Cerebellar infarction requiring surgical decompression in patient with COVID 19 pathological analysis and brief review

Abstract

Background: This report and literature review describes a case of a COVID-19 patient who suffered a cerebellar stroke requiring neurosurgical decompression. This is the first reported case of a sub-occipital craniectomy with brain biopsy in a COVID-19 patient showing leptomeningeal venous intimal inflammation.

Clinical description: The patient is a 48-year-old SARS-COV-2 positive male with multiple comorbidities, who presented with fevers and respiratory symptoms, and imaging consistent with multifocal pneumonia. On day 5 of admission, the patient had sudden change in mental status, increased C-Reactive Protein, ferritin and elevated Interleukin-6 levels. Head CT showed cerebral infarction from vertebral artery occlusion. Given subsequent rapid neurologic decline from cerebellar swelling and mass effect on his brainstem emergent neurosurgical intervention was performed. Brain biopsy found a vein with small organizing thrombus adjacent to focally proliferative intima with focal intimal neutrophils.

Conclusion: A young man with COVID-19 and suspected immune dysregulation, complicated by a large cerebrovascular ischemic stroke secondary to vertebral artery thrombosis requiring emergent neurosurgical intervention for decompression with improved neurological outcomes. Brain biopsy was suggestive of inflammation from thrombosed vessel, and neutrophilic infiltration of cerebellar tissue.

Keywords: ARDS, acute respiratory distress syndrome; BiPaP, Bilevel positive airway pressure; COVID 19, Corona Virus Disease 2019; COVID-19; CP, cerebellopontine; CRP, C-reactive protein; CT, computed tomography; CTA, CT angiography; CXR, chest X-ray; Coronavirus; FiO2, fraction of inspired oxygen; Ischemic stroke; Phlebitis; SARS-COV-2; SARS-COV-2, severe acute respiratory syndrome coronavirus 2; STAT, statum which is Latin meaning immediately; Sub-occipital craniectomy; Vasculitis; WHO, World Health Organization; t-PA, tissue plasminogen activator.

Fig. 1

Chest X-Ray on admission: Multifocal pulmonary consolidative opacities are present.

Fig. 2

Noncontrast Head CT Time Course. A. Hospital Day 5. Noncontrast head CT at time of stroke alert, note no hypodensity, no hydrocephalus and no mass effect on fourth ventricle. B. CT Angiogram head at time of stroke alert, note vertebral artery occlusion (arrows). C. Hospital Day 6. CT head non-contrast shows left cerebellar infarct with effacement of the CP angle cistern and left-to-right midline shift without hydrocephalus, fourth ventricle remains patent. D. Hospital Day 7. CT head non-contrast shows evolving left cerebellar stroke with increasing mass effect on the fourth ventricle without hydrocephalus. E. Hospital Day 9. CT head non-contrast shows left cerebellar infarct with significant mass effect on the fourth ventricle and paramesencephalic cistern. No hydrocephalus.

Fig. 3

H&E permanent section of left cerebellum brain biopsy, note histology leptomeningeal vein with neutrophilic infiltrates (arrows) in the blood vessel wall. The asterisk denotes a fibrin plug in the lumen of the vein. The scale bar equals 50 µm.