Imaging Features of Acute Encephalopathy in Patients with COVID-19: A Case Series

Abstract

Coronavirus disease 2019 was declared a global pandemic by the World Health Organization on March 11, 2020. There is a scarcity of data on coronavirus disease 2019-related brain imaging features. We present 5 cases that illustrate varying imaging presentations of acute encephalopathy in patients with coronavirus disease 2019. MR features include leukoencephalopathy, diffusion restriction that involves the GM and WM, microhemorrhages, and leptomeningitis. We believe it is important for radiologists to be familiar with the neuroradiologic imaging spectrum of acute encephalopathy in the coronavirus disease 2019 population.

FIG 1.

An axial MR image of a 59-year-old woman with COVID-19 who presented with respiratory distress and acute disorientation (case 1). A, FLAIR image demonstrates confluent FLAIR hyperintensity that involves cerebral WM (arrowheads) and patchy involvement of cerebral cortices; a small amount of scattered frontoparietal leptomeningeal FLAIR hyperintensity is noted (arrow). B, FLAIR image shows hyperintensity that involves the splenium (arrows) and basal ganglia (arrowhead). C, DWI demonstrates restricted diffusion that involves the splenium of the corpus callosum (arrows) and the cortex (arrowhead). D, DWI shows a diffusion-restricting focus in the pons (arrow).

FIG 2.

An axial MR imaging of the brain of a 60-year-old man with COVID-19 who presented with disorientation and decreased alertness (case 2). A, A FLAIR image demonstrates diffuse confluent WM hyperintensity with sparing of the subcortical U-fibers (arrowheads). B, DWI shows corresponding restricted diffusion throughout the involved WM (arrowheads).

FIG 3.

An axial MR imaging of the brain of a 35-year-old woman with COVID-19 who presented with decreased alertness (case 3). A, A gradient recalled-echo (GRE) image demonstrates numerous small foci of susceptibility in the peripheral subcortical WM (arrows). B, A more inferior GRE image shows numerous small foci of susceptibility throughout the corpus callosum, particularly the splenium (arrows). C, A FLAIR image demonstrates confluent bilateral hyperintensity that involves the splenium (arrows).

FIG 4.

An axial MR imaging of the brain of a 48-year-old man with COVID-19 and with acute flaccid paralysis of the bilateral lower extremities (case 4). A, DWI demonstrates multiple diffusion-restricting foci in the WM, including right greater than left corona radiata (arrows). B, A T2 FSE image shows a “halo” appearance of a dominant right corona radiata lesion (inset), suggestive of demyelination. C, A T2 FSE image demonstrates a focal lesion in the right lateral column of the spinal cord at C1 (arrow), which corresponds to a diffusion-restricting focus on MR imaging of the brain.

FIG 5.

An axial MR imaging of the brain of 41-year-old man with COVID-19 and with persistent disorientation and decreased alertness 1 week after extubation (case 5). A, A FLAIR image demonstrates hyperintensity throughout the cerebral WM (arrowheads). B, A more-inferior FLAIR image demonstrates hyperintensity of the globi pallidi bilaterally (arrows).