key: cord-264504-nnvof29x
authors: Malentacchi, Maria; Gned, Dario; Angelino, Valeria; Demichelis, Sara; Perboni, Alberto; Veltri, Andrea; Bertolotto, Antonio; Capobianco, Marco
title: Concomitant brain arterial and venous thrombosis in a COVID‐19 patient
date: 2020-06-05
journal: Eur J Neurol
DOI: 10.1111/ene.14380
sha: 
doc_id: 264504
cord_uid: nnvof29x

COVID‐19 infection can cause a severe pneumonia which, in some cases, can lead to admission in intensive care unit for respiratory support.(1) In severe cases, systemic thrombotic complication has been described, including cerebrovascular disease (5.7‐23% of cases).(2,3)

COVID-19 infection can cause a severe pneumonia which, in some cases, can lead to admission in intensive care unit for respiratory support. 1 In severe cases, systemic thrombotic complication has been described, including cerebrovascular disease (5.7-23% of cases). 2, 3 We describe a patient with severe form of COVID-19 that developed sudden impairment of consciousness leading to coma. Neuroimaging suggested concomitant venous and arterial thrombosis of the brain.

An 81 years old man was admitted in respiratory semi-intensive care unit for interstitial pneumonia with respiratory distress on March 25 th . Reverse-transcriptase-polymerase-chainreaction (RT-PCR) assay of nasopharyngeal swab tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV2).

Previous medical history was relevant for ocular myasthenia, trans-urethral resection of the prostate (TURP) for adenocarcinoma, B-chronic lymphatic leukemia and recent admission (first days of March) for hemolytic anemia treated with high dose iv steroids and iv Immunoglobulin with complete remission.

Covid-19 infection was treated with a combination of antiretroviral drugs (darunavir/ritonavir), hydroxicloroquine and steroids.

During hospitalization, the patient experienced worsening of respiratory failure with necessity to non-invasive respiratory support.

Few days later the patient suffered deterioration of the neurological condition with mental confusion, and progressive reduction of consciousness till coma on April 13 th when it was registered a very severe respiratory insufficiency (PaO 2 /FiO 2 <100).

The neurological examination revealed absence of responsiveness to pain stimulus with pyramidal signs (bilateral Babinski signs), normal pupils reflexes and periodical breathing. Unenhanced brain CT showed bilateral subacute infarcts in the middle cerebral arteries (MCAs) territory. Then, a CT angiogram of the head was performed, and bilateral occlusion of the MCAs was demonstrated; the occlusion involved the left M1 segment and the right M2 segment. A

This article is protected by copyright. All rights reserved subsequent contrast-enhanced CT scan, performed with a pre-scanning delay of 40 seconds, showed a filling defect in the right sigmoid sinus, consistent with venous cloth (Figure) .

Blood analysis was not consistent with disseminated intravascular coagulation (DIC) and/or multiorgan failure while inflammatory indexes dramatically arose as typical seen in COVID-19 disease:

white blood cells 59000/mcl, LDH 2466 U/l, CRP 13.62 mg/dl, fibrinogen 539 mg/dl, d-dimer 2017 ng/ml, INR for PT 1.20, aPTT 26.6 sec.

Unfortunately, the patient died on April 15 th , despite anticoagulant treatment and non-invasive respiratory support.

Notification has been sent to the Ethics Committee of the University Hospital S. Luigi according to local rules.

Our case underlines that one of the main causes for clinical deterioration and death during COVID-19 infection is coagulopathy that can involve both arterial and venous systems. In this particular case, despite the absence of clinical signs of systemic coagulopathy, there was a concomitant involvement of cerebral arteries and veins.

Unfortunately, the absence of pathological analysis at autopsy does not allow us to determine whether thrombosis has been caused by large vessel vasculitis, or hypercoagulability due to antiphospholipid antibodies, that can arise transiently in patients with critical illness and various infections. This last hypothesis has been already described in COVID-19 patients. 4 In addition, other comorbidities (leukemia) and the recent use of steroids could influence the prothrombotic status of our patient.

Acute and subacute consciousness deterioration in COVID-19 patients could be due to different pathogenetic mechanisms: nevertheless, the probability of acute cerebrovascular disease represents the main cause as encephalitis, for example, has been described in few case reports. [2] [3] 5 As far as we know, the simultaneous occurrence of venous and arterial thrombosis of the brain has not been described yet, and it could represent an important cause of neurological impairment in patients affected by COVID-19: prompt execution of neuroradiological examination of the Accepted Article parenchyma and post-contrast imaging of both arterial and venous systems could allow to perform a correct diagnosis and to apply the more appropriate treatment strategy. This article is protected by copyright. All rights reserved

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. 

Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China

Neurologic Features in Severe SARS-CoV-2 Infection

Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease

Coagulopathy and Antiphospholipid Antibodies in Patients with Covid-19

Detection of SARS Coronavirus RNA in the Cerebrospinal Fluid of a Patient with Severe Acute Respiratory Syndrome