A Fulminant Reversible Cerebrovascular Disorder in Fatal Breakthrough COVID-19 Infection

A 64-year-old lady with long standing history of migraine and recently diagnosed hypertension on amlodipine, presented with history of continuous excruciating headache and vomiting of 10 days duration. Five days after onset of headache, she developed drowsiness and difficulty in walking. She had received two doses of COVISHIELD (AstraZeneca, ChAdOx1) vaccine, 2 months back. On examination, patient had significant vision impairment in both eyes with normal pupillary reflexes, quadriplegia and recurring focal seizures involving right upper limb. She tested positive for SARS-CoV-2. Repeat MR angiogram showed widespread vasoconstriction of intracranial blood vessels suggestive of Reversible Cerebral Vasoconstriction Syndrome (RCVS). 

CSF analysis was normal. Although patient was diagnosed with COVID 19, patient did not complain of cough, breathlessness or fever. Oxygen saturation in room air was 92% and CT chest showed mild basal ground glass opacities. Hence, no steroids were administered, and patient was started on low molecular weight heparin in view of high D dimer levels and given oxygen supplementation as treatment for COVID infection.

She went on to develop status epilepticus, hemorrhagic transformation and significant brain edema. Patient succumbed to aspiration pneumonia and sepsis ten days after admission.


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REFERENCE

Ray S, Kamath VV, Raju A, Rajesh KN, Shalini N. Fulminant Reversible Cerebral Vasoconstriction Syndrome in Breakthrough COVID 19 Infection. Journal of Stroke and Cerebrovascular Diseases. 2022 Feb 1;31(2):106238.


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