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      Cerebellar Infarction Requiring Surgical Decompression in patient with COVID 19 Pathological Analysis, Brief Review

      case-report
      Author(s): a , c , * , b , d , e , f , a , a
      Publication date (Electronic):
      Journal: Interdisciplinary Neurosurgery
      Publisher: Published by Elsevier B.V.
      Keywords: ARDS, acute respiratory distress syndrome, BiPaP, Bilevel positive airway pressure, COVID 19, Corona Virus Disease 2019, CP, cerebellopontine, CRP, C-reactive protein, CT, computed tomography, CTA, CT angiography, CXR, chest X-ray, FiO2, fraction of inspired oxygen, SARS-COV-2, severe acute respiratory syndrome coronavirus 2, STAT, statum which is Latin meaning immediately, t-PA, tissue plasminogen activator, WHO, World Health Organization, Coronavirus, COVID-19, SARS-COV-2, ischemic stroke, sub-occipital craniectomy, vasculitis, phlebitis

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          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.

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          Structure of the SARS-CoV-2 spike receptor-binding domain bound to the ACE2 receptor

          Jun Lan, Jiwan Ge, Jinfang Yu … (2020)
          A new and highly pathogenic coronavirus (severe acute respiratory syndrome coronavirus-2, SARS-CoV-2) caused an outbreak in Wuhan city, Hubei province, China, starting from December 2019 that quickly spread nationwide and to other countries around the world1-3. Here, to better understand the initial step of infection at an atomic level, we determined the crystal structure of the receptor-binding domain (RBD) of the spike protein of SARS-CoV-2 bound to the cell receptor ACE2. The overall ACE2-binding mode of the SARS-CoV-2 RBD is nearly identical to that of the SARS-CoV RBD, which also uses ACE2 as the cell receptor4. Structural analysis identified residues in the SARS-CoV-2 RBD that are essential for ACE2 binding, the majority of which either are highly conserved or share similar side chain properties with those in the SARS-CoV RBD. Such similarity in structure and sequence strongly indicate convergent evolution between the SARS-CoV-2 and SARS-CoV RBDs for improved binding to ACE2, although SARS-CoV-2 does not cluster within SARS and SARS-related coronaviruses1-3,5. The epitopes of two SARS-CoV antibodies that target the RBD are also analysed for binding to the SARS-CoV-2 RBD, providing insights into the future identification of cross-reactive antibodies.
          Article 0 comments Cited 2929 times – based on 0 reviews     Review now
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            Reduction and Functional Exhaustion of T Cells in Patients With Coronavirus Disease 2019 (COVID-19)

            Bo Diao, Chenhui Wang, Yingjun Tan … (2020)
            Background: The outbreak of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has posed great threat to human health. T cells play a critical role in antiviral immunity but their numbers and functional state in COVID-19 patients remain largely unclear. Methods: We retrospectively reviewed the counts of T cells and serum cytokine concentration from data of 522 patients with laboratory-confirmed COVID-19 and 40 healthy controls. In addition, the expression of T cell exhaustion markers were measured in 14 COVID-19 cases. Results: The number of total T cells, CD4+ and CD8+ T cells were dramatically reduced in COVID-19 patients, especially in patients requiring Intensive Care Unit (ICU) care. Counts of total T cells, CD8+ T cells or CD4+ T cells lower than 800, 300, or 400/μL, respectively, were negatively correlated with patient survival. T cell numbers were negatively correlated to serum IL-6, IL-10, and TNF-α concentration, with patients in the disease resolution period showing reduced IL-6, IL-10, and TNF-α concentrations and restored T cell counts. T cells from COVID-19 patients had significantly higher levels of the exhausted marker PD-1. Increasing PD-1 and Tim-3 expression on T cells was seen as patients progressed from prodromal to overtly symptomatic stages. Conclusions: T cell counts are reduced significantly in COVID-19 patients, and the surviving T cells appear functionally exhausted. Non-ICU patients with total T cells counts lower than 800/μL may still require urgent intervention, even in the immediate absence of more severe symptoms due to a high risk for further deterioration in condition.
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              Large-Vessel Stroke as a Presenting Feature of Covid-19 in the Young

              Thomas Oxley, J Mocco, Shahram Majidi … (2020)
              To rapidly communicate information on the global clinical effort against Covid-19, the Journal has initiated a series of case reports that offer important teaching points or novel findings. The case reports should be viewed as observations rather than as recommendations for evaluation or treatment. In the interest of timeliness, these reports are evaluated by in-house editors, with peer review reserved for key points as needed. We report five cases of large-vessel stroke in patients younger than 50 years of age who presented to our health system in New York City. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was diagnosed in all five patients. Cough, headache, and chills lasting 1 week developed in a previously healthy 33-year-old woman (Patient 1) (Table 1). She then had progressive dysarthria with both numbness and weakness in the left arm and left leg over a period of 28 hours. She delayed seeking emergency care because of fear of Covid-19. When she presented to the hospital, the score on the National Institutes of Health Stroke Scale (NIHSS) was 19 (scores range from 0 to 42, with higher numbers indicating greater stroke severity), and computed tomography (CT) and CT angiography showed a partial infarction of the right middle cerebral artery with a partially occlusive thrombus in the right carotid artery at the cervical bifurcation. Patchy ground-glass opacities in bilateral lung apices were seen on CT angiography, and testing to detect SARS-CoV-2 was positive. Antiplatelet therapy was initiated; it was subsequently switched to anticoagulation therapy. Stroke workup with echocardiography and magnetic resonance imaging of the head and neck did not reveal the source of the thrombus. Repeat CT angiography on hospital day 10 showed complete resolution of the thrombus, and the patient was discharged to a rehabilitation facility. Over a 2-week period from March 23 to April 7, 2020, a total of five patients (including the aforementioned patient) who were younger than 50 years of age presented with new-onset symptoms of large-vessel ischemic stroke. All five patients tested positive for Covid-19. By comparison, every 2 weeks over the previous 12 months, our service has treated, on average, 0.73 patients younger than 50 years of age with large-vessel stroke. On admission of the five patients, the mean NIHSS score was 17, consistent with severe large-vessel stroke. One patient had a history of stroke. Other pertinent clinical characteristics are summarized in Table 1. A retrospective study of data from the Covid-19 outbreak in Wuhan, China, showed that the incidence of stroke among hospitalized patients with Covid-19 was approximately 5%; the youngest patient in that series was 55 years of age. 1 Moreover, large-vessel stroke was reported in association with the 2004 SARS-CoV-1 outbreak in Singapore. 2 Coagulopathy and vascular endothelial dysfunction have been proposed as complications of Covid-19. 3 The association between large-vessel stroke and Covid-19 in young patients requires further investigation. Social distancing, isolation, and reluctance to present to the hospital may contribute to poor outcomes. Two patients in our series delayed calling an ambulance because they were concerned about going to a hospital during the pandemic.
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                Author and article information

                Contributors
                Hiren N. Patel
                Asma Syed
                Jeffrey S. Lobel
                Robert Galler
                Joseph Georges
                Margaret Carmody
                Micheal Puumala
                Journal
                Journal ID (nlm-ta): Interdiscip Neurosurg
                Journal ID (iso-abbrev): Interdiscip Neurosurg
                Title: Interdisciplinary Neurosurgery
                Publisher: Published by Elsevier B.V.
                ISSN (Electronic): 2214-7519
                Publication date PMC-release: 29 July 2020
                Publication date (Electronic): 29 July 2020
                Electronic Location Identifier: 100850
                Affiliations
                [a ]Avera McKennan Hospital, Department of Neurosurgery, USA
                [b ]Infectious Disease, 1301 S Cliff Ave Ste 610, Sioux Falls, SD, USA
                [c ]Newton-Wellesley Hospital, Department of Neurosurgery, 2014 Washington St, Newton, MA, USA
                [d ]Lima Memorial Hospital, Department of Neurosurgery, 1001 Bellefontaine Ave, Lima, OH, USA
                [e ]Northwell Health, Department of Neurosurgery, 1300 Roanoke Ave, Riverhead, NY 11901
                [f ]Cooper University Hospital, Department Neurosurgery, 1 Cooper Plaza, Camden, New Jersey, USA
                Author notes
                [* ]Corresponding author at: Department of Neurosurgery, Avera McKennan Hospital, 1301 S Cliff Ave Ste 610, Sioux Falls, SD 57105, United States hpatel8@ 123456partners.org
                Article
                Publisher ID: S2214-7519(20)30411-4 Publisher ID: 100850
                DOI: 10.1016/j.inat.2020.100850
                PMC ID: 7387273
                SO-VID: 51a0c359-fbd5-4082-9ef8-a2728c18a6a4
                Copyright © © 2020 Published by Elsevier B.V.
                License:

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

                History
                Date received : 17 July 2020
                Date accepted : 26 July 2020
                Categories
                Subject: Article

                Keywords: ards, acute respiratory distress syndrome,bipap, bilevel positive airway pressure,covid 19, corona virus disease 2019,cp, cerebellopontine,crp, c-reactive protein,ct, computed tomography,cta, ct angiography,cxr, chest x-ray,fio2, fraction of inspired oxygen,sars-cov-2, severe acute respiratory syndrome coronavirus 2,stat, statum which is latin meaning immediately,t-pa, tissue plasminogen activator,who, world health organization,coronavirus,covid-19,sars-cov-2,ischemic stroke,sub-occipital craniectomy,vasculitis,phlebitis
                Data availability:
                Keywords: ards, acute respiratory distress syndrome, bipap, bilevel positive airway pressure, covid 19, corona virus disease 2019, cp, cerebellopontine, crp, c-reactive protein, ct, computed tomography, cta, ct angiography, cxr, chest x-ray, fio2, fraction of inspired oxygen, sars-cov-2, severe acute respiratory syndrome coronavirus 2, stat, statum which is latin meaning immediately, t-pa, tissue plasminogen activator, who, world health organization, coronavirus, covid-19, sars-cov-2, ischemic stroke, sub-occipital craniectomy, vasculitis, phlebitis

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