Is a Brain Stroke Caused by the COVID-19 Seen Under Two Years of Age? A Case Report

Introduction: Brain ischemic stroke in children especially in infancy is a rare condition. Stroke presents with a variety of symptoms and usually is an underestimated diagnosis in infants. The current pandemic of novel coronavirus disease type 2 (COVID-19), involves different organs in the human body, like the central nervous system. Researchers believe that there is a probable association between this retroviral infection and stroke but there were a few cases of strokes in the pediatrics eld with positive RT-PCR for SARS-CoV-2. Case presentation: Herein we introduce a 17-month-old girl with a hemiparesis and focal status epilepticus that was admitted to Firoozabadi hospital. The onset of symptoms was approximately 4 days before the admission with non-bloody, watery diarrhea, nausea, vomiting, and low-grade fever. The brain MRI with DWI sequence conrmed acute ischemic stroke (AIS). Because of her multisystemic involvement, the COVID-19 RT-PCR test was requested and the result was positive. So according to the positive PCR test and negative of other results along with fever and gastrointestinal involvement picture which is a common form of COVID-19 infection in pediatric patients- her neurological symptoms could be explainable with COVID-19 infection. Based on our knowledge, this is the rst case of acute ischemic stroke (AIS) due to SARS CoV-2 infection that was reported under two years of age in the world. Conclusion: COVID-19 infection in pediatric patients has different presentations. In a signicant number of these patients, the involvement of more than 2 body organs could be seen, known as “Multisystem Inammatory Syndrome in Children (MIS-C) Associated with Coronavirus Disease 2019 (COVID-19). There are some reports of stroke due to COVID-19 infection and it's related to hypercoagulability state so far and we introduce one infant case of that. According to this new emerging coronavirus and probability of nervous system involvement with this virus, we recommended checking the COVID-19 RT-PCR test in nasopharynx and cerebrospinal uid of all children presented with neurological symptoms, even in the post-COVID-19 era.


Introduction
Brain stroke in children especially in infancy is a rare condition. It has 2 main types; hemorrhagic and ischemic, which due to brain vessel rupture or occlusion, respectively (1). Stokes can lead to serious morbidity. Up to 25% of children will have recurrent episodes of strokes and up to 66% will have persistent neurological de cits or epilepsy (2,3,4). Stroke presents with a variety of symptoms and usually is an underestimated diagnosis in infants. The etiologies of stroke are classi ed into 4 main categories: heart disorders, blood disorders, infections, and vascular disorders (1,2,3,4). The current pandemic of novel coronavirus disease type 2 (COVID-19), involves different organs in the human body, like the central nervous system. Researchers believe that there is a probable association between this retroviral infection and stroke but there were a few cases of strokes in the pediatrics eld with positive RT-PCR for SARS-CoV-2 (5, 6, 7, 8).
Herein we introduce a 17-month-old girl with a focal neurological symptom and a positive RT-PCR test for covid-19 infection that was admitted to Firouzabadi hospital. The brain RT-PCR with DWI sequence con rmed acute ischemic stroke (AIS). Based on our knowledge, this is the rst case of acute ischemic stroke (AIS) due to SARS CoV-2 infection that was reported under two years of age in the world. Case A17-month-old infant was admitted because of abnormal jerky movements of the right upper limb in favor of seizure. The onset of symptoms was approximately 4 days before the admission with nonbloody, watery diarrhea, nausea, vomiting, and low-grade fever. On the 2nd day, she developed neurologic symptoms as frequent focal seizures that were taken more than 30 minutes and this condition got worse on the 3rd day and she had hemiparesis in the right side of her limbs, so the parents bring her to the emergency department. The patient was admitted while she had moderate dehydration and was ill but oriented.
Her past medical history didn't show any illness or hospital admission previously. She is the 4th child of all 4 children in their family and didn't have any birth complications or insult. She didn't receive any special medication except acetaminophen. The family history was negative for neurological disorders.
Vital signs at admission were as below: Blood Pressure: 88/55 mmHg, Pulse Rate: 140/ min, Respiratory Rate: 36/min, Oral Temperature: 37°C and her rst blood glucose was 114 mg/dl. Cranial nerve examinations were normal. There was no visual problem, neck stiffness, seizure, or jerky movement, but she had right-side deviated posture while sited and muscle force of right side was decreased that reveals hemiparesis. The plantar re exes were asymmetric and upward in the right side. Deep tendon re exes were brisk in the right limbs.
Due to her gastrointestinal symptoms which were followed by focal seizures and right-side hemiparesis, viral encephalitis placed on the top of the differential diagnosis list. Brain CT scan without contrast showed hypodensity in the left temporoparietal region and lower corticomedullary differentiation of left hemisphere compare with right side (Fig. 1). The brain MRI with DWI sequence con rmed acute ischemic stroke (AIS) in left hemisphere (Fig. 1 Table 1).
Because of her multisystemic involvement, the COVID-19 RT-PCT test was requested and the result was positive. So according to the positive PCR test and negative of other results along with fever and gastrointestinal involvement picture -which is a common form of COVID-19 infection in pediatric patients-her neurological symptoms could be explainable with COVID-19 infection. Based on our knowledge, this is the rst case of acute ischemic stroke (AIS) due to SARS CoV-2 infection that was reported under two years of age in the world. She underwent treatment with phenytoin, acyclovir, enoxaparin, and aspirin and was discharged from the hospital in a good condition. Conclusion COVID-19 infection in pediatric patients has different presentations. In a signi cant number of these patients, the involvement of more than 2 body organs could be seen, known as "Multisystem In ammatory Syndrome in Children (MIS-C) Associated with Coronavirus Disease 2019 (COVID-19). One of the involved systems could be the neurologic system and theoretically, it could be any neurological sign with no other alternative plausible diagnoses (9). There are some reports of stroke due to COVID-19 infection and it's related to hypercoagulability state so far and we introduce one infant case of that. According to this new emerging coronavirus and probability This case study was accredited by Ethical Committee of Iran University of Medical Sciences.

Consent to publish:
Written informed consent was obtained from the parents of the patient for publication of this Case Report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
Availability of data and material: The datasets used during the current case study are in the manuscript.

Competing interests:
The authors declare no con ict of interest in preparing this case presentation. Funding: This case presentation received no speci c grant from any funding agency in the public, institutions or not-for-pro t sectors.
Authors' contributions: VM and ZMR analyzed and interpreted the patient data regarding the neurologic disease. RA,YS and AH performed follow up the patient and were major contributors in writing the