key: cord-302015-z2k6wuhm authors: Bonardel, Claire; Bonnerot, Mathieu; Ludwig, Marie; Vadot, Wilfried; Beaune, Gaspard; Chanzy, Bruno; Cornut, Lucie; Baysson, Hélène; Farines, Magali; Combes, Isabelle; Macheda, Gabriel; Bing, Fabrice title: Bilateral posterior infarction in a SARS-Cov-2 infected patient: discussion about an unusual case date: 2020-06-28 journal: J Stroke Cerebrovasc Dis DOI: 10.1016/j.jstrokecerebrovasdis.2020.105095 sha: doc_id: 302015 cord_uid: z2k6wuhm In time of SARS-Cov2 pandemic, neurologists need to be vigilant for cerebrovascular complications of Covid-19. We present a case of bilateral occipito-temporal infarction revealed by a sudden cortical blindness with haemorrhagic transformation after intravenous thrombolysis in a diabetic patient infected by Covid-19. Differential diagnoses are discussed in front of this unusual presentation and evolution. Bilateral posterior infarction in a SARS-Cov-2 infected patient: discussion about an unusual case Abstract In time of SARS-Cov2 pandemic, neurologists need to be vigilant for cerebrovascular complications of Covid-19. We present a case of bilateral occipito-temporal infarction revealed by a sudden cortical blindness with haemorrhagic transformation after intravenous thrombolysis in a diabetic patient infected by . Differential diagnoses are discussed in front of this unusual presentation and evolution. A 51-year-old-man presented with one-week history of cough, dysgeusia and diarrhea. The patient complained of moderate headache without fever. The patient had a history of diabetes mellitus, hypertension and obesity. Blood investigation showed a lymphocytopenia (1.08 giga/L), an increased fibrinogen (5.1 g/L), ferritin (1190 µg/l), creatin-kinase (749 UI/L), C-reactive protein (71 g/L), ASAT (54 UI/L) and glycated hemoglobin (9.1%) concentrations. Prothrombin Ratio was low (66%). Antiphospholipid, platelets and partial thromboplastin time were normal. The RT-PCR for SARS-Cov-2 using a nasopharyngeal swab was positive. A chest scan showed bilateral ground glass opacities concerning more than 50% of the parenchymal lung ( Figure 1 ). Six days after arrival and 30 minutes after the fourth injection of remdesivir (loading dose: 200mg IV, 100mg IV per day thereafter), he presented an abrupt cortical blindness and disorientation (NIHSS score: 4). An atrial fibrillation (AF) was recorded. A first brain MRI performed one hour after clinical onset showed bilateral and asymmetric acute occipito-temporal infarction without visibility of the P3 segments of the posterior cerebral arteries (PCA) (Figure 2A to C). Fluid-attenuated inversion recovery (FLAIR), T2*, MR venography and MR angiography of the supra-aortic trunks were normal. No pathological enhancement in leptomeningeal spaces was observed. Alteplase was injected 128 min after symptom onset. The following morning, blindness was unchanged and anterograde memory disorders with anosognosia were noticed. The 24-hour control multimodality MRI showed a haemorrhagic transformation of the previous lesions ( Figure 2E -F). Dynamic susceptibilityweighted contrast-enhanced magnetic resonance perfusion imaging (DSC-MRI perfusion) showed an increase of cerebral blood volume (CBV) and flow (CBF) in the right thalamus and an increase of the mean transit time (MTT) and CBV in the right hemisphere ( Figure 1H ). Distal segments of the PCA were permeable ( Figure 2D ). Nine hours later, the patient died due to a rapid respiratory breakdown, without neurological worsening. This bilateral cerebral posterior stroke may be secondary to an embolic event (AF). Stroke could also be explained by the state of hypercoagulability induced by SARS-Cov-2 infection 1 . Severe patients are more likely to have neurologic symptoms 2 and bilateral frontotemporal hypoperfusion 3 has been reported. In our case, MTT and CBV were increased in the right hemisphere which may reflect reduced cerebral perfusion pressure. The increase value of the CBF in the right thalamus may correspond to a post-recanalization hyperperfusion 4 . Other stroke mechanisms can be suggested. Infection may have induced cerebral vasculitis, explaining the stroke and the perfusion's anomalies. Severe reversible cerebral vasoconstriction syndrome (RCVS) cases with cerebral infarction and intracranial haemorrhage have been reported but the absence of thunderclap headache is unusual in RCVS 5 . The absence of rapid increase in blood pressure and the presence of an initial cytotoxic oedema instead of vasogenic is less in favour of Posterior Reversible Encephalopathy Syndrome (PRES) 6 . An adverse effect of remdesivir is also to be discussed, but no neurological adverse effect potentially related to remdesivir have been reported 7 . Finally, the absence of thalamus involvement makes the diagnosis of acute necrotizing encephalitis unlikely 8 . In conclusion, the origin of the stroke is probably multifactorial: the cytokine storm syndrome and hypercoagulability may have induced blood flow dysregulation, associated with an embolic event that may finally induce arterial thrombosis. A cerebral artery vasculitis or a RVCS are not excluded. This unusual case confirms the increased risk of thrombotic events in SARS-Cov2 infected patients. Figures Legend Figure 1 . Axial CT scanner shows focal subpleural ground-glass opacities in the left and right lobes. The right lower lobe lesion is accompanied by air bronchogram (arrow). Second MRI (D to F). TOF shows better visualisation of distal segments of bilateral PCA (arrows) (D). Fluid--attenuated inversion recovery (FLAIR) shows a hypersignal in the initial ischemic lesions (initial FLAIR was normal) (E). Susceptibility-Weighted imaging (SWI) shows hypointensity (haemorrhage) concerning the totality of the ischemic lesion (F). MRI perfusion shows an increase cerebral blood volume (CBV) in the right thalamus (arrow) (G) and an increase of MTT in the right hemisphere (H). Annecy Hospital Annecy Hospital * Corresponding author: Fabrice Bing Imaging Unit, Annecy Hospital, 74374 Metz-Tessy, France Email : fabricebing@yahoo.fr Phone number Author contact information: Claire Bonardel: cbonardel@chu-grenoble.fr Mathieu Bonnerot: mbonnerot@ch-annecygenevois.fr Wilfried Vadot: wvadot@ch-annecygenevois.fr Gaspard Beaune: gbeaune@ch-annecygenevois.fr Lucie Cornut : lcornut@ch-annecygenevois.fr Hélène Baysson : hbaysson@ch-annecygenevois.fr Magali Farines : mfarines@ch-annecygenevois.fr Isabelle Combes : icombes@ch-annecygenevois.fr Gabriel Macheda : gmacheda@ch-annecygenevois.fr Keywords: Infarction; MR perfusion; COVID-19; Visual loss; SARS-Cov2 Running title: Stroke in a SARS-Cov-2 infected patient Conflict of interest: The authors report no disclosures Difference of coagulation features between severe pneumonia induced by SARS-CoV2 and non-SARS-CoV2 Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease Neurologic Features in Severe SARS-CoV-2 Infection Diffusion-perfusion MRI characterization of postrecanalization hyperperfusion in humans Severe Reversible Cerebral Vasoconstriction Syndrome with Large Posterior Cerebral Infarction Posterior Reversible Encephalopathy Syndrome and Reversible Cerebral Vasoconstriction Syndrome: Clinical and Radiological Considerations Controlled Trial of Ebola Virus Disease Therapeutics COVID-19-associated Acute Hemorrhagic Necrotizing Encephalopathy: CT and MRI Features