Focal Cerebral Vasculitis due to SARS-CoV-2 Infection With a Robust Response to Intravenous Steroids.

INTRODUCTION: Severe and less common neurological manifestations of SARS-CoV-2 infection include acute ischemic stroke, intracerebral hemorrhage, central venous sinus thrombosis, and vasculitis. In this report, we present a case of a 42-year-old man with acute ischemic stroke due to SARS-CoV-2 infection-associated central nervous system vasculitis that improved with steroid therapy. CASE REPORT: A 42-year-old man with SARS-CoV-2 infection presented with non-fluent aphasia and right-sided hemiparesis. Computed tomography angiography revealed an occlusion of the proximal left middle cerebral artery (MCA), with acute infarcts in the left posterior parietal, lentiform nucleus, and cortical frontal cortex on magnetic resonance imaging (MRI). Patient developed pulmonary emboli and was discharged on apixaban and atorvastatin. Four weeks later, the patient presented with recurring symptoms and was found to have worsening left MCA stenosis. MRI and MR angiography revealed a penumbra within the left MCA territory and pruning of the distal branches with severe stenosis. Laboratory workup for autoimmune causes of vasculitis was unrevealing. High-dose intravenous steroid treatment was initiated. Subsequent MRI and MR angiography revealed improved flow in the left cerebral vasculature and no novel ischemic infarcts. CONCLUSION: Central nervous system vasculitis is a rare manifestation of SARS-CoV-2 infection. This case suggests that high-dose intravenous steroids may have a therapeutic role in this patient population. Steroid use, in combination with vasopressor support to augment cerebral blood flow, may prevent further stroke burden.

Postictal Todd's Paralysis Associated with Focal Cerebral Hypoperfusion on Magnetic Resonance Perfusion Studies.

BACKGROUND: The exact underlying physiology of postictal motor deficits, known as Todd's paralysis, is not well understood and its vascular perfusion physiology is not well studied. Reversible postictal perfusion abnormalities have been sparsely described in the literature. METHODS: We report abnormal brain magnetic resonance perfusion maps in a 9-year-old boy who presented with postictal left hemiparesis. This case correlates postictal hemispheric cerebral hypoperfusion with clinical evidence of Todd's paralysis. CONCLUSIONS: Our case provides an insight into the potential pathophysiology mechanism underlying Todd's paralysis and the practicality of magnetic resonance perfusion studies in localizing an epileptogenic zone in the postictal patient.