Susceptibility-weighted imaging reveals cerebral microvascular injury in severe COVID-19

Abstract

We evaluated the incidence, distribution, and histopathologic correlates of microvascular brain lesions in patients with severe COVID-19. Sixteen consecutive patients admitted to the intensive care unit with severe COVID-19 undergoing brain MRI for evaluation of coma or neurologic deficits were retrospectively identified. Eleven patients had punctate susceptibility-weighted imaging (SWI) lesions in the subcortical and deep white matter, eight patients had >10 SWI lesions, and four patients had lesions involving the corpus callosum. The distribution of SWI lesions was similar to that seen in patients with hypoxic respiratory failure, sepsis, and disseminated intravascular coagulation. Brain autopsy in one patient revealed that SWI lesions corresponded to widespread microvascular injury, characterized by perivascular and parenchymal petechial hemorrhages and microscopic ischemic lesions. Collectively, these radiologic and histopathologic findings add to growing evidence that patients with severe COVID-19 are at risk for multifocal microvascular hemorrhagic and ischemic lesions in the subcortical and deep white matter.

Personalized Approach to Patient with MRI Brain Changes after SARS-CoV-2 Infection

“…The lesions had a predilection site subcortically and in deep white matter. They also showed radiological–pathological correlates of these microlesions, which included red blood cell extravasation, ischemia, deficiency, but not loss of axons and myelin, and microglial response [ 19 ]. Our patients did not have lesions in the corpus callosum, which may be a sign of a bad clinical picture and a worse clinical outcome [ 16 , 19 ].…”

“…They also showed radiological–pathological correlates of these microlesions, which included red blood cell extravasation, ischemia, deficiency, but not loss of axons and myelin, and microglial response [ 19 ]. Our patients did not have lesions in the corpus callosum, which may be a sign of a bad clinical picture and a worse clinical outcome [ 16 , 19 ]. Significant consequences and pathological changes after infection remained on all organs, especially on the lung parenchyma [ 22 ].…”

“…The first inclusion criterion was the severity of the clinical picture. Patients were classified as mild, moderate or severe based on WHO criteria [ 19 , 20 ]. There were 249 patients with a mild clinical picture, 510 with a moderate clinical picture and 120 with a severe clinical picture.…”

Neurological update: COVID-19

“…Whilst these disorders of coagulation and endothelial integrity represent potential drivers of large vessel cerebrovascular disease, they also raise the possibility that impairment of the microvasculature might be involved in some of the less clear-cut neurological presentations, such as prolonged disorders of consciousness (including akinetic-mutism states) [63,[100][101][102], myoclonus (a relatively common complication with over 50 cases reported in the literature, which is seemingly unrelated to hypoxic ischaemic brain injury [103]), or even on the long-term cognitive outcomes of those who recover. Indeed, neuroimaging studies have commonly described cerebral microhaemorrhages occurring in those with severe COVID-19, reminiscent of microangiopathic disorders such as amyloid and hypertensive angiopathies [100,104,105], a phenomenon borne out in pathology series [32,75,100,106]. As would be expected in a disorder of the endothelium, similar microvascular changes have been described in multiple organ systems [107], and it has even been suggested that this process might be the cause of the mononeuritis multiplex seen in a substantial minority of survivors of severe COVID-19 [108].…”

Nervous System-Systemic Crosstalk in SARS-CoV-2/COVID-19: A Unique Dyshomeostasis Syndrome

“…It is increasingly evident that SARS-CoV-2 is not only neurotropic, but is associated with a much broader spectrum of acute and atypical neurological syndromes and manifestations than prior infections, particularly those involving β-coronaviruses (Bohmwald et al, 2018;Desforges et al, 2019;Ellul et al, 2020;Iadecola et al, 2020;Koralnik and Tyler, 2020;Paterson et al, 2020). Severe acute neurological events observed in COVID-19 have included ischemic stroke, intracranial hemorrhage, diffuse encephalopathy, encephalitis and neuromuscular disorders (Alquisiras-Burgos et al, 2020;Lee et al, 2020;MacLean et al, 2020;Conklin et al, 2021). Neurocognitive symptoms and dysfunction of various severities have also become increasingly recognized as potential consequences of SARS-CoV-2 infection (Levine et al, 2020;Graham et al, 2021;Taquet et al, 2021).…”