Viral Storm to Vascular Inflammation: A Case of COVID-19 Induced CNS Vasculitis
Farwah Fatima1, Fatima Tuz Zahra3, Kirvia Williams4, Suzanne Crandall2
1Neurology, Charleston Area Medical Center, 2Charleston Area Medical Center, 3Camc, 4Desert Regional Medical Center
Objective:
We present a case of suspected COVID-19 associated central nervous system (CNS) vasculitis with classic head and neck vessel imaging showing multifocal vascular stenosis in the setting of bilateral multivascular territory ischemic strokes. Early recognition and management of inflammatory causes of multifocal strokes can prevent long-term morbidity and mortality.
Background:
Covid-19 is well recognized to cause fatal respiratory infection. Covid-19 related CNS pathologies are increasingly reported in literature, hypothesized to be triggered by cytokine storm resulting in immune-mediated vessel injury. CNS vasculitis is a rare cause of multifocal strokes that pose significant diagnostic challenges.
Results:
A 40-year-old woman with hypertension, hyperlipidemia, type 2 diabetes, POTS, hypothyroidism, anxiety, and depression presented with acute left-sided weakness, tunnel vision, and new-onset headaches shortly after hospitalization for COVID-19 and Haemophilus influenzae pneumonia.
CT head showed left occipital and bilateral parietal hypodensities concerning for ischemia. CTA revealed moderate multifocal stenoses in bilateral MCA and ACA territories. MRI brain verified multifocal infarcts involving bilateral occipital, frontal, and left parietal lobes. Digital Subtraction Angiography (DSA) confirmed diffuse luminal irregularities throughout bilateral anterior and posterior circulations, consistent with vasculitis. An extensive infectious, autoimmune, and inflammatory workup, including CSF studies, was negative. A diagnosis of COVID-19-related CNS vasculitis was made. The patient was treated with high-dose corticosteroids followed by a six-week taper.
Six months later, she presented again with headaches. Repeat imaging showed chronic infarct changes without new ischemia. Repeat DSA showed complete resolution of prior multifocal vascular stenosis. She was diagnosed with post-vasculitis migraine and managed with CGRP inhibitors.
Conclusions:
COVID-19–associated CNS vasculitis can present with fulminant findings but may carry a favorable prognosis with rapid recognition and treatment. Integrating vascular imaging with infarct patterns is key for diagnosis, acute management, and secondary prevention.
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