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Immunosuppression for intracranial vasculitis associated with SARS-CoV-2: therapeutic implications for COVID-19 cerebrovascular pathology

Acute cerebrovascular disease, particularly ischaemic stroke, has emerged as a serious complication of COVID-19.1 However, the mechanism and optimal management of this remain incompletely understood. In the pulmonary and cardiac circulation, there is evidence that thrombotic complications may relate to endothelial inflammation and injury but evidence for this in the cerebrovascular system is limited.2 We demonstrate direct imaging evidence of vasculitis in a patient with COVID-19 complicated by multiple territory ischaemic strokes which responded to steroids and targeted interleukin-1 (IL-1) and interleukin-6 (IL-6) inhibition.

### Case report

A 64-year-old man with type 2 diabetes mellitus, hypertension, hypercholesterolaemia and ischaemic heart disease was admitted with a 5-day history of dry cough and fever. He was diagnosed with COVID-19 pneumonia requiring early intubation, mechanical ventilation, inotropic support and haemofiltration for acute kidney injury. Blood tests showed lymphopenia (0.6×109/L), elevated C-reactive protein (196 mg/L), renal dysfunction (creatinine 156 μmol/L) and raised D-dimer (>20 000 µg/L). Given this, and his need for continuous renal replacement therapy, the patient was systemically heparinised. SARS-CoV-2 infection was confirmed with nasopharyngeal swab reverse-transcriptase PCR testing.

On day 24 of admission, following a sedation hold, he was not appropriately responsive with Glasgow Coma Scale 8 (E4, V2, M2) and episodic clonic movements of the proximal upper limbs. The patient was on aspirin and intravenous heparin at this time.

MRI brain demonstrated abnormal signal, variable restricted diffusion and peripheral enhancement in the left occipital and right parietal, occipital and temporal lobes (figure 1). Appearances were consistent with multiple subacute infarcts in the right middle cerebral artery …