key: cord-0859676-gatwv3sd
authors: Victorino, Daniella Balduino; Guimarães-Marques, Marcia; Nejm, Mariana; Scorza, Fulvio Alexandre; Scorza, Carla Alessandra
title: COVID-19 and stroke: red flags for secondary movement disorders?()
date: 2020-11-10
journal: eNeurologicalSci
DOI: 10.1016/j.ensci.2020.100289
sha: 833e63ae19e1b8bfe2102fee5dd1c09d9730d669
doc_id: 859676
cord_uid: gatwv3sd

• Hypercoagulability may predispose COVID-19 patients to thromboembolic complications; • Movement disorders may develop as complications of vascular events and infections; • Health professionals should be vigilant for abnormal movements in COVID-19 patients.

Dear editor,

The coronavirus disease 2019 , caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has sickened more than 23 million people across the globe over the past eight months. Acute cerebrovascular disease is a common complication of COVID-19 infection [1, 2] . Previous reports estimated a 0.5-5% risk of stroke among patients with COVID-19 [1] . The presence of SARS-CoV-2 within endothelial cells facilitates diffuse endothelial inflammation, which may disrupt the vascular equilibrium in favor of a procoagulant state [3] . In addition, the exaggerated inflammatory immune response exhibited by patients with COVID-19 may also stimulate the activation of coagulation and clotting processes [4] . These findings suggest that the presence of a hypercoagulable state along with a severe inflammatory response may predispose COVID-19 patients to thromboembolic complications [2, 4] .

CoV-2 who presented with generalized myoclonus. They showed both positive and negative myoclonic jerks, which mostly involved the facial, trapezius, sternocleidomastoid, and upper extremity muscles. These jerking movements occurred spontaneously and worsened with voluntary movement and tactile and auditory stimuli. An excessive startle reaction was also present. Neuroimaging was normal in all patients, and clinical improvement was observed following immunotherapy [5] . A suspected mild decreased uptake in the left caudate was also observed [7] .

Post-stroke movement disorders develop as residual complications of brain lesions mainly involving the basal ganglia and thalamus. These disorders can either occur immediately after the acute stroke onset or have a progressive, delayed onset. Small vessel disease, primarily impacting deep structures, is the most frequent stroke subtype resulting in movement disorders [8, 9] . Stroke may present with hypokinetic or hyperkinetic movements depending on the affected brain structure [8] [9] [10] . Given that cerebrovascular diseases account for about 20% of all secondary movement disorders [11] , might we expect an increase in the prevalence of movement disorders as a consequence of neurological injuries in COVID-19 patients?

The neurotropism of SARS-CoV- 2 has not yet been conclusively demonstrated [2] and, although there is no clear evidence for the association between COVID-19 and movement disorders, a direct consequence of an active SARS-CoV-2 infection on the development of abnormal movements should not be underestimated. A prospective study of 103 patients done by Netravathi and colleagues found that vascular events (22.3%) and infections (20.4%) were the most common causes of secondary movement disorders. They

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