Cerebellar infarction requiring surgical decompression in patient with COVID 19 pathological analysis and brief review

Abstract

Background This report and literature review describes a case of a COVID-19 patient who suffered a cerebellar stroke requiring neurosurgical decompression. This is the first reported case of a sub-occipital craniectomy with brain biopsy in a COVID-19 patient showing leptomeningeal venous intimal inflammation. Clinical description The patient is a 48-year-old SARS-COV-2 positive male with multiple comorbidities, who presented with fevers and respiratory symptoms, and imaging consistent with multifocal pneumonia. On day 5 of admission, the patient had sudden change in mental status, increased C-Reactive Protein, ferritin and elevated Interleukin-6 levels. Head CT showed cerebral infarction from vertebral artery occlusion. Given subsequent rapid neurologic decline from cerebellar swelling and mass effect on his brainstem emergent neurosurgical intervention was performed. Brain biopsy found a vein with small organizing thrombus adjacent to focally proliferative intima with focal intimal neutrophils. Conclusion A young man with COVID-19 and suspected immune dysregulation, complicated by a large cerebrovascular ischemic stroke secondary to vertebral artery thrombosis requiring emergent neurosurgical intervention for decompression with improved neurological outcomes. Brain biopsy was suggestive of inflammation from thrombosed vessel, and neutrophilic infiltration of cerebellar tissue.

Neuropathologic findings of patients with COVID-19: a systematic review

“…Microscopic evaluation further exhibited cellular components signifying distinct stages into the inflammatory process as demonstrated by the presence of cerebral venous neutrophilic infiltrates ( n =2, 1.4%) [ 21 , 22 ], perivascular lymphocytic infiltrates ( n =50, 34.2) [ 11 , 13 , 16 , 22 , 24 ], perivascular degeneration and calcification ( n =5, 3.4%) [ 15 , 16 ], and variable degrees of neuronal cell loss and axonal degeneration/injury ( n =10, 6.8%) [ 11 , 12 , 22 ]. Other findings included small-vessel ectasia with variable perivascular edema and perivascular microhemorrhages ( n =10, 6.8%) [ 18 ], endovascular microthrombi ( n =10, 6.8%) [ 18 ], recent microscopic cortical infarcts ( n =24, 16.4%) [ 11 , 13 , 14 , 16 – 18 , 22 ], and acute microscopic/punctate hemorrhages ( n =15, 10.3%) [ 11 , 12 , 14 , 17 , 19 , 22 , 23 ].…”

“…This evaluation left 24 articles, only 14 of which met the eligibility criteria for synthesis in this review. There were ten case series [11][12][13][14][15][16][17][18][19][20], two case reports [21,22], one retrospective cohort [23], and one prospective cohort [24]. Figure 1 illustrates our search strategy.…”

“…Other findings include malignancies (solid or hematologic) (n=15, 10.3%). The limited available data on presenting neurologic symptoms revealed that altered mental status was the most common symptom (n=14, 43.8%) followed by delirium (n=9, 28.1%) [12,14,15,19,21,23,24]. Less common encountered presentations included cranial nerve pathologies signifying a cerebrovascular event (n=2, 6.3%), headache, nausea and vomiting, aphasia, and ageusia (n=1, 3.1%) while the rest remained unreported (n=114, 78.1%).…”

“…A subset of cases (n=146) diagnosed with SARS-CoV-2 infection underwent biopsy or post-mortem examination for pathologic study of the brain [11][12][13][15][16][17][18][19][20][21][22][23]. SARS-CoV-2 reactivity in brain sections of these patients was positive in only 15.1% (n=22) [13,18].…”

A case-based systematic review on the SARS-COVID-2-associated cerebrovascular diseases and the possible virus routes of entry

“…The remaining 71 articles (127 patients) that satisfied the criteria mentioned above were included in this review. In this review, 80 cases of patients developed IS during COVID-19 infection (Aasfara et al 2021 ; Abdulkadir et al 2020 ; Agarwal et al 2020 ; Al-Mufti et al 2021 ; Al Saiegh et al 2020 ; Appavu et al 2021 ; Ashraf and Sajed 2020 ; Avula et al 2020 ; Bessa et al 2020 ; Bigliardi et al 2020 ; Burkert and Patil 2020 ; Co et al 2020 ; Dakay et al 2020a , b ; de Almeida Lima et al 2020 ; de Lorenzo Alvarez et al 2021 ; Deliwala et al 2020 ; Dumitrascu et al 2020 ; Efendizade et al 2020 ; El Nahas et al 2020 ; Elshereye and Erdinc 2020 ; Eskandarani et al 2021 ; Fu et al 2021 ; Garg et al, 2020 ; Gemcioglu et al 2020 ; Goette et al 2020 ; Goldberg et al 2020 ; Guillan et al 2020 ; Iqbal et al 2021 ; Kwon et al 2020 ; Mahboob et al 2020 ; Mansour et al 2020 ; Mirzaee et al 2020 ; Morassi et al 2020 ; Mowla et al 2020 ; Patel et al 2020a , b ; Patel et al 2020a , b ; Prasad et al 2021 ; Priftis et al 2020 ; Rajdev et al 2020 ; Rascón-Ramírez et al 2020 ; Roy et al 2021 ; Valderrama et al 2020 ; Viguier et al 2020 ; Zhai et al 2020 ), 32 cases developed intracranial hemorrhage (Ahmad et al 2021 ; Al-Mufti et al 2021 ; Al Saiegh et al 2020 ; Carroll and Lewis 2021 ; Cezar-Junior et al 2020 ; Dakay et al 2020a , b ; Dakay et al 2020a , ...…”