Brain microvascular occlusive disorder in COVID-19: a case report

Abstract

We describe the case of a COVID-19 patient with severely impaired consciousness after sedation hold, showing magnetic resonance imaging (MRI) findings of (i) acute bilateral supratentorial ischemic lesions involving the fronto-parietal white matter and the corpus callosum and (ii) multiple diffuse susceptibility weighted imaging (SWI) hypointense foci, infra and supratentorial, predominantly bithalamic, suggestive of microhemorrhage or alternatively microthrombi. Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) RNA was detected in the cerebrospinal fluid. Our findings suggest the occurrence of vascular damage, predominantly involving microvessels. The underlying mechanisms, which include direct and indirect penetration of the virus to the central nervous system and systemic cardiorespiratory complications, are yet to be elucidated, and a direct correlation with SARS-CoV-2 infection remains uncertain.

Cerebrospinal fluid in COVID-19: A systematic review of the literature

“…Although the CSF RBC count was only reported for 61/430 (14%) patients [ 22 , 28 , 29 , 31 , 35 , 39 , 40 , 44 , 73 , 74 , 77 , 78 , 81 , 89 , 92 , 102 , 110 , 118 , [120] , [121] , [122] , [123] , 128 , 133 , 134 , [138] , [139] , [140] , 156 , 165 , 166 , [172] , [173] , [174] , [175] , [176] , 180 , 184 , 188 , 191 , 192 , 198 , 202 , 204 , 208 , 215 , 220 , 225 , 227 , 233 , 241 , 242 , 246 ], the CSF white blood cell (WBC) count was provided for 409/430 (95%) patients, 270 (66%) of whom had >0 cells/μL, >1 WBC:1,000 RBC or were noted to have “pleocytosis” ( Fig. 3 ) [ [5] , [6] , [7] , [8] , 10 , 13 , [15] , [16] , [17] , [18] ...…”

“…The CSF SARS-CoV-2 PCR resulted positive for 16/303 (5%) patients, all of whom had symptoms that localized to the CNS (16/238 (7%) patients with symptoms that localized to the CNS): 8/16 (50%) who had encephalopathy/coma +/- seizures, 4/16 (25%) who had headache +/- encephalopathy, 1/16 (6%) who had cerebellar symptoms, 1/16 (6%) who had paresthesias, 1/16 (6%) who had seizures without encephalopathy and 1/16 (6%) who had vision loss ( Table 2 ) [ [26] , [27] , [28] , [29] , 150 , 164 , 180 , 195 , 199 , 224 , 225 , 227 , 236 , 238 , 241 ]. The cycle threshold (Ct; the number of amplification cycles required for the target gene to exceed the threshold, which is inversely related to viral load) was only provided for 2/16 (13%) patients with a positive CSF SARS-CoV-2 PCR (37.12, 37.52 and 36.44 for the N1 gene, but negative for N2 for the patient reported by Moriguchi et al and 34.29 for the patient reported by Virhammar et al), though Fadakar et al noted that a Ct of 35 was the cutoff for a positive SARS-CoV-2 PCR [ [26] , [27] , [28] , [29] , 150 , 164 , 180 , 184 , 195 , 199 , 224 , 225 , 227 , 236 , 238 , 241 ]. There were 6/16 (38%) patients who did not have a positive nasopharyngeal/oropharyngeal SARS-CoV-2 PCR, 1 of whom had positive SARS-CoV-2 serum antibodies [ 26 , 27 , 153 , 184 , 241 , 250 ].…”

“…The majority (12/16, 75%) of patients with a positive CSF SARS-CoV-2 PCR were admitted to the hospital because of neurological symptoms [ [26] , [27] , [28] , [29] , 150 , 164 , 180 , 195 , 224 , 236 , 241 ]. There were 10/16 (63%) patients who had acute findings on neuroimaging and 5/16 (31%) patients who had acute findings on chest imaging [ 26 , 27 , 150 , 153 , 164 , 180 , 199 , 225 , 227 , 236 , 238 ]. CSF WBC count, when provided, ranged from 0 to 90 cells/μL for every patient except the patients reported by Mardani et al and Yousefi et al, who had a CSF WBC count of 1,920 cells/μL (90% neutrophils) and 1,870 cells/μL (90% neutrophils, CSF RBC count of 350 cells/μL), respectively [ [26] , [27] , [28] , [29] , 150 , 164 , 180 , 195 , 199 , 224 , 225 , 227 , 238 , 241 ].…”

Neurological manifestations of coronavirus disease 2019: exploring past to understand present

“…Infective • Acute encephalitis [ 13 , 14 ] • Acute encephalitis [ 1 ] • Bickerstaff encephalitiswith GBS [ 15 ] • Acute necrotizing hemorrhagicencephalitis [ 16 , 17 ] • Viral encephalitis [ 18 – 20 ] • Meningoencephalitis [ 21 ] • Rhombencephalitis [ 22 ] 2. Vascular • Ischemic stroke [ 23 ] • Ischemic stroke[ 1 ] • Ischemic stroke with large vesselocclusion [ 11 , 24 ] • Intracerebral hemorrhage,subarachnoidhemorrhage [ 25 , 26 ] • CVST [ 27 – 29 ] • PRES [ 30 – 33 ] • Microvascular occlusivedisorder [ 34 ] 3. Immunological • ADEM [ 35 ] • MS like illness [ 35 – 38 ] • ADEM[ 15 ] • Post infectious ADEM [ 38 , 39 ] • Acute transverse myelitis [ 40 – 43 ] • Anti-NMDA encephalitis [ 44 ] • Generalized and diaphragmaticmyoclonus [ 45 , 46 ] • Opsoclonus and ocularflutter [ 47 ] 4.…”

“…CSF was positive for SARS-CoV-2 RNA. This might have resulted from a systemic pro-coagulant state along with local and systemic inflammation–related endothelium damage and eventual immune-mediated vascular injury [ 34 ].…”