MEDICAL  ILLUSTRATION

Acute Cerebellar Strokes with Anoxic Brain Injury After a 
Cardiopulmonary Arrest in SARS-CoV-2 Patient

Tariq Janjua1, Luis R. Moscote-Salazar2

1 Intensive Care Department, Regions Hospital, Saint Paul, Minnesota, United States.
2 Cartagena Neurotrauma Research Group, University of Cartagena, Cartagena, Colombia.

Corresponding Author:
Luis Rafael Moscote-Salazar, MD. University of Cartagena, Cartagena de Indias, Colombia. email: mineurocirujano@
aol.com.

Figure 1. PA chest radiograph showing bilateral pulmonary 
infiltrates.

Figure 2. CT scan head showed diffuse low attenuation 
involving the bilateral basal ganglia, occipital lobes and 
cerebellar hemispheres.

Figure 3. CT scan head showed diffuse low attenuation 
involving the bilateral basal ganglia, occipital lobes and 
cerebellar hemispheres.

Figure 4. CT scan head showed diffuse low attenuation 
involving the bilateral basal ganglia, occipital lobes and 
cerebellar hemispheres.

177Acta Med Indones - Indones J Intern Med • Vol 52 • Number 2 • April 2020



Tariq Janjua                                                                                                                      Acta Med Indones-Indones J Intern Med

Neurological complications from novel 
coronavirus is becoming more common.1,2 
These patients usually have primary pulmonary 
problem of acute lung injury. Presentation in 
the form of encephalitis, meningitis, Guillain-
Barre syndrome and seizures are noted. It is 
also noted that SARS-CoV-2 has predilection 
for brain stem leading to patient not feeling 
extensive pulmonary injury. Here we share 
another neurological presentation.

A 65-year-old women of a history diabetes, 
active SARS-CoV-2 infection and mild dementia. 
She was at her home in quarantined state. 
Emergency services were called for unresponsive 
state. On arrival patient was apneic and in cardiac 
arrest. It took 10 minutes for ROSC after CPR 
and multiple doses of epinephrine. She was 
intubated in the emergency department. Her GCS 
was 3T at this that stage. Investigations showed 
lactic acidosis, profound hypoxemia and bilateral 
pulmonary infiltrates. (Figure 1)  CT scan 
head showed diffuse low attenuation involving 
the bilateral basal ganglia, occipital lobes and 
cerebellar hemispheres concerning for diffuse 
anoxic injury probably related to posterior 
circulation limitation. There was no early 
cerebral edema. (Figure 2-4) She had no cough, 
gag and conjunctival reflexes. The pupillary 
light reflex was absent with fixed 2 mm pupils 
bilateral. With pupillometry there was minimal 
response with intact Neurological Pupil index™ 
(Neuroptics NPI -200 Pupillometer, Laguna 
Hills, CA). There was no breath triggering in 
spontaneous mode trial even with serum lactate 
of 11.7 mmol/l (0.5-2.0 mmol/l). MRI was not 
possible due to hemodynamic instability. Based 
upon presentation, severe brain injury and severe 
SARS-CoV-2 pulmonary involvement, patient 
was made comfort care.

This patient was thought to have secondary 
cardiac arrest from severe pulmonary disease. It 
is known that patient donot sense the impending 
worsening with SARS-CoV-2 progressive 
disease. Since the onset of this pandemic, multiple 
reports have demonstrated neuroinvasion by 
human respiratory coronaviruses. SARS-CoV-2 
facilitates the formation of venous and arterial 
thromboembolic events through multiple 
associated pathophysiological mechanisms. 
The presence of inflammatory hyper-response, 
hypoxia, and disseminated intravascular 
coagulation create the necessary conditions for 
the development of stroke. Subclinical hypoxia 
has been reported as an event that is part of 
the initial phases, including asymptomatic.3 
Hypercoagubility could be the substrate for 
ischemic cerebrovascular events, and very 
high numbers of ischemic phenomena have 
been reported in critically ill SARS-CoV-2 
patients of up to 31%.4 The evolution of rapid 
cerebellar infarction with sudden death forcing 
to investigate the characteristics of the invasion 
of the coronavirus in the brain stem, especially 
in the centers that control breathing. This opens 
a new alert scenario for patients diagnosed with 
coronavirus infection.

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