Leukoencephalopathy Associated with Severe COVID-19 Infection: Sequela of Hypoxemia?

Abstract

There is increasing evidence to suggest that complications of coronavirus disease 2019 (COVID-19) infection are not only limited to the pulmonary system but can also involve the central nervous system. Here, we report 6 critically ill patients with COVID-19 infection and neuroimaging findings of leukoencephalopathy. While these findings are nonspecific, we postulate that they may be a delayed response to the profound hypoxemia the patients experienced due to the infection. No abnormal enhancement, hemorrhage, or perfusion abnormalities were noted on MR imaging. In addition, Severe Acute Respiratory Syndrome coronavirus 2 was not detected in the CSF collected from the 2 patients who underwent lumbar puncture. Recognition of COVID-19-related leukoencephalopathy is important for appropriate clinical management, disposition, and prognosis.

FIG 1.

Head CT of a critically ill patient (patient 2) with COVID-19 infection. Axial CT images demonstrate multiple hypodense foci within the bilateral periventricular white matter (white arrows) without evidence of hemorrhage.

FIG 2.

Brain MR images of a critically ill patient (Patient 2) with COVID-19 infection exhibiting impaired arousal, aphasia, and lethargy. A and B, Paired axial DWI and ADC map show symmetric foci of restricted diffusion involving the deep white matter of both cerebral hemispheres. C, Axial T2/FLAIR image through the same level shows associated increased T2/FLAIR hyperintensity corresponding to the regions of restricted diffusion. D, Axial fractional anisotropy map shows focal disruption of white matter tracts in the regions of diffusion restriction (white arrows). E and F, Paired axial DWI and ADC map show restricted diffusion of the body of the corpus callosum (arrow). G and H, Paired axial DWI and ADC map show restricted diffusion of the splenium of the corpus callosum (arrow).

FIG 3.

Brain MR images of a critically ill patient (patient 1) with COVID-19 infection exhibiting altered mental status. A and B, Paired axial DWI and ADC map show symmetric restricted diffusion of the deep white matter of both cerebral hemispheres. C, Axial T2 FLAIR image through the same level shows associated increased T2 FLAIR hyperintensity corresponding to the regions of restricted diffusion.

FIG 4.

Brain MR images of a critically ill patient (patient 5) with COVID-19 infection exhibiting impaired arousal and diffuse hypertonicity. A, Axial FLAIR image shows increased T2 FLAIR signal in the bilateral middle cerebellar peduncles (arrows). B, Contrast-enhanced T1-weighted image shows absence of abnormal enhancement of the bilateral middle cerebellar peduncles (arrows). C and D, Paired axial DWI and ADC map show corresponding restricted diffusion of bilateral middle cerebellar peduncles (arrows).

FIG 5.

Brain MR images of a critically ill patient (patient 4) with COVID-19 infection exhibiting impaired arousal and left distal lower extremity paresis. A and B, Paired axial DWI and ADC map show symmetric restricted diffusion of the bilateral perirolandic white matter (arrows). C, Axial contrast-enhanced T1-weighted image at the same level demonstrates no corresponding abnormal enhancement. D, Susceptibility-weighted image at the same level demonstrates no susceptibility effect to suggest hemorrhage. E, 3D reconstruction of the circle of Willis from time-of-flight imaging demonstrates no vascular abnormality.