key: cord-1009710-jntgi7a7 authors: Kahan, Joshua; Gibson, Cameron J.; Strauss, Sara B.; Bronstein, Matthew; Winchell, Robert J.; Barie, Philip S.; Segal, Alan Z. title: Cervical Spinal Cord Infarction Associated with Coronavirus Infectious Disease (COVID)-19 date: 2021-03-08 journal: J Clin Neurosci DOI: 10.1016/j.jocn.2021.02.027 sha: 933d740a0b2816afc3a14eb5ef72462ecd4d4427 doc_id: 1009710 cord_uid: jntgi7a7 Coronavirus disease (COVID-19) has a number of emerging neurological manifestations in addition to pneumonia and respiratory distress. In what follows, we describe a case of a previously healthy young man with severe COVID-19 who subsequently developed an acute flaccid paralysis. Work up revealed a lesion in his cervical spinal cord concerning for spinal infarction or transverse myelitis. He received empiric pulsed steroids without improvement. Taken together, we felt his presentation was most consistent with spinal cord infarction in the setting of critical illness with COVID-19. We believe this is a rare case of spinal cord stroke associated with COVID-19. Coronavirus disease (COVID-19) has a number of emerging neurological manifestations in addition to pneumonia and respiratory distress. In what follows, we describe a case of a previously healthy young man with severe COVID-19 who subsequently developed an acute flaccid paralysis. Work up revealed a lesion in his cervical spinal cord concerning for spinal infarction or transverse myelitis. He received empiric pulsed steroids without improvement. Taken together, we felt his presentation was most consistent with spinal cord infarction in the setting of critical illness with COVID-19. We believe this is a rare case of spinal cord stroke associated with COVID-19. Coronavirus disease (COVID-19), has variable manifestations in the critical illness phase beyond acute respiratory distress syndrome including neurologic manifestations [1, 2] and a marked hypercoagulable state [3] . Clinical manifestations of the hyper-coagulable state may include venous thromboembolic disease; thrombosis of arterial monitoring and venous dialysis access catheters; and cerebral infarction [4] . Laboratory evaluation often demonstrates elevated pro-inflammatory biomarkers including serum concentrations of C-reactive protein, D-dimer, fibrinogen, and interleukin-6, among others [5, 6] . We report a case of cervical spinal cord infarction and flaccid quadriparesis associated with COVID-19 disease. A 31 year-old male with no known medical history was admitted to a network inpatient facility with eight days of an acute respiratory illness, which was confirmed by reverse transcriptase polymerized chain reaction of a nasal swab sample to be COVID-19. On hospital day (HD) 6, he was intubated for worsening respiratory failure and transferred to our facility the next day. His vital signs upon admission were T 35.6 o C, HR 126 beats/min, BP 147/93 mm Hg, and RR 18 breaths/min. Neurologic examination revealed spontaneous movement of all four extremities, with no focal findings. There were no other abnormalities on physical examination. Laboratory data are shown in Table 1 . Previous undiagnosed diabetes mellitus was identified (hemoglobin A1c, 12.7%). Hypercoagulability was confirmed by rotational thromboelastometry (ROTEM) [7] . Blood cultures and duplex ultrasonography of the lower extremities were normal. Once admitted to our ICU the patient was started on enoxaparin 80 mg subcutaneously every 12 hours for aggressive thromboprophylaxis [8] . Desired anti-coagulation was confirmed by an antifactor Xa concentration of 0.7 IU/mL (therapeutic range, 0.5-1.0 IU/mL) on HD 9. Over the following four days mechanical ventilation, vasopressor therapy, and sedation were weaned. There was an isolated recorded blood pressure of 60/37 on HD 8, however on detailed chart review this was reversed with increasing vasopressors within moments. Blood pressure was otherwise consistently at target. The patient moved all extremities during daily sedation holidays. On the morning of HD 12 the patient was unable to move his lower extremities and endorsed absent sedation below the nipples. Up to that point, he had maintained oxygen saturation >90% and was normotensive. Formal neurologic evaluation revealed that cranial nerves were intact except for multirotational nystagmus. Sensation to light touch and pinprick were intact above the nipples, but absent caudally. The sensory level was at the T4 dermatome. Power of the upper extremities was present but diminished bilaterally (bilateral deltoid muscle 2/5, bilateral triceps muscle 2/5, right biceps muscle and wrist extensors 2/5, left biceps muscle and wrist extensors As in sepsis generally, COVID-19 disease is characterized by interactions between inflammatory and coagulation cascades [5] , but the hypercoagulable state associated with COVID-19 disease is distinct from the typical hypocoagulable state of bacterial sepsis, which is associated with thrombocytopenia. Therapeutic anticoagulation has been advocated in view of recent observations of pathologic clotting in COVID-19 [9, 10] , and a suggestion of a survival benefit for critically ill patients [10] . Neurologic associations with COVID-19 are numerous, including both central and peripheral neurologic symptoms [2] [3] [4] . The distribution of cord injury in this case does not conform to classically described vascular distributions of the anterior or posterior spinal arteries, and instead is in central "watershed" areas. This pattern is usually associated with prolonged hypotension in the setting of cardiac arrest [11] . A case series (n = 60) comparing MRI features of spinal infarcts and inflammatory lesions secondary to neuromyelitis optica spectrum disorder suggest that while anterior cord predominance is more consistent with infarct, of the 39 patients with infarcts, 24 had central cord imaging changes on axial slices [12] . Moreover, longitudinally extensive T2 hyperintensity has been observed in the setting of spinal cord infarction, and is attributed to secondary vasogenic edema can be seen in the brain [13] . Of note, the presence of diffusion restriction is not specific for infarct, and it has been seen with inflammatory etiologies [14] . It should be highlighted that because CSF analysis was not performed due to infection control practices at the time, there remained significant clinical uncertainty to justify a trial of high dose steroids. The lack of clinical improvement following steroids is more suggestive of a cord infarct, but not conclusive. Spinal cord pathology associated with the Covid-19 pandemic has included primary spinal epidural abscesses [15] , two published case reports of acute myelitis [16, 17] -both of which showed neurological improvement with high-dose steroids, and two cases of possible infarction [18] . Central nervous system manifestations of COVID-19: A systematic review Neurologic manifestations of hospitalized patients with coronavirus disease 2019 in Wuhan, China Humanitas COVID-19 Task Force. Venous and arterial thromboembolic complications in COVID-19 patients admitted to an academic hospital in Large-vessel stroke as a presenting feature of Covid-19 in the young COVID-19 cytokine storm: The interplay between inflammation and coagulation Clinical characteristics of coronavirus disease 2019 in China Rotational thromboelastometry (ROTEM)-based coagulation management in cardiac surgery and major trauma Association of treatment dose anticoagulation with inhospital survival among hospitalized patients with COVID-19 High risk of thrombosis in patients in severe SARS-CoV-2 infection: A multicenter prospective cohort study COVID-19 and its implications for thrombosis and anticoagulation Spinal cord ischemia: practical imaging tips, pearls, and pitfalls A comparison between spinal cord infarction and neuromyelitis optica spectrum disorders: Clinical and MRI studies Longitudinally extensive vasogenic edema following spinal cord infarction A case of longitudinally extensive transverse myelitis with an isolated pontine lesion following epidural and spinal anesthesia for cesarean section. eNeurologicalSci Spinal epidural abscess in COVID-19 patients COVID-19-associated acute necrotizing myelitis SARS-CoV-2 can induce brain and spine demyelinating lesions Case Report: Acute Spinal Cord Myelopathy in Patients With COVID-19