Abstract Number ‐ 266: Focal Cerebral CNS Vasculitis due to SARS‐CoV‐2 Infection

Introduction Several neurological manifestations of the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection, including anosmia, encephalopathy, and stroke, have been reported. We report a case of a 42‐year‐old man presenting with ischemic stroke due to cerebral vasculitis in the setting of SARS‐CoV‐2 infection. Methods Case report Results A 42‐year‐old man, recently diagnosed with SARS‐CoV‐2 infection, presented with nonfluent aphasia and right‐sided hemiparesis that started five hours prior. Neurological examination revealed nonfluent aphasia, right‐sided facial palsy, and hemiparesis. Computed tomography (CT) of the head showed left‐sided caudate infarct and early ischemic changes in the left putamen. CT angiography (CTA) revealed occlusion of the proximal left M1 segment. Patient’s symptoms rapidly improved and mechanical thrombectomy was not pursued. Patient was started on dual antiplatelet therapy with aspirin and clopidogrel. Magnetic resonance imaging (MRI) of the brain showed acute infarcts in the left posterior parietal, lentiform nucleus, and frontal cortex. CT of the chest revealed bilateral subsegmental pulmonary emboli. Patient was discharged on apixaban and atorvastatin daily, with mild residual aphasia. A month later, the patient returned with dysarthria and right‐sided paresthesia that began three hours prior. CTA showed severe left proximal M1 stenosis involving a longer segment. He was started on vasopressor. Symptoms resolved within 24 hours with residual mild aphasia. MRI brain revealed multiple foci of cortical infarcts within the left MCA territory with no diffusion/ perfusion mismatch. MRA head showed further pruning of the distal MCA branches within the left sylvian fissure with severe stenosis along the mid‐M1 and minimal flow anteriorly, with contrast enhancement at the site of the stenosis, suggestive of vasculitis. Autoimmune vasculitis panel was unremarkable. Due to suspicion of focal inflammatory vasculopathy related to recent SARS‐CoV‐2 infection, patient was started on intravenous methylprednisolone 1 gram daily for 5 days followed by a prednisone taper. MRA revealed improved blood flow in the left middle cerebral artery and branches. The was discharged on apixaban, aspirin, atorvastatin, and a prednisone taper with mild residual aphasia. Conclusions To our knowledge, this is the first reported case of CNS vasculitis associated with an underlying SARS‐CoV‐2 infection with radiographic improvement of blood flow in the affected vessel within 4 days of treatment with high‐dose steroids. This case supports the use of high‐dose steroids in patients with CNS vasculitis associated with SARS‐CoV‐2 to prevent further stroke burden

Focal Cerebral Vasculitis due to SARS-CoV-2 Infection With a Robust Response to Intravenous Steroids.

INTRODUCTION: Severe and less common neurological manifestations of SARS-CoV-2 infection include acute ischemic stroke, intracerebral hemorrhage, central venous sinus thrombosis, and vasculitis. In this report, we present a case of a 42-year-old man with acute ischemic stroke due to SARS-CoV-2 infection-associated central nervous system vasculitis that improved with steroid therapy. CASE REPORT: A 42-year-old man with SARS-CoV-2 infection presented with non-fluent aphasia and right-sided hemiparesis. Computed tomography angiography revealed an occlusion of the proximal left middle cerebral artery (MCA), with acute infarcts in the left posterior parietal, lentiform nucleus, and cortical frontal cortex on magnetic resonance imaging (MRI). Patient developed pulmonary emboli and was discharged on apixaban and atorvastatin. Four weeks later, the patient presented with recurring symptoms and was found to have worsening left MCA stenosis. MRI and MR angiography revealed a penumbra within the left MCA territory and pruning of the distal branches with severe stenosis. Laboratory workup for autoimmune causes of vasculitis was unrevealing. High-dose intravenous steroid treatment was initiated. Subsequent MRI and MR angiography revealed improved flow in the left cerebral vasculature and no novel ischemic infarcts. CONCLUSION: Central nervous system vasculitis is a rare manifestation of SARS-CoV-2 infection. This case suggests that high-dose intravenous steroids may have a therapeutic role in this patient population. Steroid use, in combination with vasopressor support to augment cerebral blood flow, may prevent further stroke burden