COVID-19-related intracranial imaging findings: a large single-centre experience

Abstract

Aim To describe the neuroradiological changes in patients with coronavirus disease 2019 (COVID-19). Materials and methods A retrospective review was undertaken of 3,403 patients who were confirmed positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, and admitted to our institution between 1 March 2020 and 31 May 2020, and who underwent neuroimaging. Abnormal brain imaging was evaluated in detail and various imaging patterns on magnetic resonance imaging MRI were identified. Results Of the 3,403 patients with COVID-19, 167 (4.9%) had neurological signs or symptoms warranting neuroimaging. The most common indications were delirium (44/167, 26%), focal neurology (37/167, 22%), and altered consciousness (34/167, 20%). Neuroimaging showed abnormalities in 23% of patients, with MRI being abnormal in 20 patients and computed tomography (CT) in 18 patients. The most consistent neuroradiological finding was microhaemorrhage with a predilection for the splenium of the corpus callosum (12/20, 60%) followed by acute or subacute infarct (5/20, 25%), watershed white matter hyperintensities (4/20, 20%), and susceptibility changes on susceptibility-weighted imaging (SWI) in the superficial veins (3/20, 15%), acute haemorrhagic necrotising encephalopathy (2/20, 10%), large parenchymal haemorrhage (2/20, 10%), subarachnoid haemorrhage (1/20, 5%), hypoxic–ischaemic changes (1/20, 5%), and acute disseminated encephalomyelitis (ADEM)-like changes (1/20, 5%). Conclusion Various imaging patterns on MRI were observed including acute haemorrhagic necrotising encephalopathy, white matter hyperintensities, hypoxic-ischaemic changes, ADEM-like changes, and stroke. Microhaemorrhages were the most common findings. Prolonged hypoxaemia, consumption coagulopathy, and endothelial disruption are the likely pathological drivers and reflect disease severity in this patient cohort.

Hemorrhagic and ischemic stroke in patients with coronavirus disease 2019: incidence, risk factors, and pathogenesis - a systematic review and meta-analysis

“…All 18 studies were included in the meta-analysis to calculate the global prevalence of hemorrhagic stroke in COVID-19 patients and the frequency of symptoms leading to hospital admission 32 – 49 . Data from nine studies were included to calculate the mortality rate of hemorrhagic stroke in COVID-19 patients 32 , 33 , 35 – 37 , 40 , 45 , 48 , 49 , while the other nine studies did not report relevant data. The 18 studies and the prevalence of hemorrhagic stroke reported in each of them are summarized in Table 1 .…”

Etiologies of Delirium in Consecutive COVID-19 Inpatients and the Relationship Between Severity of Delirium and COVID-19 in a Prospective Study With Follow-Up

“…Delirium is an acute impairment of consciousness that affects all higher cerebral-cortical functions and is common in seriously medically ill patients, with reported incidence rates between 4% and 55% among patients in intensive care units (ICUs) (1). Increasingly recognized as commonly occurring during the COVID-19 pandemic (2), delirium has a higher prevalence than other conditions affecting the central nervous system (CNS) when compared with stroke, encephalitis, convulsions, or meningitis (3).…”

“…There are limited reports on delirium during the COVID-19 pandemic, mostly case reports (11)(12)(13) or retrospective studies (3,14), although one prospective study of two ICU cohorts in France reported a 79.5% incidence rate of delirium using the Confusion Assessment Method-ICU (CAM-ICU) (9). COVID-19 delirium often presents as the hyperactive motor subtype in up to 69% of patients (9,12), although the hypoactive subtype may be more common in the elderly (11,14).…”

“…EEGs have shown generalized slowing consistent with delirium (15). Neuroimaging has most often found microhemorrhage with a predilection for the splenium in 60% of patients, acute and subacute infarcts in 25%, and watershed white matter hyperintensities in 20% (3).…”

Non-aneurysmal subarachnoid haemorrhage in COVID-19—authors’ reply to Kawada T

“…We are grateful to Dr. Kawada for highlighting additional cases of non-aneurysmal subarachnoid haemorrhage (SAH) which have occurred in the context of severe coronavirus disease 2019 (COVID-19). Indeed, several additional case series have recently been published, including those with pathological findings [ 1 – 3 ], and we anticipate that additional cases of CNS haemorrhagic complications of COVID-19 infection will be reported in emerging registry data.…”