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COVID-19–associated Leukoencephalopathy

2020; Radiological Society of North America; Volume: 296; Issue: 3 Linguagem: Inglês

10.1148/radiol.2020201753

1527-1315

Jeffrey R. Sachs, Kevin W. Gibbs, Dionne Swor, Adam P. Sweeney, Daniel W. Williams, Jonathan H. Burdette, Thomas G. West, Carol P. Geer,

COVID-19 Clinical Research Studies

HomeRadiologyVol. 296, No. 3 PreviousNext Reviews and CommentaryFree AccessImages in RadiologyCOVID-19–associated LeukoencephalopathyJeffrey R. Sachs , Kevin W. Gibbs, Dionne E. Swor, Adam P. Sweeney, Daniel W. Williams, Jonathan H. Burdette, Thomas G. West, Carol P. GeerJeffrey R. Sachs , Kevin W. Gibbs, Dionne E. Swor, Adam P. Sweeney, Daniel W. Williams, Jonathan H. Burdette, Thomas G. West, Carol P. GeerAuthor AffiliationsFrom the Department of Radiology (J.R.S., A.P.S., D.W.W., J.H.B., T.G.W., C.P.G.), Department of Pulmonary, Critical Care, Allergy, and Immunologic Medicine (K.W.G.), and Department of Neurology (D.E.S.), Wake Forest School of Medicine, Wake Forest Baptist Health, 1 Medical Center Blvd, Winston-Salem, NC 27157.Address correspondence to J.R.S. (e-mail: [email protected]).Jeffrey R. Sachs Kevin W. GibbsDionne E. SworAdam P. SweeneyDaniel W. WilliamsJonathan H. BurdetteThomas G. WestCarol P. GeerPublished Online:May 14 2020https://doi.org/10.1148/radiol.2020201753MoreSectionsPDF ToolsAdd to favoritesCiteTrack Citations ShareShare onFacebookXLinked In As the coronavirus disease 2019 (COVID-19) pandemic has progressed, the recognition of neurologic sequelae has increased. Herein, we report on a case of COVID-19–associated leukoencephalopathy with microhemorrhage.A 59-year-old man with known persistent asthma (managed with inhaled steroids and long-acting beta agonists) presented with upper respiratory symptoms (10 days duration) and fever (7 days duration). COVID-19 was confirmed by means of polymerase chain reaction assay. He was intubated on hospital day 6. Severe agitation required high-dose analgesics (including dilaudid, fentanyl, and morphine), and blood pressure required intermittent pressor support (mean, 70–90 mm Hg, without sustained hypertension). Laboratory results included a platelet count of 175 000/μL, an activated partial thromboplastin clotting time of 34.7 seconds, an international normalized ratio of 1.3, a D-dimer level of 11 720 ng/mL, and a fibrinogen level of 693 mg/dL. Lumbar puncture was not performed.Unenhanced head CT images showed subtle hypoattenuation of the bilateral cerebral hemispheric white matter and corpus callosum (Fig 1). T2-weighted fluid-attenuated inversion recovery MRI scans of the brain revealed diffuse, confluent posterior predominant white matter hyperintensities, scattered microhemorrhages predominantly in the corpus callosum, and apparent posterior circulation hyperperfusion (Fig 2), without diffusion restriction or abnormal enhancement.Figure 1: Unenhanced CT image of head demonstrates confluent hypoattenuation in genu (anterior) and splenium (posterior) of corpus callosum (arrows).Figure 1:Download as PowerPointFigure 2a: (a) T2-weighted fluid-attenuated inversion recovery MRI scan of brain shows extensive posterior greater than anterior white matter hyperintensity (arrows) without mass effect. (b) Susceptibility-weighted image demonstrates a cluster of microhemorrhages in corpus callosum (arrows). (c) Arterial-spin-labeling perfusion images are suggestive of posterior circulation hyperperfusion (arrows). CBF = cerebral blood flow.Figure 2a:Download as PowerPointFigure 2b: (a) T2-weighted fluid-attenuated inversion recovery MRI scan of brain shows extensive posterior greater than anterior white matter hyperintensity (arrows) without mass effect. (b) Susceptibility-weighted image demonstrates a cluster of microhemorrhages in corpus callosum (arrows). (c) Arterial-spin-labeling perfusion images are suggestive of posterior circulation hyperperfusion (arrows). CBF = cerebral blood flow.Figure 2b:Download as PowerPointFigure 2c: (a) T2-weighted fluid-attenuated inversion recovery MRI scan of brain shows extensive posterior greater than anterior white matter hyperintensity (arrows) without mass effect. (b) Susceptibility-weighted image demonstrates a cluster of microhemorrhages in corpus callosum (arrows). (c) Arterial-spin-labeling perfusion images are suggestive of posterior circulation hyperperfusion (arrows). CBF = cerebral blood flow.Figure 2c:Download as PowerPointThese imaging findings are nonspecific and can accompany several well-established leukoencephalopathies. Confluent corpus callosal involvement can occur in acute disseminated encephalomyelitis (1) or acute hemorrhagic encephalomyelitis (2). Microbleeds can be seen with these or other vasculitides (3), as well as with posterior reversible encephalopathy syndrome (note that there was no documented hypertension in this case). Anesthesia-related toxicity is also possible. Although the mechanism of white matter injury and its relationship to COVID-19 is uncertain, possibilities include endotheliitis with thrombotic microangiopathy (4) as well as COVID-19–associated cytokine release syndrome, which may have implications for treatment (5).Disclosures of Conflicts of Interest: J.R.S. disclosed no relevant relationships. K.W.G. disclosed no relevant relationships. D.E.S. disclosed no relevant relationships. A.P.S. disclosed no relevant relationships. D.W.W. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: occasionally provides expert testimony for medical-legal cases. Other relationships: disclosed no relevant relationships. J.H.B. disclosed no relevant relationships. T.G.W. disclosed no relevant relationships. C.P.G. disclosed no relevant relationships.References1. Banerjee A, Suthar R, Vyas S, Singh MP. Acute disseminated encephalomyelitis: complication of a vaccine preventable disease. BMJ Case Rep 2018;11(1):e225710. Crossref, Medline, Google Scholar2. Pinto PS, Taipa R, Moreira B, Correia C, Melo-Pires M. Acute hemorrhagic leukoencephalitis with severe brainstem and spinal cord involvement: MRI features with neuropathological confirmation. J Magn Reson Imaging 2011;33(4):957–961. Crossref, Medline, Google Scholar3. Abdel Razek AA, Alvarez H, Bagg S, Refaat S, Castillo M. Imaging spectrum of CNS vasculitis. RadioGraphics 2014;34(4):873–894. Link, Google Scholar4. Varga Z, Flammer AJ, Steiger P, et al. Endothelial cell infection and endotheliitis in COVID-19. Lancet 2020;395(10234):1417–1418. Crossref, Medline, Google Scholar5. Moore JB, June CH. Cytokine release syndrome in severe COVID-19. Science 2020;368(6490):473–474. Crossref, Medline, Google ScholarArticle HistoryReceived: Apr 21 2020Revision requested: Apr 29 2020Revision received: Apr 30 2020Accepted: May 8 2020Published online: May 14 2020Published in print: Sept 2020 FiguresReferencesRelatedDetailsCited ByPathophysiology and probable etiology of cerebral small vessel disease in vascular dementia and Alzheimer's diseaseYasuteruInoue, FrancisShue, GuojunBu, TakahisaKanekiyo11 July 2023 | Molecular Neurodegeneration, Vol. 18, No. 1Central nervous system reactivation of herpesviridae family in patients with COVID-19MahboubehHaddad, FereshteSheybani, NahidOlfati, Mohammad AliNahayati, RezaBoostani, ParvanehLayegh, AzraRashid-Nejad25 April 2023 | Journal of NeuroVirology, Vol. 29, No. 2Guillain‐Barre syndrome secondary to COVID ‐19 infection: A case reportDena H.Tran, DalwinderBasra, ZaidBilgrami, Suryanarayana R.Challa, ChristinaKwon, EllenMarciniak, Avelino C.Verceles30 March 2023 | Clinical Case Reports, Vol. 11, No. 4Neuroimaging findings and neurological manifestations in hospitalized COVID-19 patients: Impact of cancer and ventilatory support statusLilyMcCarthy, OleksandrKhegai, JonathanGoldstein, PuneetBelani, PuneetPawha, ShingoKihira, BrianMathew, KapilGururangan, QingHao, AnuradhaSingh, AllisonNavis, Bradley N.Delman, NathalieJette, PritiBalchandani, YiminChen24 March 2023 | PLOS ONE, Vol. 18, No. 3Acute Neurological Complications of Coronavirus DiseaseSandersChang, MichaelSchecht, RajanJain, PuneetBelani2023Feb1 | Neuroimaging Clinics of North America, Vol. 33, No. 1Case report: Bilateral globus pallidus lesions and delayed progressive leukoencephalopathy in COVID-19: Effects of hypoxia alone or combination of hypoxia and inflammation?Ahmad A.Ballout, MichaelKolesnik, YunaChoi, Marc S.Ayoub, AsaffHarel, SouhelNajjar9 January 2023 | Frontiers in Neurology, Vol. 13Can Patients with Asymptomatic/Mild Illness and Moderate Illness COVID-19 Have White Matter Damage?CunshengWei, XiaorongYu, YuanChen, TingtingYang, ShenghuaLi, JunrongLi, XuemeiChen1 October 2023 | International Journal of General Medicine, Vol. Volume 16Prevalence of acute neurological complications and pathological neuroimaging findings in critically ill COVID-19 patients with and without VV-ECMO treatmentAngeloIppolito, HansUrban, KimiaGhoroghi, NicolasRosbach, NeelamLingwal, Elisabeth H.Adam, BenjaminFriedrichson, Andrea U.Steinbicker, ElkeHattingen, Katharina J.Wenger19 October 2022 | Scientific Reports, Vol. 12, No. 1Central neuroinflammation in Covid-19: a systematic review of 182 cases with encephalitis, acute disseminated encephalomyelitis, and necrotizing encephalopathiesRahaZamani, RozhinaPouremamali, NimaRezaei17 September 2021 | Reviews in the Neurosciences, Vol. 33, No. 4Posterior Reversible Encephalopathy Syndrome (PRES) Associated With COVID-19 Infection—A Case Report and ReviewShamikShah, UrvishPatel, NeevMehta, PratikShingru12 January 2022 | Journal of Stroke Medicine, Vol. 5, No. 1Rare case study of Covid agitation: The novel sinner causes a diagnostic dilemmaGyanendra SinghBhadauria, SwarnimaSingh, M KPatra15 March 2022 | IP Archives of Cytology and Histopathology Research, Vol. 7, No. 1COVID-Related Leukoencephalopathy: Unusual MRI Features and Comparability to Delayed Post Hypoxic Ischemic EncephalopathyManzoorAhmed, Waqar HaiderGaba, Fahim MKhan, Rabab AlMansoori, Abd Al KareemAdi2022Mar1 | Radiology Case Reports, Vol. 17, No. 3Association of CNS demyelination and COVID-19 infection: an updated systematic reviewIsmail IbrahimIsmail, SaraSalama12 August 2021 | Journal of Neurology, Vol. 269, No. 2Neuroimaging Findings of Hospitalized Covid-19 Patients: A Canadian Retrospective Observational StudyVibeeshanJegatheeswaran, Michael W. 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