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DOI: 10.1590/0004-282X20200184
Hemorrhagic PRES: an unusual neurologic manifestation in two COVID-19 patients
PRES hemorrágica: uma manifestação neurológica incomum em dois pacientes com COVID-19Two patients with confirmed COVID-19 infection both manifesting with typical computerized tomography (CT) lung findings (less than 50% of lung parenchyma affected by ground-glass opacities) presented sudden altered mental status. By the time of neurologic deterioration, despite improved respiratory parameters, they were still in an intensive care unit under mechanical ventilation. Both patients had parieto-occipital cortico-subcortical hypodensities with associated acute hemorrhage foci on brain CT ([Figures 1] and [2]). Brain magnetic resonance imaging (MRI) was additionally obtained in one of those subjects, confirming areas of vasogenic edema and hemorrhage ([Figure 1]). Such findings are compatible with atypical posterior reversible encephalopathy syndrome (PRES), complicated by hemorrhage. Angiographic studies (magnetic resonance angiography — MRA — for one patient and CT angiography — CTA — for the other) excluded venous thrombosis.
Critically-ill patients with COVID-19 have an extreme inflammatory reaction, causing a cytokine storm syndrome that may damage the blood-brain barrier and complicate with PRES[1]. The associated hemorrhage seen in our patients may also be explained by coagulation impairment, another common complication reported in COVID-19 patients[2].
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Conflict of interest:
There is no conflict of interest to declare.
Authors’ contributions:
DAD: equal contributions to the design or development of the study; to the collection, analysis and interpretation of data; to the writing of the article and its critical revision; to the approval of the final version. LAB: design or development of the study. LON: approval of the final version. RGSP: writing of the article. OABJ: data collection, analysis and interpretation of data. JWLTJ: equal contributions to the design or development of the study; the collection, analysis and interpretation of data; the writing of the article and its critical revision; and the approval of the final version.
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References
- 1 Mehta P, McAuley DF, Brown M, Sanchez E, Tattersall RS, Manson JJ; HLH Across Specialty Collaboration, UK. COVID-19: consider cytokine storm syndromes and immunosuppression. Lancet. 2020 Mar;395(10229):1033-4. https://doi.org/10.1016/S0140-6736(20)30628-0
- 2 Franceschi AM, Ahmed O, Giliberto L, Castillo M. Hemorrhagic Posterior Reversible encephalopathy syndrome as a manifestation of COVID-19 infection. AJNR Am J Neuroradiol. 2020 Jul;41(7):1173-6. https://doi.org/10.3174/ajnr.A6595
Address for correspondence
Publication History
Received: 12 August 2020
Accepted: 17 September 2020
Article published online:
07 June 2023
© 2020. Academia Brasileira de Neurologia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commecial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)
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References
- 1 Mehta P, McAuley DF, Brown M, Sanchez E, Tattersall RS, Manson JJ; HLH Across Specialty Collaboration, UK. COVID-19: consider cytokine storm syndromes and immunosuppression. Lancet. 2020 Mar;395(10229):1033-4. https://doi.org/10.1016/S0140-6736(20)30628-0
- 2 Franceschi AM, Ahmed O, Giliberto L, Castillo M. Hemorrhagic Posterior Reversible encephalopathy syndrome as a manifestation of COVID-19 infection. AJNR Am J Neuroradiol. 2020 Jul;41(7):1173-6. https://doi.org/10.3174/ajnr.A6595