Concurrent Acute Ischemic Stroke and Non-Aneurysmal Subarachnoid Hemorrhage in COVID-19

On examination, he had a blood pressure of 150/90 with a normal heart rate and regular rhythm right superior quadrantanopia, right hypesthesia, and right hemiparesis. Possible routes of SARS-CoV-2 in the cerebrovascular system include the olfactory epithelium and the respiratory tract with subsequent viremia.1 The virus can bind to the ACE-2 receptors of the cerebrovascular endothelium and causes endothelial damage and induces cytokine storm, which can then lead to vasculitis and subsequent stroke.3 Endothelial dysfunction and the consequent hyperinflammatory reaction may also increase the risk of plaque rupture and thrombosis.4 A hypercoagulable state is also another mechanism by which the virus can cause stroke, as evidenced by the increase in D-dimer seen in our patient.5,6 These mechanisms may explain why our patient had ischemic stroke. The disease is also associated with a downregulation of the ACE-2 receptors, elevated angiotensin II levels, and aforementioned endothelial damage, which can cause an increase in blood pressure and subsequently increase the risk for hemorrhagic stroke.4 The presence of other well-known risk factors for stroke, such as hypertension and smoking in our patient may have placed him at a greater risk for acquiring COVID-19 and developing cerebrovascular disease.