key: cord-1005272-ev5t3myu
authors: Degeneffe, Aurélie; De Witte, Olivier; Lubansu, Alphonse
title: Acute hemorrhage after intra-cerebral biopsy in COVID-19 patients: a report of 3 cases
date: 2020-07-15
journal: World Neurosurg
DOI: 10.1016/j.wneu.2020.07.045
sha: 791b1b475b68f45289ba560edff3de4fea1e0d01
doc_id: 1005272
cord_uid: ev5t3myu

nan

We appreciate the interest and valuable suggestions by Munakomi et al. regarding our recently published paper "Acute hemorrhage after intra-cerebral biopsy in COVID-19 patients: a report of 3 cases".

In their letter, the authors rightly emphasize the necessity for preoperative screening of COVIDpatients, in order to identify patients prone to hemorrhagic complications after neurosurgical interventions. They discuss the three stages of NeuroCovid, described by Fotuhi et al. 1 NeuroCovid stage I, where the binding of SARS-CoV-2 is limited to the ACE-II receptors in the nasal and gustatory cells, may lead to impairment of smell or taste without a significant cytokine storm. 1 They refer to stage II as the phase where an immune response is activated, which subsequently leads to increased cytokines and triggers hypercoagulation cascades. 1 During NeuroCovid stage III the blood brain barrier (BBB) is damaged, which results in edema and brain injury, potentially leading to encephalopathy. At this stage the risk of intracranial hemorrhage is at its highest. 1 Post-mortem brain-MRI analyses and autopsies, recently conducted in our center, support this theory.

Analyses of post-mortem brain-MRIs have demonstrated macro-and micro-subcortical bleeds, asymmetric olfactory bulbs and PRES-related brain lesions in deceased COVID-19 patients. 2 No specific brainstem abnormalities were found. In addition, 11 brain autopsy reports have revealed Munakomi et al. propose the assessment of anosmia and ageusia, as well as examining viral load of the SARS-CoV-2 in the CSF in order to screen for high-risk patients. However, we believe that careful interpretation is needed when assessing these data.

We do agree with the importance of a preoperative check for symptoms such as fever, cough, shortness of breath, anosmia, ageusia and other neurological symptoms. The presence of alteration of olfactory and taste function is, however, not limited to NeuroCovid stage I. It is crucial to realize that COVID-patients can present with a variety of immune-mediated neurological symptoms, but other underlying etiologies may still be present for their neurological conditions. 1 

Neurobiology of COVID-19

Early Postmortem Brain MRI Findings in COVID-19 Non-Survivors

Unspecific post-mortem findings despite multiorgan 1 viral spread in COVID-19 patients. 2020. Article under review

A first case of meningitis/encephalitis associated with SARS-Coronavirus-2

Response to Commentary on "The neuroinvasive potential of SARS-CoV-2 may play a role in the respiratory failure of COVID-19 patients

Encephalitis as a clinical manifestation of COVID-19