Akahashi, Jorge Tomio

Oliveira, Roberto de Magalhães Carneiro de

Olivetti, Bruno Casola

Santos, Diogo Haddad

English

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Status: Preprint has been submitted for publication in journalBILATERAL TROCHLEAR PALSY DUE TO CEREBRAL VASCULITISRELATED TO COVID-19 INFECTIONDiogo Haddad Santos, Roberto de Magalhães Carneiro de Oliveira, Bruno Casola Olivetti, JorgeTomio AkahashiDOI: 10.1590/0004-282X20200052This preprint was submitted under the following conditions: The authors declare that they are aware that they are solely responsible for the content of the preprint andthat the deposit in SciELO Preprints does not mean any commitment on the part of SciELO, except itspreservation and dissemination.The authors declare that the research that originated the manuscript followed good ethical practices andthat the necessary approvals from research ethics committees are described in the manuscript, whenapplicable.The authors declare that the necessary Terms of Free and Informed Consent of participants or patients inthe research were obtained and are described in the manuscript, when applicable.The authors declare that the preparation of the manuscript followed the ethical norms of scientificcommunication.The authors declare that the manuscript was not deposited and/or previously made available on anotherpreprint server.The submitting author declares that all authors responsible for preparing the manuscript agree with thisdeposit.The authors declare that in the event that this manuscript has previously been submitted to a journal andbeing evaluated, they have received the journal's consent to make the deposit on the SciELO Preprintsserver.The submitting author declares that all authors' contributions are included on the manuscript.The authors declare that if the manuscript is posted on the SciELO Preprints server, it will be availableunder a Creative Commons CC-BY license.The deposited manuscript is in PDF format.If the manuscript is being reviewed and published by a journal, the authors declare that they have receivedauthorization from the journal to make this deposit.Submitted on (YYYY-MM-DD): 2020-05-14Posted on (YYYY-MM-DD): 2020-09-08Powered by TCPDF (www.tcpdf.org)ANP-2020-0184 – Fast Track COVID-19 DOI: https://doi.org/10.1590/0004-282X20200052   BILATERAL TROCHLEAR PALSY DUE TO CEREBRAL VASCULITIS RELATED TO COVID-19 INFECTION  Cabeçalho: Oliveira RMC et al. Cerebral Vasculitis related to COVID-19 Infection.  Roberto de Magalhães Carneiro de Oliveira1  Diogo Haddad Santos2 - https://orcid.org/0000-0003-1474-1849 Bruno Casola Olivetti3  Jorge Tomio Akahashi3   1Hospital Alemão Oswaldo Cruz, Departamento de Neurologia, São Paulo SP, Brazil 2Irmandade da Santa Casa de Misericórdia de São Paulo, Neurologia, São Paulo SP, Brazil 3Hospital Alemão Oswaldo Cruz, Departamento de Neuroradiologia, São Paulo SP, Brazil  Correspondence: Diogo Haddad Santos; Email: dhaddadsantos@gmail.com.  Conflict of interest: There is no conflict of interest to declare.  Received on April 29, 2020; Received in its final form on May 06, 2020; Accepted on May 11, 2020.   A 69-year-old caucasian man presented fever (38°C) with abdominal pain, left posterior chest pain without cough or dyspnea and mild occipital headache that remained in the next few days. Eleven days later, he woke up with binocular diplopia and a severe stabbing occipital headache. There were no peripheral signs of systemic vasculitis. Neurologic evaluation identified bilateral paresis of the IV cranial nerves. He had well-controlled arterial hypertension and denied trauma or use of other medications. COVID-19 infection was confirmed by the reverse transcription technique followed by polymerase chain reaction (RT-PCR) in a nasopharyngeal swab. A magnetic resonance imaging (MRI) of the brain with MRI angiography and vessel wall study showed signs of vasculitis of the vertebrobasilar system1, as well inflammatory radiologic signs in periaqueductal region, along with the topography of the trochlear nuclei (FIG.1). Chest computed tomography (CT) showed peripheral ground-glass parenchymal opacities, suggesting viral pneumonia. Cerebrospinal Fluid (CSF) revealed 2 cells/mm3 (69% lymphocytes, 29% monocytes, 2% macrophages) and proteins slightly increased from 46 mg/dl (with 17,01% of gamma globulin). CSF antibody tests were negative for syphilis and other viruses. Rheumatological causes, hypovitaminosis and thyroid dysfunction were ruled out. Erythrocyte sedimentation rate (ESR) was 33 mm/h. He received IV methylprednisolone for 5 days with complete improvement of pain and diplopia. This case is the first report of cerebral vasculitis related to COVID-19 infection in an adult patient. We emphasize that headache2 could be an alarm signal of cerebral vasculitis in these patients.   References 1. Mandell, D. M., et al. "Intracranial vessel wall MRI: principles and expert consensus recommendations of the American Society of Neuroradiology." American Journal of Neuroradiology 38.2 (2017): 218-229. 2. Mao L, Jon H, Wang M, et al. Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China. JAMA Neurol. Published online April 10, 2020. doi:10.1001/jamaneurol.2020.1127   Figure 1: A and B, axial MRI images 3D-T1 FATSAT post contrast vessel wall imaging, on the level of the vertebral arteries (A) and basilar artery (B) shows subtle abnormal concentric enhancement of the basilar artery wall (arrow) and intense abnormal concentric enhancement of the vertebral arteries wall, that are tortuous and lateralized to the left (arrow). C, Reformated Coronal Oblique 3D-T1 FATSAT post contrast vessel wall imaging shows abnormal concentric enhancement of the basilar and vertebral arteries walls (arrows).   

BILATERAL TROCHLEAR PALSY DUE TO CEREBRAL VASCULITIS RELATED TO COVID-19 INFECTION

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BILATERAL TROCHLEAR PALSY DUE TO CEREBRAL VASCULITIS RELATED TO COVID-19 INFECTION

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