Magnetic resonance neurography findings in three critically ill COVID-19 patients with new onset of extremity peripheral neuropathy

Abstract

IntroductionCoronavirus-19 (COVID-19) is most commonly associated with respiratory syndromes, although patients are presenting more frequently with neurological symptoms. When they occur, neurological conditions most commonly involve the central nervous system, and peripheral nervous system effects, particularly in the extremities, have been less commonly described. The mechanisms of peripheral neuropathy in critically ill patients with COVID-19 are likely to be multifactorial, and extremity peripheral nerve imaging in these cases has not been well described.Case presentationIn this case series, we describe the magnetic resonance neurography (MRN) findings in 3 critically ill patients who presented with new onset of peripheral neuropathies in the extremities, and we discuss possible common mechanisms of nerve injury, including the role of position-related nerve injury.ConclusionsMRN can be useful in identifying and localizing peripheral nerve abnormalities in the extremities of COVID-19 patients, and patients who are placed in the prone position during ventilation may be more susceptible to these injuries.

Brachial plexopathy as a result of anatomical prone position in COVID‐19 patients—Systematic review

“…In every case examination evaluating the treatment was performed at least a month after diagnosis. In the last observation, we paid attention to the other complications of the prone position like right musculocutaneous nerve injury and left lumbosacral plexopathy (Brugliera et al, 2021), bilateral anterior ischemic optic neuropathy (Clarke et al, 2021), single musculocutaneous neuropathy on the other side (Mano & Fujimura, 2022), distal right radial neuropathy, and the rotator cuff muscle edema, but related to myopathy (Omar & Garg, 2021).…”

Musculoskeletal Manifestations of COVID-19: Currently Described Clinical Symptoms and Multimodality Imaging Findings

“…COVID-19–associated peripheral neuropathies are more commonly described in patients who are critically ill and require ventilation and have several possible causes, including GBS, toxic neuropathy, critical illness polyneuropathy (CIP), compressive neuropathy, and position-related neuropathy ( 51 ). While damage from direct viral infection was initially considered a possible mechanism, more recent evidence suggests other causes are likely, since viral particles are rarely recovered in PCR testing of the nerves and cerebrospinal fluid in most patients ( 52 ).…”

“…MRI is the best imaging modality to help assess GBS and is usually performed to exclude other possible causes, such as central nervous system insults. Lumbar spine MRI may show distal spinal cord hyperintensity at T2-weighted imaging and nerve root thickening of the cauda equina, with surface enhancement of these nerve roots as well as the conus medullaris ( 51 ) ( Fig 14 ). Occasionally, there can be leptomeningeal and spinal nerve root enhancement on brain MR images ( 56 ).…”

“…However, contrast material can help suppress vascular signal intensity, especially during isotropic three-dimensional short τ inversion-recovery (STIR) techniques, making the distinction between peripheral nerves and blood vessels clearer. There may also be associated muscle edema with fluid-sensitive sequences, and/or decreased muscle bulk and muscle fatty atrophy on T1-weighted non–fat-suppressed images corresponding to a peripheral nerve distribution ( 51 ) ( Fig 16 ).…”

“…Several medications specifically used in treating COVID-19, such as hydroxychloroquine and remdesivir, can result in toxic neuropathies, which are usually diagnosed clinically and aided by electrodiagnostic examinations rather than imaging examinations ( 51 ).…”