The spectrum of severe neurological complications following COVID-19 vaccination includes cerebrovascular events, inflammatory diseases of the CNS, cranial and peripheral nerve involvement and muscle affections. Post-vaccinal acute disseminated encephalomyelitis (ADEM) and acute encephalitis are rare. We report on a patient suffering from acute encephalitis and another with post-vaccinal monophasic ADEM. Beside imaging features typical for acute autoimmune associated inflammation, cranial MRI disclosed also transient haemorrhagic signal alterations in some cerebral lesions. To our best knowledge, this has not been mentioned before in literature. Competing causes were excluded by extensive laboratory investigations including serial CSF analysis. In line with the literature, repeated iv high-dosage corticosteroid therapy resulted in impressive improvement of neurological symptoms in both patients.
A 39-year-old man was admitted to the hospital 70 minutes after the acute onset of dysarthria. Examination revealed left hemiparesis and multimodal neglect; there was no disturbance of the senses of taste and smell. The patient had been in quarantine at home for 11 days because of a respiratory infection with a positive test for COVID-19. Laboratory findings prior to admission had included a mild polycythemia; on admission, the hematocrit was 53.4% and the hemoglobin concentration was 19.1 g/dL. There was also an elevated D-dimer concentration (2.1 mg / L; normal range, <0.5 mg / L). The patient was informed both of the findings relating to COVID-19 (Figure a) and of the neurological findings, and he gave his informed consent to treatment by systemic thrombolysis and therapeutic phlebotomy. Although his neurologic state improved, a follow-up scan revealed a demarcated infarct (Figure b). Further tests ruled out a cardiac embolic source, a patent foramen ovale, and a deep venous thrombosis, and the patient was discharged to his home. Even in the absence of severe pulmonary manifestations, the D-dimer concentration was pathological. This case indicates that patients with a SARS-CoV-2 infection and associated activation of the clotting system may be at elevated risk for stroke even if they are young.
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