Background and aims
Cerebral amyloid angiopathy (CAA) is characterized by microangiopathy with increased susceptibility to hemorrhages. Some patients may develop an inflammatory form presenting with focal deficits, seizures and alterations of vigilance (CAA-related inflammation episodes-CAA-ri). To report on clinical and biological findings of a case of CAA-ri after COVID-19 Tozinameran vaccination.
Methods
CSF exam and brain MRI were done.
Results
A 77 year-old male with recent brain hemorrhage in an established probable CAA presented to ER for fever and confessional state 14 days after Tozinameran first dose vaccination. Neurological examination found the patient alert, confused, with hypertonia and action tremor but no meningeal signs. Blood investigations revealed inflammation without microbiological findings. CSF study showed increased proteins, lymphocytic pleocytosis (122 cells/uL) and mirror pattern. CSF Beta42 amyloid level was reduced (158 ng/L), t-Tau level increased. ApoE haplotype resulted E3/E4. The patient had refractory convulsive status epilepticus. MRI confirmed known subacute occipital hemorrhage, multiple microbleeds and occipito-parietal and frontal white matter vasogenic oedema. After a diagnosis of probable CAA-ri, high dose steroid therapy was started followed by clinical improvement and CSF normalization. Anti SARS CoV 2 antibodies were found in serum and CSF before and after steroid therapy.
Conclusions
Following Tozinameran vaccine, a patient with probable CAA developed a systemic inflammation with neuroimaging signs of CAA-ri and persisting positive CSF anti-spike protein antibodies. We suggest that systemic inflammation evoked by anti-COVID vaccination may have induced CAA-ri in a patient with sub acute intracerebral hemorrhage. Cross-reaction of anti-spike antibodies with endothelial antigens in amyloid microangiopathy should be further studied.
