Covid in the brain: rare case of covid associated amyloid beta related angiitis leading to hemorrhagic stroke

Case Diagnosis: 72-year-old female with Covid associated Amyloid-Beta-Related-angiitis (ARBA) Case Description: 72-year-old female with recent Covid presented with headache, right-sidedhemiparesis, non-fluent-aphasia, and altered-mentalstatus. Patient was diagnosed with left parietotemporal intracranial-hemorrhage (ICH) status-post craniotomy. Surgical pathology confirmed ARBA. Patient was given intravenous methylprednisolone for five days and transitioned to long-term daily oral prednisone. Setting: Acute Inpatient Standalone Rehabilitation Hospital Assessment/Results: At week five poststroke, repeat computed-tomography-scan showed no reoccurrence of ICH or new infarct. Patient continued daily prednisone treatment as recommended by neurologist. With therapy, patient quickly regained all functional strength of right-sided-hemiparesis. However, progress with speech and cognition was slow, requiring additional outpatient therapy. Discussion: ABRA, first described in 2005, is a very rare inflammatory disorder that destroys central-nervous- system (CNS) arteries and subsequent brain parenchyma. It is pathologically characterized by amyloid-beta (Aβ)-deposition in the cerebral vasculature walls with perivascular lymphocytic infiltrates and surrounding granulomatous inflammation. Pathogenesis is not fully understood. However, favorable response to steroids and immunosuppressive therapy, including clinical improvement and decreased relapse, supports an autoimmune mediated response against amyloid-beta deposited CNS vessel walls. Although SARS-COV-2 is primarily known for respiratory presentation, diverse neurological presentations correlated with SARS-COV-2 are well-documented. This case uniquely shows SARS-COV-2 associated ABRA. Research shows hypoxic and pro-inflammatory state caused by Covid leads to accelerated Aβ-amyloid accumulation in intracranial vasculature walls through dysregulation of Aβ-amyloid synthesis and clearance. Furthermore, data shows increased new onset and exacerbation of preexisting autoimmune diseases in Covid-19 patients. SARS-Cov-2 initiate hyperstimulated state of immune system, leading to synthesis of autoantibodies. In this case, SARS-Cov-2 hyperstimulated immune response could have triggered novel ABRA or exacerbated preexisting ABRA, leading to hemorrhagic stroke. Conclusion: ABRA is very rare CNS disease, however, with Covid-19 pandemic, the prevalence of ABRA might increase. ARBA should be consider early as part of differential in patients with history of Covid-19. Initiating appropriate treatment quickly could prevent poor outcomes and reoccurrence.