Importance: Reported cerebrovascular events in patients with COVID-19 are mainly ischemic, but hemorrhagic strokes and cerebral venous sinus thrombosis (CSVT), especially in critically ill patients, have also been described. To date, it is still not clear whether cerebrovascular manifestations are caused by direct viral action or indirect action mediated by inflammatory hyperactivation, and in some cases, the association may be casual rather than causal. Objective: To conduct a systematic review on the cerebrovascular events in COVID-19 infection. Evidence review: A comprehensive literature search on PubMed was performed including articles published from January 1, 2020, to July 23, 2020, using a suitable keyword strategy. Additional sources were added by the authors by reviewing related references. The systematic review was conducted in accordance with the PRISMA guidelines. Only articles reporting individual data on stroke mechanism and etiology, sex, age, past cardiovascular risk factors, COVID symptoms, admission NIHSS, D-dimer levels, and acute stroke treatment were selected for the review. Articles that did not report the clinical description of the cases were excluded. A descriptive statistical analysis of the data collected was performed. Finding: From a total of 1,210 articles published from January 1, 2020, to July 23, 2020, 80 articles (275 patients), which satisfied the abovementioned criteria, were included in this review. A total of 226 cases of ischemic stroke (IS), 35 cases of intracranial bleeding, and 14 cases of CVST were found. Among patients with IS, the mean age was 64.16 ±14.73 years (range 27-92 years) and 53.5% were male. The mean NIHSS score reported at the onset of stroke was 15.23 ±9.72 (range 0-40). Primary endovascular thrombectomy (EVT) was performed in 24/168 patients (14.29%), intravenous thrombolysis (IVT) was performed in 17/168 patients (10.12%), and combined IVT+EVT was performed in 11/168 patients (6.55%). According to the reported presence of large vessel occlusion (LVO) (105 patients), 31 patients (29.52%) underwent primary EVT or bridging. Acute intracranial bleeding was reported in 35 patients: 24 patients (68.57%) had intracerebral hemorrhage (ICH), 4 patients (11.43%) Fraiman et al. COVID-19 and Cerebrovascular Diseases had non-traumatic subarachnoid hemorrhage (SAH), and the remaining 7 patients (20%) had the simultaneous presence of SAH and ICH. Fourteen cases of CVST were reported in the literature (50% males), mean age 42.8 years ±15.47 (range 23-72). Treatment was reported only in nine patients; seven were treated with anticoagulant therapy; one with acetazolamide, and one underwent venous mechanical thrombectomy. Conclusion: Cerebrovascular events are relatively common findings in COVID-19 infection, and they could have a multifactorial etiology. More accurate and prospective data are needed to better understand the impact of cerebrovascular events in COVID-19 infection.

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Amyloid Protein Precursor gene duplication is a rare cause of early-onset Alzheimer's disease that can be associated with Cerebral Amyloid Angiopathy. This condition predisposes cerebrovascular events, specifically, intracerebral hemorrhagic stroke. This report describes a case of first-time intracerebral hemorrhage in a patient with APP gene duplication during SARS-CoV-2 infection, a typically pro-thrombotic and pro-inflammatory condition, as a possible trigger for this condition.

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A 56-year-old woman developed progressive subacute lower limb weakness with sensory and autonomic abnormalities. She had received a living-donor kidney transplantation 21 years before for end-stage chronic kidney disease and took mycophenolate mofetil and prednisolone. MR scan of the spinal cord showed bilateral cauda equina gadolinium enhancement and MR scan of the brain showed enhancing nodular hyperintensities in the internal capsule and globus pallidus. Cerebrospinal fluid (CSF) showed a pleocytosis with extremely low glucose, and positive DNA-PCR for Epstein-Barr virus. Her condition worsened despite empirically guided antimicrobial treatment. CSF immunophenotyping later identified mature, clonal B lymphocytes of large size, expressing CD19, CD20, CD200 antigens, and kappa light chain immunoglobulin, with absent CD5 and CD10 expression. We diagnosed a myeloradiculopathy from a monomorphic post-transplant lymphoproliferative disorder. This condition occurs after kidney transplantation and falls on the lymphoma spectrum. We review its clinical features, diagnosis and management.

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Introduction: New onset of a refractory status epilepticus (NORSE) is a clinical presentation, without a clear cause, within the first 72h of admission of a non-epileptic patient. FIRES (Febrile Infection-Related Epilepsy Syndrome) is a NORSE subgroup with febrile prodrome 24 hours to 2 weeks before the onset of status. This case reports a previously healthy 7-year-old female with FIRES and super refractory status epilepticus (SE). Methods: This is a case report based on retrospective analysis of a single patient’s medical record. Results: The patient presented with SE four days after low grade fever and airway infection. Midazolam (MDZ) 0.15 mg/kg, phenytoin (PFT) 30 mg/ kg, phenobarbital (PB) 15 mg/kg were administered in sequence; followed by continuous infusion of MDZ 1 mg/kg/h and ketamine (KET) 30 mcg/kg/ min. Empirical treatment started with ceftriaxone, acyclovir and ampicillin. Exams on admission: Brain magnetic resonance (MRI) with no abnormalities; normal serum leukocyte count and electrolyte levels; cerebrospinal fluid (CSF) with 61 cells (71% lymphocytes), protein 38, Lactate 15, glucose 61 (mg/dL). CSF on two different occasions was negative for infectious agents and autoimmune antibodies. Electroencephalograms (EEG) on the 3rd, 4th and 7th days after hospitalization revealed SE despite the followings drugs: Levetiracetam 60 mg/kg, Lacosamide 10 mg/kg, topiramate 10 mg/kg, MDZ 2 mg/kg/h, KET 2 mg/kg/h. Throughout hospitalization, she received a 3 days course of methylprednisolone 30 mg/kg/day, followed by five days of immunoglobulin 2 g/ kg/day, ketogenic diet and thiopental 5 mg/kg/h. From the 13th day on, EEG maintained global suppression and no epileptiform activity. The patient died on the 18th day after a septic shock. Conclusion: NORSE and FIRES are entities with unfavorable outcomes and high mortality rates. Autoimmune/inflammatory encephalitis represents 40% of NORSE causes.

Introduction: Optic perineuritis is a rare disorder with multiple possible etiologies, including systemic autoimmune or infectious syndromes and, more rarely, neurosyphilis. The aim of this report is to describe an uncommon manifestation of this reemerging infectious disease. Case report based on a retrospective analysis of the medical records of the patient. Case report: A previously healthy 35-year-old female presented to the hospital with a seven-day history of progressive right eye vision loss and pain on extraocular movement, with development of a pink maculopapular rash on the trunk. On the sixth day of her disease, similar symptoms appeared in the contralateral eye. Physical examination showed reduced fotomotor reflex and finger counting at 50 cm in both eyes. Magnetic resonance imaging revealed bilateral and circumferential thickening with enhancement of the optic nerve sheath, suggesting bilateral optic nerve perineuritis. Serum Venereal Disease Research Laboratory (VDRL) was 1/64 and cerebrospinal fluid (CSF) showed 440 cells (86% lymphocytes), proteins 97 mg/dL, glucose 47 mg/dL, lactate 21 mg/dL and VDRL 1/4. She was treated with IV crystalline penicillin for 21 days and had partial improvement of bilateral vision within two months. At follow-up, her visual acuity was 20/40 in the right eye and 20/100 in the left; her CSF normalized, with nonreactive VDRL. Conclusion: Neurosyphilis is a treatable cause of optic perineuritis, and its recognition is important to establish the right antibiotic treatment.