Cerebral Microbleeds and Leukoencephalopathy in Critically Ill Patients With COVID-19

Abstract

Background and Purpose: We conducted this study to investigate the prevalence and distribution of cerebral microbleeds and leukoencephalopathy in hospitalized patients with coronavirus disease 2019 (COVID-19) and correlate with clinical, laboratory, and functional outcomes. Methods: We performed a retrospective chart review of 4131 COVID-19 positive adult patients who were admitted to 3 tertiary care hospitals of an academic medical center at the epicenter of the COVID-19 pandemic in New York City from March 1, 2020, to May 10, 2020, to identify patients who had magnetic resonance imaging (MRI) of the brain. We evaluated the MRIs in detail, and identified a subset of patients with leukoencephalopathy and/or cerebral microbleeds. We compared clinical, laboratory, and functional outcomes for these patients to patients who had a brain MRI that did not show these findings. Results: Of 115 patients who had an MRI of the brain performed, 35 (30.4%) patients had leukoencephalopathy and/or cerebral microbleeds. Patients with leukoencephalopathy and/or cerebral microbleeds had neuroimaging performed later during the hospitalization course (27 versus 10.6 days; P <0.001), were clinically sicker at the time of brain MRI (median GCS 6 versus 14; P <0.001), and had higher peak D-dimer levels (8018±6677 versus 3183±3482; P <0.001), lower nadir platelet count (116.9±62.2 versus 158.3±76.2; P =0.03), higher peak international normalized ratio (2.2 versus 1.57; P <0.001) values when compared with patients who had a brain MRI that did not show these findings. They required longer ventilator support (34.6 versus 9.1 days; P <0.001) and were more likely to have moderate and severe acute respiratory distress syndrome score (88.6% versus 23.8%, P <0.001). These patients had longer hospitalizations (42.1 versus 20.9 days; P <0.001), overall worse functional status on discharge (mRS 5 versus 4; P =0.001), and higher mortality (20% versus 9%; P =0.144). Conclusions: The presence of leukoencephalopathy and/or cerebral microbleeds is associated with a critical illness, increased mortality, and worse functional outcome in patients with COVID-19.

Serial Imaging of Virus-Associated Necrotizing Disseminated Acute Leukoencephalopathy (VANDAL) in COVID-19

“…26,46 In the population of critically ill patients with COVID-19, neuroimaging findings of diffuse leukoencephalopathy may be seen in conjunction with microhemorrhages, as is seen in some of our patients. 7,10,11,47 The appearance of cotton wool spots and microhemorrhages on fundus examinations further suggests pathologic and ophthalmologic evidence of thrombotic microangiopathy in patients with COVID-19. 48 Thus, endothelial dysfunction, cytokine storming, and thrombotic microangiopathy may contribute to the development of the acute disseminated leukoencephalopathy seen in patients with severe COVID-19 described herein.…”

“…[1][2][3][4][5] Although the current literature is limited regarding neuroimaging findings in patients with COVID-19, [6][7][8] there have been recent reports of critically ill patients with leukoencephalopathy with or without cerebral microhemorrhages. [9][10][11][12][13][14] Different radiologic patterns of white matter (WM) injury have been described in critically ill patients with viral infections, including diffuse leukoencephalopathy with microhemorrhages, acute disseminated encephalomyelitis (ADEM), and posterior reversible encephalopathy syndrome (PRES). 11,[15][16][17][18][19][20] Due to a paucity of neuropathologic data, the pathophysiologic processes responsible for these imaging characteristics are not completely understood.…”

Studying the neuropsychological sequelae of SARS-CoV-2: lessons learned from 35 years of neuroHIV research

“…This notion is supported by the findings of a retrospective study of COVID-19 patients seen in New York City. In that study, p a t i e n t s w h o h a d a b r a i n M R I w i t h e v i d e n c e leukoencephalopathy and/or cerebral microbleeds had high peak D-dimer levels and lower nadir platelet counts compared with those who did not have findings of such pathology (Agarwal et al 2020). Those patients who develop acute respiratory distress syndrome (ARDS) are at risk of cerebral hypoxemia (Hopkins et al 2006).…”

Effects of Antimalarial Drugs on Neuroinflammation-Potential Use for Treatment of COVID-19-Related Neurologic Complications

“…This can lead to symmetric thalamic encephalitis as well as similar symmetric lesions in other brain regions [45]. Cerebral microbleeds and leukoencephalopathy have also been detected in critically ill patients with COVID-19 [46]. It is likely that the paucity of brain imaging studies being performed in critically ill COVID-19 patients may be an important factor in the lack of wider recognition of such complications.…”