Post-COVID-19 Multisystem Inflammatory Syndrome-Related Cerebral Infarction in a Pediatric Patient Managed with Decompressive Craniectomy.

INTRODUCTION: Most people who are infected with the novel severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) are asymptomatic or present with mild upper respiratory symptoms. This is especially true in the pediatric population; however, rarely, a massive cytokine storm can develop, causing multisystem inflammatory syndrome associated with COVID (MIS-C). Furthermore, children may also suffer from acute ischemic strokes secondary to SARS-CoV-2 infection. CASE PRESENTATION: Here, we present a 2-year-old male who was admitted to the hospital with MIS-C and evidence of a previous SARS-CoV-2 infection. On postadmission day 2, the patient was in cardiogenic shock, had acute kidney injury, liver dysfunction, and metabolic acidosis. He had concurrent altered mental status, and his computed tomography scan showed ischemic infarcts in the territory of the right middle cerebral artery and superior cerebellar artery bilaterally. Magnetic resonance angiography confirmed occlusion of the right middle cerebral artery and right superior cerebellar artery. He underwent an emergent decompressive craniectomy due to rapid deterioration and cerebral edema. After the procedure, he continued to improve and was discharged with moderate disability that improved during outpatient rehab. CONCLUSION: Though rare in children, SARS-CoV-2 can lead to AIS, especially in the presence of underlying risk factors such as MIS-C and hypercoagulopathy. AIS can be associated with severe mortality and morbidity; however, even in this severe case of AIS, the patient was successfully treated with a decompressive craniectomy.

Pathogeny of cerebral venous thrombosis in SARS-Cov-2 infection: Case reports.

RATIONALE: Pathogeny of thrombosis in COVID-19 is related to interaction of SARS-Cov-2 with vascular wall through the angiotensin converting enzyme 2 (ACE2) receptor. This induces 2 pathways with immunothrombosis from activated endothelium (cytokine storm, leukocyte and platelet recruitment, and activation of coagulation extrinsic pathway), and rise of angiotensin II levels promoting inflammation. While thrombosis is widely described in COVID-19 patients admitted in intensive care unit, cerebrovascular diseases remains rare, in particular cerebral venous thrombosis (CVT). PATIENT CONCERNS: We describe 2 cases of women admitted during the spring of 2020 for intracranial hypertension signs, in stroke units in Great-east, a French area particularly affected by COVID-19 pandemia. DIAGNOSES: Cerebral imaging revealed extended CVT in both cases. The first case described was more serious due to right supratentorial venous infarction with hemorrhagic transformation leading to herniation. Both patients presented typical pneumonia due to SARS-Cov-2 infection, confirmed by reverse transcription polymerase chain reaction on a nasopharyngeal swab in only one. INTERVENTIONS: The first patient had to undergo decompressive craniectomy, and both patients were treated with anticoagulation therapy. OUTCOMES: Favorable outcome was observed for 1 patient. Persistent coma, due to bi thalamic infarction, remained for the other with more serious presentation. LESSONS: CVT, as a serious complication of COVID-19, has to be searched in all patients with intracranial hypertension syndrome. Data about anticoagulation therapy to prevent such serious thrombosis in SARS-Cov-2 infection are lacking, in particular in patients with mild and moderate COVID-19.

COVID-19 and Decompressive Hemicraniectomy for Acute Ischemic Stroke.

BACKGROUND AND PURPOSE: Young patients with malignant cerebral edema have been shown to benefit from early decompressive hemicraniectomy. The impact of concomitant infection with coronavirus disease 2019 (COVID-19) and how this should weigh in on the decision for surgery is unclear. METHODS: We retrospectively reviewed all COVID-19-positive patients admitted to the neuroscience intensive care unit for malignant edema monitoring. Patients with >50% of middle cerebral artery involvement on computed tomography imaging were considered at risk for malignant edema. RESULTS: Seven patients were admitted for monitoring of whom 4 died. Cause of death was related to COVID-19 complications, and these were either seen both very early and several days into the intensive care unit course after the typical window of malignant cerebral swelling. Three cases underwent surgery, and 1 patient died postoperatively from cardiac failure. A good outcome was attained in the other 2 cases. CONCLUSIONS: COVID-19-positive patients with large hemispheric stroke can have a good outcome with decompressive hemicraniectomy. A positive test for COVID-19 should not be used in isolation to exclude patients from a potentially lifesaving procedure.