We eagerly read the article by Poisson et al. about a SARS-CoV-2 positive 8yo female, who was diagnosed with cerebral vasculitis upon two brain biopsies [1]. Since IgM antibodies against SARS-CoV-2 were positive in the cerebro-spinal fluid (CSF), vasculitis was attributed to COVID-19 [1]. The study is appealing but raises concerns which require discussion. The condition presented in the case report could be also interpreted as acute, haemorrhagic, necrotising encephalitis (AHNE). This condition has been recently described in an adult patient with tuberculosis and COVID-19 [2]. Thus, it is crucial that cerebral tuberculosis had been excluded by culture, immune-histology, and PCR in the CSF and the brain tissue at autopsy. Cerebral tuberculosis is accompanied by cerebral vasculitis in a quarter of the cases [3]. Unfortunately, only serum antibodies against mycobacterium tuberculosis had been determined in the index patient. Missing are the results of conventional digital subtraction angiography (DSA), computed tomography angiography (CTA), or magnetic resonance angiography (MRA) to confirm the histological diagnosis. Vascular imaging may not only help to confirm the histological diagnosis but also to delineate between vasculitis of large, medium-sized, or small arteries. 

We do not agree with the notion that neuro-COVID only includes stroke, venous sinus thrombosis (VST), seizures, meningitis, encephalitis, ADEM, acute fulminant cerebral edema, posterior reversible encephalopathy syndrome (PRES), headache, myelitis, Guillain-Barre syndrome (GBS), cranial neuropathies, and myositis. The spectrum of neuro-COVID is much broader and additionally includes reversible cerebral vasoconstriction syndrome (RCVS), acute, haemorrhagic, necrotising encephalitis (AHNE), hypophysitis, cerebellitis, myoclonus syndrome, immune encephalitis, multiple sclerosis, neuromyelitis optica spectrum disorder, ventriculitis, pontine myelinolysis, subarachnoid bleeding, Wernicke encephalopathy, insomnia, psychosis, myasthenia, and myasthenic syndrome.

Overall, the elegant study has limitations which challenge the results and their interpretation. Cerebral tuberculosis should be excluded by appropriate means.