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This is a pre-copyedited, author-produced version of an article accepted for publication in Neurosurgery following peer review. The version of record Sweid A, Hammoud B, Weinberg JH, Oneissi M, Raz E, Shapiro M, DePrince M, Tjoumakaris S, Gooch MR, Herial NA, Zarzour H, Romo V, Rosenwasser RH, Jabbour P. Letter: Thrombotic Neurovascular Disease in COVID-19 Patients. Neurosurgery. 2020 Sep 1;87(3):E400-E406 is available online at:


Although the respiratory system is the primary target of the coronavirus, studies have demonstrated a strong tropism to the central nervous system (CNS).1,2 The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infects cells by binding to the angiotensin-converting enzyme 2 (ACE2) receptor. This receptor is also found in the CNS and plays a crucial role in autoregulating cerebral perfusion pressure.3,4 Additionally, epidemiological data demonstrated increased mortality due to cardiovascular and cerebrovascular diseases during flu pandemics due to a hypercoagulable state.5,6 The triad of neuroinvasion of SARS-CoV-2, induction of hypercoagulable state,5-9 and the inhibition of ACE2 blocking the formation of Angiotensin (1-7) serve as the pathophysiology for neurovascular insults.3,4 We present a case series of coronavirus disease 2019 (COVID-19) patients from 2 health systems developing cerebrovascular insult.

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