Brain Imaging Use and Findings in COVID-19: A Single Academic Center Experience in the Epicenter of Disease in the United States

Abstract

Coronavirus disease 2019 (COVID-19) is a serious public health crisis and can have neurologic manifestations. This is a retrospective observational case series performed March 1-31, 2020, at New York University Langone Medical Center campuses. Clinical and imaging data were extracted, reviewed, and analyzed. Two hundred forty-two patients with COVID-19 underwent CT or MRI of the brain within 2 weeks after the positive result of viral testing (mean age, 68.7 ± 16.5 years; 150 men/92 women [62.0%/38.0%]). The 3 most common indications for imaging were altered mental status (42.1%), syncope/fall (32.6%), and focal neurologic deficit (12.4%). The most common imaging findings were nonspecific white matter microangiopathy (134/55.4%), chronic infarct (47/19.4%), acute or subacute ischemic infarct (13/5.4%), and acute hemorrhage (11/4.5%). No patients imaged for altered mental status demonstrated acute ischemic infarct or acute hemorrhage. White matter microangiopathy was associated with higher 2-week mortality (P < .001). Our data suggest that in the absence of a focal neurologic deficit, brain imaging in patients with early COVID-19 with altered mental status may not be revealing.

FIG 1.

Acute intracranial hemorrhage in patients with COVID-19. A, A 74-year-old man with COVID-19, intubated for hypoxic respiratory failure and on heparin due to a history of stented carotid stenosis. On day 10 of intensive care unit admission, he suddenly became unresponsive, and neurologic examination revealed absent brain stem reflexes. Brain CT showed extensive supra- and infratentorial acute hemorrhage with subarachnoid and intraventricular extensions, along with cerebral swelling and hypodensity (likely hypoperfusion injury), as well as uncal, subfalcine, and transtentorial herniations. B, A 61-year-old woman with COVID-19 and compensated hepatic cirrhosis (due to primary sclerosing cholangitis). On day 7 of intensive care unit admission, the patient developed right-sided weakness and numbness. Brain CT showed left parietal intraparenchymal hemorrhage with surrounding vasogenic edema. C, A 68-year-old man with COVID-19 was found fallen. Head CT showed bilateral inferior frontal lobe hemorrhagic contusions and a small subarachnoid hemorrhage, suggesting traumatic brain injury, likely related to the fall. D, A 61-year-old man with COVID-19 who presented after a fall. Brain CT revealed acute left cerebral convexity subdural and left ambient cistern subarachnoid hemorrhage, possibly related to the fall.

FIG 2.

Acute or subacute infarct in patients with COVID-19. A, A 62-year-old man with COVID-19, intubated for acute hypoxic respiratory failure, who initially presented with left MCA syndrome. Noncontrast head CT showed a dense left MCA sign suggesting a left MCA occlusion, later confirmed on CT angiography and catheter angiography (not shown here). B, A 77-year-old woman with COVID-19 presented with left-sided weakness. Noncontrast CT showed an acute/subacute right MCA territory infarct. C, A 63-year-old COVID-19 patient with ataxia. Brain MRI revealed a patchy acute infarct in the left cerebellar hemisphere. D, A 78-year-old man with COVID-19 presented following an unwitnessed fall. Brain MRI showed left more than right cingulate gyrus and callosal body acute infarct.