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Brain MRI in a patient with normal pressure hydrocephalus after COVID19 infection showing: A Axial T2-weighted image with dilated lateral ventricles, B coronal T1-weighted image depicting acute callosal angle and upward bowing of the corpus callosum and C sagittal T1-weighted image showing normal infratentorial ventricular compartment
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Background
COVID-19 is a pandemic disease responsible for many deaths worldwide. Many neurological manifestations have been described. We report a case of normal pressure hydrocephalus (NPH) 2 months after acute COVID19 infection, in a patient without other risk factors.
Case presentation
A 45-year-old male patient presented an 8-month history of...
Citations
... There was an improvement in the mean, but it did not return to the value before the infection, a mean of 21.8. 15 Damiano (2022) Vasconcelos (2022), 17 in his case report, described the following symptoms: weight gain, excessive sleepiness, and cognitive alteration, with a final diagnosis of normal pressure hydrocephalus, after 8 months of COVID. 17 A demyelinating neuropathy, Lewis-Sumner syndrome, has also been described 3 months after COVID-19. ...
Background The post-COVID-19 condition is a major modern challenge in medicine and has a high global impact on the health of the population.
Objective To determine the main neurological and neuropsychiatric manifestations after acute COVID-19 infection in South American countries.
Methods This is a systematic review study, registered on the PROSPERO platform following the PRISMA model. 4131 articles were found with the search strategies used. Neurological and neuropsychiatric manifestations were investigated in individuals three months or more after acute COVID-19 infection, and older than 18 years, including studies conducted in South American countries published between 2020 and 2022.
Results Six studies (four from Brazil and two from Ecuador) were analyzed. Regarding the type of study: three were cohorts, two were case reports, and one was cross-sectional. The main outcomes found were new pain (65.5%) and new chronic pain (19.6%), new headache (39.1%), daily chronic headache (13%), paresthesia (62%), in addition to neuropsychiatric diseases, such as generalized anxiety disorder (15.1%), post-traumatic stress syndrome (13.4%), depression and anxiety (13.5%), suicidal ideation (10.1%), and several cognitive disorders.
Conclusion Neurological and neuropsychiatric manifestations related to depression and anxiety, and cognition disorders are reported during the post-COVID-19 condition in South America. Symptoms associated with chronic pain appear to be associated with the condition. More studies on post-COVID-19 conditions are needed in the South America region.
... Two studies [8,9] were removed after reading the full text, because, although they met inclusion criteria, the reported hydrocephalus was to refer to acute SAH. Thus, a total of six articles [10][11][12][13][14][15] were included. ...
... Literature review yielded six studies, four case reports [10][11][12][13] and two case series [14,15] iNPH: idiopatic normal pressure hydrocephalus; ADHD: attention-deficit/hyperactivity disorder According to our review, hydrocephalus onset during or after COVID-19 infection shows in adults an equal distribution among genders (five female, four male) and ages (age interval: 20-79). In almost half of the identified cases, the diagnosis of hydrocephalus was made concomitantly with the diagnosis of COVID-19 infection. ...
... Furthermore, the systemic reaction occurring during COVID-19 infection could lead to a hypercoagulable state of the blood system. In some patients, the presence of hypercoagulability may lead to venous congestion and abnormal CSF flow dynamic, resulting in hydrocephalus [11]. ...
Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), typically affects the respiratory system but can also present with neurological manifestations. Although some cases of hydrocephalus related to COVID-19 infection have been reported, a clear association between these two entities is not universally recognized yet. Here, we report another interesting case of hydrocephalus in a 60-year-old man with a previous aneurysmal subarachnoid haemorrhage (aSAH) who tested positive for COVID-19. Secondly, we illustrate a systematic overview of the previously reported cases of hydrocephalus related to COVID-19 infection. Finally, in light of the literature, we discuss the supposed underlying mechanisms that could make the association between COVID-19 infection and hydrocephalus plausible.
... In addition, the 'Trojan horse' mechanism of SARS-CoV-2 infection of multiple immune cells and the immunemediated cytokine storm triggered by SARS-CoV-2 infection may also lead to inflammation of the arachnoid villi, resulting in reduced absorption of CSF, combined with inflammatory local adhesions causing obstruction or aggravation of existing obstruction, leading to hydrocephalus. 1 It has also been reported that the possible mechanism is a systemic reaction to COVID-19 leading to a hypercoagulable state of the blood system which in turn leads to venous congestion and abnormal flow of CSF leading to hydrocephalus. 5 However, the three existing cases we reported had no significant abnormalities in coagulation parameters at the time of admission for hydrocephalus symptoms within 2-4 weeks of infection with COVID-19, so it is presumed that hydrocephalus due to a hypercoagulable state is less likely in the three patients. ...
... Since the beginning of the SARS-CoV-2 pandemic only three cases of previously healthy patients who developed NPH after COVID-19 infection have been described [11][12][13], suggesting that NPH may have been a complication of the neuro-inflammation response triggered by SARS-CoV2 in the nervous system. ...
... To our knowledge there are no other cases reported in the literature of an NPH worsening shortly before the evidence of SARS-CoV-2 infection. Other authors reported cases of patients with "delayed" development of NPH after COVID-19 (one week three months from infection), requiring surgery for the treatment of the hydrocephalus [11][12][13]. All these patients did not have other risk factors for NPH or significant medical history apart from a recent SARS-CoV-2 infection. ...
Although the etiopathology of normal pressure hydrocephalus (NPH) is still not completely defined, several studies in recent years have highlighted the role of neuro-inflammation mediators in its development. During COVID-19, the infected host develops a multifaceted inflammatory syndrome, that may lead to an uncontrolled immune system response also localized in the host nervous system. In fact, the target of the viral Spike protein, the angiotensin-converting enzyme 2 (ACE2) receptors, is widely expressed in different areas of CNS such as the olfactory epithelium, and the choroid plexus. As for idiopathic NPH, the massive release of inflammatory mediators may result in altered CSF dynamics and consequent sudden clinical decompensation.
We report the cases of two patients with a known iNPH condition, in which neurological symptoms suddenly worsened, requiring hospitalization, without any evident precipitating cause. Both patients tested positive for the COVID-19 virus shortly after the neurological impairment, which had occurred, therefore, during the incubation period of the infection.
On the basis of our experience we advise, in cases of NPH patients with sudden neurological worsening, to perform a molecular COVID-19 swab at the moment of clinical impairment. We, therefore, recommend considering SARS-CoV-2 infection in the differential diagnosis of a sudden and otherwise unexplainable impairment of hydrocephalic patients. Furthermore, we believe clinicians should invite NPH patients to adopt adequate preventive measures to protect them from SARS-CoV-2 infection.
... The involvement of the CNS is poorly understood however medical literature on this topic is rapidly expanding [7][8][9][10][11][12][13]. Along these lines, we present the case of a 48-year-old male who developed normal pressure hydrocephalus (NPH) shortly after a COVID-19 infection. As per our literature review, there has been only one other similar case report published about NPH associated with COVID-19 infection [14]. ...
... It may be primary (also called idiopathic) or secondary to other disease states such as subarachnoid hemorrhage, meningitis, intracranial neoplasm, brain surgery, or traumatic brain injury [21]. In our literature review, we only came across one other case report describing a similar case of NPH associated with COVID-19 infection [14]. This case by Zubair et al. had very similar presenting symptoms with resolution after drainage of CSF. ...
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 virus) has been reported to cause significant injury to the central nervous system (CNS). Herein, we describe the case of a 48-year-old male with a past medical history of attention-deficit/hyperactivity disorder (ADHD), hypertension, and hyperlipidemia who developed typical symptomatology of normal pressure hydrocephalus (NPH) with cognitive impairment, gait dysfunction, and urinary incontinence after a mild coronavirus disease (COVID-19) infection. The diagnosis was confirmed by imaging and lumbar puncture (LP). The patient was treated with a ventriculoperitoneal (VP) shunt placed by neurosurgery and had a complete recovery.
Despite increasing reports of neurological manifestations of COVID-19 infection, the mechanism of such pathology is still not well understood. Hypotheses include viral invasion of the CNS either through the nasopharynx and olfactory epithelium or directly through the blood brain barrier.
... Other common findings such as stroke, seizures and encephalopathy have also been reported [5]. There have been very few cases reported of hydrocephalus resulting from sequelae of COVID-19 after review of the literature, making this a very rare presentation [6]. We present an interesting case of COVID-19 in a 25-year-old woman presenting with severe hydrocephalus and acute stroke, with a look into the underlying mechanisms of the disease in hopes of forming a connection between recent infection and acute hydrocephalus. ...
Hydrocephalus is the accumulation of cerebrospinal fluid (CSF) in the cerebral ventricles and is considered an emergency in acute presentation. Hydrocephalus typically presents with symptoms of headache, nausea, vomiting, lethargy, vision changes and seizure; furthermore, narrowing down the underlying etiology of hydrocephalus can aid in treatment and management options. We present a rare case of a patient that presented with a recent diagnosis of COVID-19 and was found to have acute hydrocephalus and stroke. The aim of this case report is to explore the link between COVID-19 and the development of hydrocephalus and stroke by delineating the underlying pathophysiology of COVID-19 as well as the etiologies of hydrocephalus and possible management strategies. We hope to highlight the importance of keeping an open differential for presentations of headaches and also emphasize the potential complications of COVID-19 infection to help better patient outcomes.
... There is an ever-growing list of diseases allegedly associated with COVID-19, which includes esoteric case reports describing SARS-CoV-2 -varicella-zoster meningitis coinfection 36 , COVID-19-associated vestibulopathy 37 , nasopharyngeal swab-associated carotid-artery dissection with retinal ischemia 38 , normal pressure hydrocephalus 39 , cerebral vasculitis 40 , and many other rare neurological syndromes. This list even includes diseases with well-known pathophysiological mechanisms, such as neurodegenerative 41 , metabolic 42 , autoimmune 43 , and infectious 44 diseases. ...
Background:
The COVID-19 pandemic has challenged neurologists since its early days. Neurology consultation services were then overloaded by emergency department and intensive-care patients with acute neurological syndromes. These complications are better explained today, but the growing number of patients with reported longstanding neurological symptoms constitute an emerging, complex, and still poorly understood phenomenon.
Objective:
This review summarizes data on relevant neurological manifestations of acute SARS-CoV-2 infection and lasting post-infectious disease, also known as Long COVID. The complex history of Long COVID is examined to illustrate the upsides and challenges imposed by the active participation of patient communities in the production of medical knowledge.
Methods:
Narrative review.
Results:
Infection with the severe acute respiratory syndrome coronavirus 2 is associated with encephalopathy/delirium, cerebrovascular disease, headache, and peripheral nervous system involvement. Long COVID is a living concept jointly defined by patient communities, physicians and scientists, including neurologists.
Conclusion:
Co-production of Long COVID knowledge between scientists and patients has initiated an era of patient-led research and evidence-based activism that acts as a two-edged sword - putting patient's suffering in the spotlight, but with a tradeoff in methodological consistency.
... Recent studies have shown that the interaction of SARS-CoV-2 viral spike proteins with angiotensin-converting enzyme 2 receptors on the olfactory epithelium leads to potential transsynaptic retrograde transmission through the olfactory nerve into the CNS. [4][5][6] Similarly, an abundance of these receptors in the choroid plexus of the lateral ventricles could be another pathway. 4,5 This proposed interaction between the virus and the choroid plexus could potentially alter the CSF flow dynamics, resulting in an arachnoid web formation. ...
Objective
COVID 19 infection is suggested as one of the causes for hydrocephalus (HCP) of unknown etiology. COVID-19 infection may present with a range of neurologic symptoms given viral neurotropic and neuroinvasive properties. Post-infectious hydrocephalus is a severe complication as a potential sequela of COVID-19 infection.
Methods
We identified a patient with a history of recent COVID-19 infection who presented with chronic progressive headaches with nausea, vomiting, and blurry vision over two weeks.
Results
Neurological examination showed bilateral papilledema. Head CT scan showed tetraventricular enlargement and marked fourth ventricular dilation. Cine MRI showed fourth ventricular turbulent CSF flow. The patient underwent external ventricular drain (EVD) placement and exploratory suboccipital craniotomy, which revealed a sub-arachnoid web that was microsurgically resected. Reconstituted CSF flow resolved the patient's symptoms and prevented complications.
Discussion
Fourth ventricular outlet obstruction is a rare cause of tetraventricular hydrocephalus. In most cases, it is associated with a history of inflammatory conditions or hemorrhage. In our case, history of recent COVID-19 infection and normal imaging prior to COVID-19 make COVID-19 the most probable explanation for HCP. We suggest considering COVID-19 infection in the differential diagnosis of HCP of unclear etiology
Practical implication
A pearl of wisdom for the practicing clinician: “Consider COVID-19 as the cause of Hydrocephalus of unclear etiology”.
