key: cord-0781389-tpfp1kxx
authors: Paterson, Ross W; Brown, Rachel L; Vivekanandam, Vinojini; Foulkes, Alexander J M; Thom, Maria; Wiethoff, Sarah; Benjamin, Laura; Christofi, Gerry; McNamara, Patricia; Morrow, Jasper; Miller, Thomas D; Nortley, Ross; Geraldes, Ruth; Attwell, David; Kumar, Guru; Everitt, Alex D; Davies, Nicholas W S; Trip, S Anand; Silber, Eli; Howard, Robin; Perry, Richard J; Werring, David J; Checkley, Anna; Longley, Nicky; Spillane, Jennifer; Lunn, Michael P; Hoskote, Chandrashekar; Jäger, Hans Rolf; Manji, Hadi; Zandi, Michael S
title: Reply: Concentric demyelination pattern in COVID-19-associated acute haemorrhagic leukoencephalitis: a lurking catastrophe?
date: 2020-12-16
journal: Brain
DOI: 10.1093/brain/awaa377
sha: f207eddfc62ecb916e9c3bf40bfbdf56fe936af0
doc_id: 781389
cord_uid: tpfp1kxx

nan

We are grateful to Karapanayiotides and colleagues (2020) for their description of a 57-year-old patient with acute haemorrhagic leukoencephalitis (AHLE) and concentric demyelination suggestive of Baló 's disease, and for adding insights into the neurological manifestations of COVID-19. The authors are correct to point out that the mechanisms underpinning the features in all of our collective patients remain to be determined, and the role of direct infection, hypoxia, immune-mediated injury and metabolic processes all warrant further exploration. The authors are also correct in describing the difficulty in applying historical terminology to the clinical pictures that we are now seeing in COVID-19, and that new terminologies need to be considered.

In Patient 17, the clinical picture of rapid progression, unilateral significant brain swelling with oedema and ensuing coma-with evidence of brainstem dysfunction, and resolution with decompressive craniectomy and corticosteroids, fitted best clinically with previous descriptions of haemorrhagic leukoencephalitis (AHLE) (Love et al., 2008) . We acknowledge that neither the biopsied tissue, nor the imaging, showed any evidence of haemorrhage. Whereas the former might potentially be a tissue sampling issue, it is unlikely that any significant haemorrhage would have been missed on the susceptibility-weighted MRI sequence done preoperatively, although this may have developed with time. For Patient 17, an 'aggressive hyper-acute disseminated encephalomyelitis' might therefore have been a more appropriate term.

Data availability is not applicable to this article as no new data were created or analysed in this study. 

Concentric demyelination pattern in COVID-19-associated acute haemorrhagic leukoencephalitis: a lurking catastrophe?

Greenfield's neuropathology. 8th edn. London: Hodder Arnold

The UCL Queen Square National Hospital for Neurology and Neurosurgery COVID-19 Study Group includes the authors and the following: 

C.C. has sat on an advisory panel for Roche. A.V. and the University of Oxford hold patients and receive royalties for antibody tests. M.S.Z. has received lecturing fees for Eisai and UCB pharma. All other authors report no competing interests.

Supplementary material is available at Brain online.