• Fadi Al Saiegh, Ritam Ghosh, Adam Leibold, Michael B Avery, Richard F Schmidt, Thana Theofanis, Nikolaos Mouchtouris, Lucas Philipp, Stephen C Peiper, Zi-Xuan Wang, Fred Rincon, Stavropoula I Tjoumakaris, Pascal Jabbour, Robert H Rosenwasser, and M Reid Gooch.
• Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
• J. Neurol. Neurosurg. Psychiatr. 2020 Aug 1; 91 (8): 846-848.

BackgroundEmergence of the novel corona virus (severe acute respiratory syndrome (SARS)-CoV-2) in December 2019 has led to the COVID-19 pandemic. The extent of COVID-19 involvement in the central nervous system is not well established, and the presence or the absence of SARS-CoV-2 particles in the cerebrospinal fluid (CSF) is a topic of debate.Case DescriptionWe present two patients with COVID-19 and concurrent neurological symptoms. Our first patient is a 31-year-old man who had flu-like symptoms due to COVID-19 and later developed an acute-onset severe headache and loss of consciousness and was diagnosed with a Hunt and Hess grade 3 subarachnoid haemorrhage from a ruptured aneurysm. Our second patient is a 62-year-old woman who had an ischaemic stroke with massive haemorrhagic conversion requiring a decompressive hemicraniectomy. Both patients' CSF was repeatedly negative on real-time PCR analysis despite concurrent neurological disease.ConclusionOur report shows that patients' CSF may be devoid of viral particles even when they test positive for COVID-19 on a nasal swab. Whether SARS-CoV-2 is present in CSF may depend on the systemic disease severity and the degree of the virus' nervous tissue tropism and should be examined in future studies.© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.

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