Hemorrhagic Posterior Reversible Encephalopathy Syndrome as a Manifestation of COVID-19 Infection

Abstract

We describe 2 hospitalized patients with confirmed coronavirus 19 (COVID-19) infection in whom brain imaging showed hemorrhagic posterior reversible encephalopathy syndrome, and we discuss the possible reasons for these findings and their relationship to the infection. ABBREVIATIONS: ACE2 ¼ angiotensin-converting enzyme 2; COVID-19 ¼ coronavirus 19; PRES ¼ posterior reversible encephalopathy syndrome; SARS-CoV-2 ¼ Severe Acute Respiratory Syndrome coronavirus 2 T he current pandemic of Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) coronavirus 19 (COVID-19) has, to date, infected nearly 2 million people worldwide, resulting in .120,000 deaths as of mid-April 2020, spreading across continents with cases reported in 213 countries and territories. 1 Thus far, the scientific literature in terms of diagnosis and therapeutics has primarily focused on the respiratory status of affected individuals. 2 Neurologic manifestations are becoming increasingly recognized 3-5 and have been described in 78 of 214 (36.4%) patients in a study of patients with severe and nonsevere conditions who are positive for COVID-19. The findings can be, in part, attributed to the affinity of SARS-CoV-2 coronavirus for the angiotensin-converting enzyme 2 (ACE2) receptor, which is a relatively common functional receptor in both the respiratory and nervous systems. In fact, in some patients, neurologic symptoms preceded respiratory illness by several days or were the only indicators of disease in otherwise asymptomatic COVID-19 carriers. 5 Postmortem data have demonstrated hyperemic and edematous brain parenchyma with associated neuronal degeneration in early postmortem studies of patients with SARS-CoV-2, 6 and similar neurologic manifestations have been reported in related coronavirus infections such as SARS and Middle East Respiratory Syndrome. 7,8 Case Reports

Brain abnormalities in COVID-19 acute/subacute phase: A rapid systematic review

“…Infarct was reported in 13/124 (10%) and involved bilateral anterior [X : 9/242] and posterior [X : 4/242] circulation territories. Hemorrhages were noted in 7/124 (6%) and included: bilateral posterior parietooccipital area (J) (Franceschi et al, 2020) (Muhammad et al, 2020). Hematoma was also identified in one case report (1/124 (1%) and located in right subdural and frontal area [B] (Al-olama et al, 2020).…”

“…The midline structures of the brain were affected in 12/124 (10%) affected cases and mainly included abnormalities in the corpus callosum, i.e., hyperintensities [L (Hayashi et al, 2020); β (Zoghi et al, 2020)], hemorrhage [I] (Franceschi et al, 2020) Additionally, one of those patients [F] (Dixon et al, 2020) showed signs of swelling and hemorrhage in brain stem and hemorrhage in pons. Hyperintensities were noted in midbrain [A (Abdi et al, 2020); Z (Virhammar et al, 2020)] and pons [D (Asfar et al, 2020); β (Zoghi et al, 2020)].…”

Neuroimaging findings of brain MRI and CT in patients with COVID-19: A systematic review and meta-analysis

“…Since the initial case reports describing COVID-19-associated acute hemorrhagic necrotizing encephalopathy [ 6 ], other neuroimaging findings in patients with COVID-19 have been reported, including encephalitis/meningitis [ [7] , [8] , [9] ], hemorrhagic posterior reversible encephalopathy syndrome (PRES) [ 10 , 11 ], acute disseminated encephalomyelitis (ADEM) [ 12 , 13 ], cerebral venous thrombosis [ [14] , [15] , [16] ], and acute ischemic stroke [ 8 , 16 , 17 ]. Over the past several months, the number of publications reporting COVID-19-related neuroimaging findings since the outbreak of SARS-CoV-2 has been unprecedented and evolving.…”

Mechanisms of Stroke in COVID-19

“…In addition, it is possible that the cytokine storm that accompanies this disorder could be the cause of hemorrhagic strokes, as reported in a CO-VID-19 patient who developed an acute necrotizing encephalopathy associated with late parenchymal brain hemorrhages [4]. This massive release of cytokines may also damage and result in breakdown of the blood-brain barrier and cause hemorrhagic posterior reversible encephalopathy syndrome (PRES) [11]. Secondary hemorrhagic transformation of ischemic strokes has also been reported in COVID-19 patients [3,12].…”