To report a unique presentation of acute synchronous cardio-cerebral infarction with intraluminal carotid thrombus (ICT) and hyperperfusion in the setting of a recent SARS-CoV-2 infection.

Simultaneous acute ischemic stroke (AIS) and acute myocardial infarction (AMI), also referred to as cardio-cerebral infarction, is an extremely rare entity. Additionally, AIS due to ICT is an infrequent condition and is often associated with ipsilateral carotid stenosis or underlying hypercoagulable state. Infection with SARS-CoV-2 is thought to cause endothelial inflammation and a hypercoagulable state. Here we report a case of concurrent AIS due to a partially occlusive ICT and AMI in the setting of recent SARS-CoV-2 infection.

Case report and literature review.

A middle-aged male presented with isolated transcortical sensory aphasia. CT angiography showed a free-floating intraluminal thrombus in the clinoid segment of the left internal carotid artery. There was an increase in regional cerebral blood flow (CBF) and cerebral blood volume (CBV) as well as decreased Tmax on perfusion imaging consistent with hyperperfusion. Additionally, he was found to have an acute inferior-wall ST-elevation MI. He did report a recent COVID-19 exposure and clinical symptoms of chills with pulmonary imaging concerning for COVID-19 pneumonia. Swab-based PCR testing for COVID-19 was negative, but IgG antibody test returned positive, suggesting a recent infection. D-dimer was elevated. Magnetic resonance imaging (MRI) brain confirmed an AIS involving the left MCA territory.

We report a unique case of simultaneous AIS from ICT and AMI in the setting of recent SARS-CoV-2 infection and with the etiology of both events attributed to a COVID-19 hypercoagulable state. Additionally, imaging studies showed a rare phenomenon of hyperperfusion that occurs when cerebral blood flow increases in the region of previous ischemia (hypoperfusion and/or infarcted brain tissue) and is thought to be a form of dysfunctional autoregulation.