Border-Zone Cerebral Infarcts Associated with COVID-19 in CADASIL: A Report of 3 Cases and Literature Review.

INTRODUCTION: Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is the most common inherited cerebral small vessel disease and is a cause of early onset ischemic lacunar stroke. COVID-19 infection may lead, in addition to acute respiratory syndrome, to vascular complications including stroke. Herein, we report three CADASIL patients presenting with cerebral border-zone infarcts concomitant to COVID-19 infection and summarize similar cases previously published in literature. METHODS: Clinical and radiological features of the 3 patients were collected and described. A narrative review of literature was performed in PubMed and Google Scholar by the end of 2022 using the "CADASIL" AND "COVID-19" AND "stroke" terms. RESULTS: In our 3 patients, aged 40-58 years, stroke symptoms occurred one to 11 days after the first COVID-19 manifestations. Pulmonary symptoms were mild or absent. One patient presented with hemodynamic failure presumably related to acute cardiomyopathy. Brain magnetic resonance imaging revealed in all cases, ischemic lesions within border-zone areas in both cerebral hemispheres, lesions in the genu of the corpus callosum or in the medium cerebellar peduncles in two cases. The watershed pattern of ischemic lesions was detected in two cases despite any blood pressure drop or severe respiratory dysfunction. Seven CADASIL patients presenting with acute brain infarcts (multiple in 4/7) in context of SARS-CoV-2 infection were identified in literature, despite no fall in blood pressure except for one of them. CONCLUSION: Our observations, in line with previous reports, further suggest that COVID-19 infection may alter blood flow autoregulation in the deepest cerebral white matter in CADASIL patients. The thrombocytopathy and endotheliopathy developing during COVID-19 infection may participate to the underlying vascular processes.

Early recurrence of ischaemic stroke of cardioembolic cause and delayed anticoagulation: a case report.

Introduction: Anticoagulation therapy is used for the management of atrial fibrillation to prevent new clots from developing. However, neurologists face the challenge of when to initiate/reintroduce treatment after a recent episode of stroke without increasing haemorrhagic risk, especially if the stroke is large and/or complicated with haemorrhagic transformation. Case presentation: This report describes the case of a 72-year-old man who had an ischaemic stroke of the right posterior cerebral artery. The patient had permanent atrial fibrillation, discovered in hospital. He was not on chronic anticoagulation therapy before stroke. His anticoagulation therapy was postponed due to a haemorrhagic lesion, leading to new ischaemic stroke. The patient suddenly had right hemiplegia with aphasia for which a mechanical thrombectomy was performed but complicated by embolization into the left posterior cerebral artery with failure of thromboaspiration of this clot. Finally, the patient presented with intracranial hypertension due to ischaemic lesions and died 3 days after his readmission. Conclusion: When to start anticoagulation therapy after ischaemic stroke is an unresolved question but should be discussed at least twice weekly in a stroke unit based on the clinical evolution of the patient.

Cerebral Amyloid Angiopathy Related Inflammation With Prominent Meningeal Involvement. A Report of 2 Cases.

Cerebral amyloid angiopathy related inflammation (CAA-RI) is a rare form of CAA characterized by subacute encephalitic symptoms (cognitive decline, seizures, focal deficits) associated with extensive and confluent white matter lesions co-localizing with lobar microbleeds on brain MRI. We report two cases of unusual CAA-RI mimicking meningoencephalitis but without typical brain lesions on FLAIR and T2* sequences. These 2 cases may extend the clinical spectrum of CAA-RI by suggesting the possible occurrence of quite purely meningeal forms of CAA-RI.