviation and torsional nystagmus. Some of the points supporting the diagnosis of skew deviation in this patient are the presence of right hypertropia with inconclusive Parks' three-step test; no obvious under/overaction was seen on ocular motility evaluation. It is prophesied that always the eye on the affected side is lower. Hence, we had left-sided cerebellar infarct with hypotropia of the left eye, excyclotorsion of the left eye, and intorsion of the right eye. We also saw more than 50% reduction in hypertropia in the lying down position, known as positive supine test. The patient did not have any other features of Wallenberg syndrome, probably due to tiny size of the infarct.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Oxley TJ, Mocco J, Majidi S, Kellner CP, Shoirah H, Singh IP, et al. Large-vessel stroke as a presenting feature of COVID-19 in the young. N Engl J Med 2020;382:e60.
2Beyrouti R, Adams ME, Benjamin L, Cohen H, Farmer SF, Goh YY, et al. Characteristics of ischaemic stroke associated with COVID-19. J Neurol Neurosurg Psychiatry 2020;91:889-91.
3Qureshi AI, Abd-Allah F, Al-Senani F, Aytac E, Borhani-Haghighi A, Ciccone A, et al. Management of acute ischemic stroke in patients with COVID-19 infection: Report of an international panel. Int J Stroke 2020;15:540-54.
4Al Saiegh F, Ghosh R, Leibold A, Avery MB, Schmidt RF, Theofanis T, et al. Status of SARS-CoV-2 in cerebrospinal fluid of patients with COVID-19 and stroke. J Neurol Neurosurg Psychiatry 2020;91:846-8.
5Muhammad S, Petridis A, Cornelius JF, Hänggi D. Letter to editor: Severe brain haemorrhage and concomitant COVID-19 Infection: A neurovascular complication of COVID-19. Brain Behav Immun 2020;87:150-1.
6Poyiadji N, Shahin G, Noujaim D, Stone M, Patel S, Griffith B. COVID-19-associated Acute hemorrhagic necrotizing encephalopathy: Imaging Features. Radiology 2020;296:E119-20.
7Sharifi-Razavi A, Karimi N, Rouhani N. COVID-19 and intracerebral haemorrhage: Causative or coincidental? New Microbes New Infect 2020;35:100669.
8Yaghi S, Ishida K, Torres J, Mac Grory B, Raz E, Humbert K, et al. SARS-CoV-2 and stroke in a New York healthcare system. Stroke 2020;51:2002-11.
9Qin C, Zhou L, Hu Z, Yang S, Zhang S, Chen M, et al. Clinical characteristics and outcomes of COVID-19 patients with a history of stroke in Wuhan, China. Stroke 2020;51:2219-23.
10Siegler JE, Heslin ME, Thau L, Smith A, Jovin TG. Falling stroke rates during COVID-19 pandemic at a comprehensive stroke center. J Stroke Cerebrovasc Dis 2020;29:104953.
11Sweid A, Hammoud B, Bekelis K, Missios S, Tjoumakaris SI, Gooch MR, et al. Cerebral ischemic and hemorrhagic complications of coronavirus disease 2019. Int J Stroke 2020;15:733-42.