Isolated intracranial hypertension associated with COVID-19

Abstract

Background Headache is a frequent complaint in COVID-19 patients. However, no detailed information on headache characteristics is provided in these reports. Our objective is to describe the characteristics of headache and the cerebrospinal fluid (CSF) profile in COVID-19 patients, highlighting the cases of isolated intracranial hypertension. Methods In this cross-sectional study, we selected COVID-19 patients who underwent lumbar puncture due to neurological complaints from April to May 2020. We reviewed clinical, imaging, and laboratory data of patients with refractory headache in the absence of other encephalitic or meningitic features. CSF opening pressures higher than 250 mmH2O were considered elevated, and from 200 to 250 mmH2O equivocal. Results Fifty-six COVID-19 patients underwent lumbar puncture for different neurological conditions. A new, persistent headache that prompted a CSF analysis was diagnosed in 13 (23.2%). The pain was throbbing, holocranial or bilateral in the majority of patients. All patients had normal CSF analysis and RT-qPCR for SARS-CoV-2 was negative in all samples. Opening pressure >200 mmH2O was present in 11 patients and, in six of these, > 250 mmH2O. 6/13 patients had complete improvement of the pain, five had partial improvement, and two were left with a daily persistent headache. Conclusions In a significant proportion of COVID-19 patients, headache was associated to intracranial hypertension in the absence of meningitic or encephalitic features. Coagulopathy associated with COVID-19 could be an explanation, but further studies including post-mortem analysis of areas of production and CSF absorption (choroid plexuses and arachnoid granulations) are necessary to clarify this issue.

COVID-19 and chronic fatigue syndrome: Is the worst yet to come?

“…From this point of view, post-COVID-19 fatigue syndrome, like CFS, might be a form of IIH, resulting from an excess of CSF in the glymphatic system. The view that at least a subgroup of COVID-19 patients may represent a variant of IIH is supported by a very recent study [36] . Silva et al [36] .…”

“…The view that at least a subgroup of COVID-19 patients may represent a variant of IIH is supported by a very recent study [36] . Silva et al [36] . described the characteristics of headache and the CSF profile during SARS-CoV-2 infection in a consecutive series of COVID-19 patients.…”

“…In this cross-sectional study, 13 out of 56 COVID-19 patients submitted to CSF analysis had severe, persistent headache. In 11 patients (84.6%), the CSF opening pressure was above 20 cmH 2 O and in 6 of these (46.1%), above 25 cmH 2 O [36] . CSF opening pressures higher than 25 cmH 2 O were considered elevated, and from 20 cmH 2 O to 25 cmH 2 O equivocal [36] .…”

Association between COVID-19 and headache: What evidence and history tell us

“…The clinical picture of these patients does not resemble those of idiopathic intracranial hypertension. Therefore, the authors suspected that a link with coagulopathy may underlie the elevated CSF pressure (22). However, this study is without a control group and warrants further validation.…”

“…However, this study is without a control group and warrants further validation. Of note, all 56 patients with headache had a negative CSF study using RT-PCR for virus RNA (22). Therefore, a direct CNS involvement is probably rare even in those with headaches.…”