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MRI images showing symmetrical white matter signal change. (a) T2W, (b) FLAIR, (c) DWI, and (d) ADC images show white matter hyperintensities in the deep watershed territory bilaterally in the posterior frontal lobes, giving an ADEM-like appearance. (e) SWI image shows small foci of blooming within these lesions indicating microhaemorrhages. In addition, there are subcortical white matter changes in the left occipital lobe with parenchymal haemorrhage on (f) T2W, (g) FLAIR, and (h) SWI images.
Source publication
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 Queen Elizabeth Hospital Birmingham, University...
Context in source publication
Context 1
... changes were seen in one patient who was slow to regain consciousness and had a background of diabetes and hypertension. MRI demonstrated bilateral symmetrical white matter hyperintensities with microhaemorrhages in the posterior frontal lobes (Fig 5). Subcortical white matter changes were also present in the left occipital lobe with parenchymal haemorrhage. ...
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Background
Measures taking aim at minimizing the risk of coronavirus transmission and fear of infection may affect decisions to seek care for other medical emergency conditions. The purpose of this analysis was to analyze intermediate-term effects of the COVID-19 pandemic on neuroradiological emergency consultations (NECs).
Methods
We conducted an...
Citations
... Signal and diffusion abnormalities are extended predominantly to the corpus callosum, cingulate cortex, and insula, jointly implicating the olfactory brain network [2,9]. Sawlani et al. also reported white matter abnormalities especially involving the splenium of the corpus callosum and brainstem in COVID-19 patients with a range of medical and neurological comorbidities [10]. ...
... Although many MRI studies report signal abnormalities on MR images in the corpus callosum [2,9,10], to our knowledge, no MRS study evaluating metabolic changes in the splenium of the corpus callosum (CCS) has been performed yet. The corpus callosum forms a bridge between the cerebral hemispheres, containing crossing axonal fibers from both hemispheres [22]. ...
... The majority of studies dealing with patients after suffering from COVID-19 with neuropsychiatric symptoms commonly report microstructural changes in the brain, predominantly in the corpus callosum (anterior part as well as splenium), manifesting as signal and diffusion abnormalities [2,7,9,10]. Although the changes in the microstructure may also imply metabolic abnormalities, to our knowledge, to-date, metabolism using MRS has been studied only in the anterior cingulate cortex, frontal WM, and COVID-19-related lesions visible on MRI [12, 14, 19-21, 30, 31]. ...
Objective
Many patients with long COVID experience neurological and psychological symptoms. Signal abnormalities on MR images in the corpus callosum have been reported. Knowledge about the metabolic profile in the splenium of the corpus callosum (CCS) may contribute to a better understanding of the pathophysiology of long COVID.
Materials and methods
Eighty-one subjects underwent proton MR spectroscopy examination. The metabolic concentrations of total N-acetylaspartate (NAA), choline-containing compounds (Cho), total creatine (Cr), myo-inositol (mI), and NAA/Cho in the CCS were statistically compared in the group of patients containing 58 subjects with positive IgG COVID-19 antibodies or positive SARS-CoV-2 qPCR test at least two months before the MR and the group of healthy controls containing 23 subjects with negative IgG antibodies.
Results
An age-dependent effect of SARS-CoV-2 on Cho concentrations in the CCS has been observed. Considering the subjective threshold of age = 40 years, older patients showed significantly increased Cho concentrations in the CCS than older healthy controls ( p = 0.02). NAA, Cr, and mI were unchanged. All metabolite concentrations in the CCS of younger post-COVID-19 patients remained unaffected by SARS-CoV-2. Cho did not show any difference between symptomatic and asymptomatic patients ( p = 0.91).
Discussion
Our results suggest that SARS-CoV-2 disproportionately increases Cho concentration in the CCS among older post-COVID-19 patients compared to younger ones. The observed changes in Cho may be related to the microstructural reorganization in the CCS also reported in diffusion measurements rather than increased membrane turnover. These changes do not seem to be related to neuropsychological problems of the post-COVID-19 patients. Further metabolic studies are recommended to confirm these observations.
... Other less common findings include hypoxic anoxic brain injury, encephalitis, acute disseminated encephalomyelitis (ADEM), leukoencephalopathy, transient perivascular inflammation of the carotid artery syndrome (TIPIC), and posterior reversible encephalopathy syndrome (PRES). [6][7][8]44,53,57,58 The ICH group had the highest mortality rate, 7,44 followed by patients with leukoencephalopathy and IS, whereas patients with microhemorrhages or encephalitis as sole neuroimaging findings had the lowest mortality rates. 7 Patients in intensive care unit (ICU) had significantly higher incidences of cerebral microhemorrhages and encephalitis/encephalopathy. ...
Background Coronavirus disease 2019 (COVID-19) has emerged as a public health emergency worldwide, predominantly affecting the respiratory tract. However, evidence supports the involvement of extrapulmonary sites, including reports of intracranial hemorrhages.
Objective To describe six original cases and review the literature on intracranial hemorrhages in patients diagnosed with COVID-19 by molecular methods.
Methods A systematic literature review was performed on MEDLINE, PubMed, and NCBI electronic databases to identify eligible studies. Of the total 1,624 articles retrieved, only 53 articles met the inclusion criteria.
Results The overall incidence of intracranial hemorrhage in patients hospitalized for COVID-19 was 0.26%. In this patient group, the mean age was 60 years, and the majority were male (68%) with initial respiratory symptoms (73%) and some comorbidity. Before the diagnosis of hemorrhage, 43% of patients were using anticoagulants, 47.3% at therapeutic doses. The intraparenchymal (50%) was the most affected compartment, followed by the subarachnoid (34%), intraventricular (11%), and subdural (7%). There was a predominance of lobar over non-lobar topographies. Multifocal or multicompartmental hemorrhages were described in 25% of cases. Overall mortality in the cohort studies was 44%, while around 55% of patients were discharged from hospital.
Conclusion Despite the unusual association, the combination of these two diseases is associated with high rates of mortality and morbidity, as well as more severe clinicoradiological presentations. Further studies are needed to provide robust evidence on the exact pathophysiology behind the occurrence of intracranial hemorrhages after COVID-19 infection.
... Although some COVID-19 patients may suffer from hypercoagulability due to some, as yet, unknown mechanism, the incidence of ischemic stroke in COVID-19 patients is only about 2-3%, and most of these patients have conventional vascular risk factors, and mechanism of ischemic injury. [8][9] Finally, the timeline of the development of a beaded pattern of IWI on radiographs four days post-admission, followed by the identification of a "cigar-shaped" IWI at autopsy nearly a month later, is supportive of the "rosary-like" pattern of IWI progressing to a confluent pattern over twenty-two days. ...
Internal watershed infarcts (IWIs) occur at the junction of the deep and superficial perforating arterial branches of the cerebrum. Despite documentation in the radiology literature, IWIs are rarely encountered at the time of autopsy. Here, we report the case of a 59-year-old incarcerated male who was brought to the emergency department after being found unresponsive on the floor of his jail cell. Initial examination and imaging demonstrated right-sided hemiplegia, aphasia, right facial droop, and severe stenosis of the left middle cerebral artery, respectively. Repeat imaging 4 days after admission and 26 days before death demonstrated advanced stenosis of the intracranial, communicating segment of the right internal carotid artery, a large acute infarct in the right posterior cerebral artery territory, and bilateral deep white matter ischemic changes with a right-sided “rosary-like” pattern of injury that is typical of IWIs. Postmortem gross examination showed that the right deep white matter lesion had progressed to a confluent, “cigar-shaped” subacute IWI involving the right corona radiata. This is the first well-documented case of an IWI with radiologic imaging and photographic gross pathology correlation. This case uniquely highlights a rarely encountered lesion at the time of autopsy and provides an excellent visual representation of internal watershed neuroanatomy.
Keywords
Internal watershed; infarction; autopsy; neuropathology
... 10 Few studies evaluated watershed infarction in patients with COVID-19. 11,12 No explicit agreement has been established on the frequency of watershed infarction in COVID-19-related stroke, mainly due to the discrepancies in imaging indications and management (e.g., patients with subtle neurologic symptoms typically do not undergo brain imaging worldwide). 8,9,13 This study aimed to evaluate the clinical and imaging characteristics of a cohort of COVID-19 patients with stroke and also identify patients with watershed infarcts. ...
... Reasons for differences between subtypes of stroke in our patients with COVID-19 and previous studies before COVID-19 pandemic are as follows: 1) high percentage of critically ill patients with unstable status and patients' death before completion of stroke workup, 2) because of patients' fear of being hospitalized in COVID center, 2 patients left the hospital with personal consent before any stroke workup, 3) slight manifestations of small vessel acute ischemic stroke (AIS) and patients' fear of going to COVID center could be stated as a reason for unexpected low percentage of small vessel AIS, and 4) most cases with watershed infarction (12/17) did not have any etiology, which could be related to short-term heart monitoring and incomplete vessel study. Apart from the expected etiology of ischemic stroke that impairs blood flow in large vessels, some authors have described a pattern of watershed white matter hyperintensities in patients with COVID-19, 11,12 which has also been found in this study in a large proportion. Sawlani et al. found that watershed white matter hyperintensities occurred in 20% of patients with COVID-19 with neurological manifestations, mainly in the deep white matter, the corpus callosum, and the cerebellar white matter. ...
... Sawlani et al. found that watershed white matter hyperintensities occurred in 20% of patients with COVID-19 with neurological manifestations, mainly in the deep white matter, the corpus callosum, and the cerebellar white matter. 11 Similarly, Katz et al. postulated that patients with severe COVID-19 had a higher prevalence of multivascular territory infarction, including a watershed pattern and hemorrhagic transformation. 12 In our study, we found that patients with a medical history of CKD were more prone to stroke with watershed patterns. ...
Background: Cerebrovascular diseases comprise a significant portion of neurological disorders related to coronavirus disease 2019 (COVID-19). We evaluated the clinical and imaging characteristics of a cohort of COVID-19 patients with stroke and also identified patients with watershed infarcts.
Methods: In this cross-sectional study, seventy-three COVID-19 patients with ischemic stroke were included between October 2020 and January 2021. Patients were evaluated based on the following clinical and imaging features: severity of COVID-19 (critical/ non-critical), stroke type, presence/absence of clinical suspicion of stroke, medical risk factors, Fazekas scale, atherothrombosis, small vessel disease, cardiac pathology, other causes, and dissection (ASCOD) criteria classification, and presence or absence of watershed infarction. Clinical outcomes were assessed based on Modified Rankin Scale (MRS) and mortality.
Results: Most cases of ischemic stroke were due to undetermined etiology (52.1%) and cardioembolism (32.9%). In terms of imaging pattern, 17 (23.0%) patients had watershed infarction. Watershed infarction was associated with the clinically non-suspicious category [odds ratio (OR) = 4.67, P = 0.007] and death after discharge (OR = 7.1, P = 0.003).
Patients with watershed infarction had a higher odds of having high Fazekas score (OR = 5.17, P = 0.007) which was also shown by the logistic regression model (adjusted OR = 6.87, P = 0.030). Thirty-one (42%) patients were clinically non-suspected for ischemic stroke. Critical COVID-19 was more common among patients with watershed infarct and clinically non-suspicious patients (P = 0.020 and P = 0.005, respectively). Patients with chronic kidney disease (CKD) were more prone to having stroke with watershed pattern (P = 0.020).
Conclusion: Watershed infarct is one of the most common patterns of ischemic stroke in patients with COVID-19, for which clinicians should maintain a high index of suspicion in patients with critical COVID-19 without obvious clinical symptoms of stroke.
... 4/26 COVID-19 positive patients had diffuse and or multifocal WMH with underlying MB and COVID-19 negative ARDS group did not have any patients with this presentation. Multiple observational studies solidified the findings in case reports and series, reporting small vessel infarctions, WMH, and MB in COVID-19 patients (Conklin et al., 2021;Dixon et al., 2020;Fällmar et al., 2022;Kremer et al., 2020;Lin et al., 2020;Sawlani et al., 2021;Shahjouei et al., 2021;Taylor et al., 2020;Uginet et al., 2022). ...
Cerebral small vessel disease (CSVD) is the leading cause of vascular cognitive impairment and is associated with COVID-19. However, contributing factors that often accompany CSVD pathology in COVID-19 patients may influence the incidence of cerebrovascular complications. Thus, a mechanism linking COVID-19 and CSVD has yet to be uncovered and differentiated from age-related comorbidities (i.e., hypertension), and medical interventions during acute infection. We aimed to evaluate CSVD in acute and recovered COVID-19 patients and to differentiate COVID-19-related cerebrovascular pathology from the above-mentioned contributing factors by assessing the localization of microbleeds and ischemic lesions/infarctions in the cerebrum, cerebellum, and brainstem. A systematic search was performed in December 2022 on PubMed, Web of Science, and Embase using a pre-established search criterion related to history of, or active COVID-19 with CSVD pathology in adults. From a pool of 161 studies, 59 met eligibility criteria and were included. Microbleeds and ischemic lesions had a strong predilection for the corpus callosum and subcortical/deep white matter in COVID-19 patients, suggesting a distinct CSVD pathology. These findings have important implications for clinical practice and biomedical research as COVID-19 may independently, and through exacerbation of age-related mechanisms, contribute to increased incidence of CSVD.
... There was no difference between the groups and 28 of the 31 patients, or 90%, experienced ARDS [58]. [59]. ...
Objective:
Magnetic resonance imaging (MRI) of the brain or spine examines the findings as well as the time interval between the onset of symptoms and other adverse effects in coronavirus disease that first appeared in 2019 (COVID-19) patients. The goal of this study is to look at studies that use neuroimaging to look at neurological and neuroradiological symptoms in COVID-19 patients.
Methods:
We try to put together all of the research on how severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes neurological symptoms and cognitive-behavioral changes and give a full picture.
Results:
We have categorized neuroimaging findings into subtitles such as: headache and dizziness; cerebrovascular complications after stroke; Intracerebral Hemorrhage (ICH); Cerebral Microbleeds (CMBs); encephalopathy; meningitis; encephalitis and myelitis; altered mental status (AMS) and delirium; seizure; neuropsychiatric symptoms; Guillain-Barre Syndrome (GBS) and its variants; smell and taste disorders; peripheral neuropathy; Mild Cognitive Impairment (MCI); and myopathy and myositis.
Conclusion:
In this review study, we talked about some MRI findings that show how COVID-19 affects the nervous system based on what we found.
... Acute COVID-19 manifestations such as pain in muscles, vertigo, headaches, and disorders of concentration may have a neurological cause and continue after the acute period (13,14). Furthermore, small emboli in cerebrum (15,16), blood-brain barrier (BBB) failure (17,18), inflammatory reactions in CNS (19) resulting in coagulopathy, and hospital admission initiators (e.g., mechanical ventilation and sedatives) may all have a role in long-term neurological issues (19,20). ...
Post COVID-19 syndrome is determined as signs and symptoms that appear during or after an infection consistent with SARS-CoV-2 disease, persist for more than 12 weeks and are not explained by an alternative diagnosis. This review presents the neuropathological findings and imaging findings in Post COVID-19 Neurological Syndrome: the focal point is on the manifestations of involvement evident on brain and spine imaging.
... Acute COVID-19 manifestations such as pain in muscles, vertigo, headaches, and disorders of concentration may have a neurological cause and continue after the acute period (13,14). Furthermore, small emboli in cerebrum (15,16), blood-brain barrier (BBB) failure (17,18), inflammatory reactions in CNS (19) resulting in coagulopathy, and hospital admission initiators (e.g., mechanical ventilation and sedatives) may all have a role in long-term neurological issues (19,20). ...
Post COVID-19 syndrome is determined as signs and symptoms that appear during or after an infection consistent with SARS-CoV-2 disease, persist for more than 12 weeks and are not explained by an alternative diagnosis. This review presents the neuropathological findings and imaging findings in Post COVID-19 Neurological Syndrome: the focal point is on the manifestations of involvement evident on brain and spine imaging.
... However, whether parainfectious, autoimmune-mediated processes such as ADEM or its hyperacute form AHLE can sincerely be attributed to COVID-19 remains debatable. One source of contention is the scarcity of neuropathological descriptions of ADEM and AHLE, despite the fact that a few clinical and imaging case studies of COVID-19 patients have revealed lesions characterization of ADEM or AHLE [54][55][56][57]. Only a few case reports with ADEM and AHLE neuropathological features in adult deaths from COVID-19 complications have been published so far. ...
Acute hemorrhagic leukoencephalitis (AHLE), also called Hurst disease, is a rare demyelinating disease of the central nervous system (CNS) marked by rapid progression and acute inflammation of the white matter. Due to the correlation in their suspected postinfectious autoimmune pathogenesis, it is regarded as the most severe form of acute disseminated encephalomyelitis (ADEM). Because this clinical scenario has a high mortality rate, aggressive and immediate treatment is required. Although the exact cause of AHLE is unknown, it usually occurs after a bacterial or viral infection, or, less frequently, after a measles or rabies vaccination. AHLE has been reported in patients with coronavirus disease 2019 (COVID-19) as a rare but serious neurological complication. However, due to the lack of evidence-based diagnostic criteria, diagnosis is difficult. The small number of cases described in the literature, which most likely reflects underreporting and/or low incidence, necessitates greater public awareness. Increased clinical suspicion and early imaging identification of this entity may allow clinicians to pursue more aggressive treatment options, potentially reducing fatal outcomes. This study focuses on symptoms and causes of AHLE, difference between AHLE and ADME, diagnosis and treatment of AHLE, and its link with COVID-19.
... Apart from the involvement of basal ganglia, bilateral hypoxic-ischemic lesions, manifesting as foci of restricted diffusion, were found within cerebral peduncles and tails of the hippocampi. Necrotic changes of the nigrostriatal tract were visible in some patients as well, and T2/FLAIR hyperintensities were detected within dentate nuclei and thalami [48]. ...
Since the very beginning of the COVID-19 pandemic, numerous researchers have made an effort to determine the molecular composition of the SARS-CoV-2 virus, and the exact pathomechanism through which the virus exerts such a devastating effect on the host/infected organism. Recent scientific evidence highlights the affinity of the virus towards ACE2 receptors, which are widespread in multiple human systems, including the central nervous system (CNS) and cerebral vessels. Such an affinity may explain endothelial dysfunction and damage that is observed in COVID-positive patients in histopathological studies, with subsequent dysregulation of the cerebral circulation leading to transient or acute cerebrovascular accidents. In this paper, we aimed to evaluate the effects of COVID-related hypoxemia and direct viral invasion on the cerebral circulation, with special respect to the postulated pathomechanism, vulnerable groups of patients, clinical course and outcomes, as well as diagnostic imaging findings.
