Ruptured cerebral aneurysms in COVID-19 patients: A review of literature with case examples

Abstract

Background: The novel severe acute respiratory syndrome coronavirus 2 is responsible for over 83 million cases of infection and over 1.8 million deaths since the emergence of the COVID-19 pandemic. Because COVID-19 infection is associated with a devastating mortality rate and myriad complications, it is critical that clinicians better understand its pathophysiology to develop effective treatment. Cumulative evidence is suggestive of cerebral aneurysms being intertwined with the hyperinflammatory state and hypercytokinemia observed in severe COVID-19 infections. Case Description: In case example 1, the patient presents with chills, a mild cough, and sore throat. The patient develops high-grade fever of 39.8° C, decreased oxygen saturation of 93% on room air, and an extensive spontaneous subarachnoid hemorrhage (SAH) in the basal cisterns from a ruptured left posterior communicating artery aneurysm. In case example 2, the patient presents with a positive PCR test for COVID-19 2 weeks prior with spontaneous SAH and found to have a large multilobulated bulbous ruptured aneurysm of the anterior communicating artery. Both patients’ symptoms and high-grade fever are consistent with hypercytokinemia and a hyperinflammatory state, with elevated granulocyte colony-stimulating factor, inducible protein-10, monocyte chemoattractant protein-1, M1P1A, and tumor necrosis factor-α inflammatory mediators found to be elevated in COVID-19 intensive care unit admissions. Conclusion: COVID-19 effect on cerebral aneurysms requires future studies to clearly delineate correlation, however, hypercytokinemia and a hyperinflammatory state are strongly implicated to cause degenerative vascular changes that may predispose patients to cerebral aneurysm formation, change in size or morphology, and resultant aneurysm rupture.

The potential role of ischaemia–reperfusion injury in chronic, relapsing diseases such as rheumatoid arthritis, Long COVID, and ME/CFS: evidence, mechanisms, and therapeutic implications

“…Clearly, the blockage of a blood vessel by a microclot is likely to exert pressure on the vessel's walls, potentially weakening it, and so it is reasonable that aneurysms might be expected to accompany diseases involving microclots. This turns out to be the case in rheumatoid arthritis [ 490 ], acute COVID [ 491 , 492 ] (which bears similarities to Kawasaki disease [ 493 ]) and Long COVID [ 17 ]. The association with ME/chronic fatigue syndrome is seemingly weaker, and is usually seen as an association of fatigue, for example, driven by a subarachnoid haemorrhage [ 494 , 495 ].…”

Persistent intracranial hyper-inflammation in ruptured cerebral aneurysm after COVID-19: case report and review of the literature

“…Cerebrovascular events occur as intracerebral hemorrhage [ 5 ] and ischemic stroke [ 6 ]. Still rarer complications include cerebral venous sinus thrombosis and aneurysmal subarachnoid hemorrhage (SAH) [ 7 , 8 ]. SAH might concurrently develop during the acute phase of COVID-19 in adult patients [ 9 ], but not reportedly in pediatric patients.…”

Rupture of Vertebral Artery Dissecting Aneurysm after mRNA Anti-COVID-19 Vaccination: A Report of Two Cases

“…5) Fever and fatigue were the most prevalent adverse effects reported in people receiving the adenovirus vector and mRNA vaccines, respectively. 5) Several investigators have reported cerebrovascular diseases, including hemorrhagic stroke, in patients with COVID-19; 6,7) however, cerebrovascular diseases after COVID-19 vaccination are rare. While some rare cases of vaccine-induced immune thrombotic thrombocytopenia and cerebral venous sinus thrombosis have been reported, mainly in association with viral vector vaccines, 8) few reports have been published on cerebrovascular diseases after mRNA COVID-19 vaccination.…”