Posterior Reversible Encephalopathy Syndrome and brain haemorrhage as COVID-19 complication: a review of the available literature

Abstract

Background SARS-CoV-2 infection has been associated with various neurological manifestations. Since patients affected by SARS-CoV-2 infection present coagulation and immune system dysregulation, ischemic or haemorragic stroke is not uncommon, irrespective of respiratory distress. However, the occurrence of focal neurological deficits together with other symptoms like headache, cortical blindness, seizure and altered mental status should prompt the diagnosis of Posterior Reversible Encephalopathy Syndrome (PRES). Antithrombotic treatment, the alteration of endothelial function, and coagulopathy due to COVID-19 and PRES leading to the breakdown of blood-brain barrier may then contribute to the occurrence of a brain haemorrhage. Methods We describe the case of a COVID-19 patient who developed bilateral occipital lobe haemorrhages suggestive of haemorrhagic PRES. We then reviewed the available literature about haemorrhagic evolution of PRES in COVID-19. Results We describe the clinical and radiological features of five COVID-19 patients who developed haemorrhagic PRES. Conclusions Coagulopathy and endothelial dysfunction resulting from the massive release of cytokines during the host immune response may be key factors in the pathogenesis of COVID-19-related PRES. Antithrombotic therapy and the leakage of the blood-brain barrier can subsequently increase the risk of haemorrhagic transformation of the lesioned brain tissue. A prompt diagnosis of PRES is mandatory, since the timely interruption/reversal of antithrombotic therapy may be a key determinant for a good prognosis.

Neurological Manifestations in a Cohort of Egyptian Patients with COVID-19: A Prospective, Multicenter, Observational Study

“…SARS-CoV-2 was found to cause CNS symptoms, including cerebrovascular strokes (ischemic, hemorrhagic, and CVST). COVID-19 has been associated with the broad family of cerebrovascular diseases [ 6 , 7 , 8 , 45 , 46 , 47 ] In our study, all three stroke subtypes were detected with a greater preponderance of ischemic types, which agrees with the findings of previous studies [ 3 , 12 ]. However, acute hemorrhagic necrotizing encephalopathy with scattered hemorrhages has previously been reported [ 48 ].…”

Ischemic Stroke in a Patient with Stable CADASIL during COVID-19: A Case Report

“…We hypothesize that in patients with disorders caused by dysregulation of endothelial cells, hypercoagulability due to COVID-19 might increase the risk of cerebrovascular events. Indeed, a similar mechanism has been proposed in the pathogenesis of COVID-19-related posterior reversible encephalopathy syndrome (PRES), another neurological condition in which endothelial dysfunction and coagulopathy, together with a cytokine storm due to the infection, may lead to pathological changes [ 8 ].…”

Posterior reversible encephalopathy syndrome following appendicitis in a young child: A case report and review of the pediatric literature

“…8 Recently, PRES is increasingly recognized in association with infection, sepsis, and Systemic Inflammatory Response Syndrome including most recently an association with COVID-19 infection. 4,10,11 Bartynski et al 10 reviewed 25 patients who have PRES in association with severe infection or sepsis. In this review, the primary infection was noted mostly in the lungs, abdomen, wound, or urinary tract.…”