Brain microvascular occlusive disorder in COVID-19: a case report

Abstract

We describe the case of a COVID-19 patient with severely impaired consciousness after sedation hold, showing magnetic resonance imaging (MRI) findings of (i) acute bilateral supratentorial ischemic lesions involving the fronto-parietal white matter and the corpus callosum and (ii) multiple diffuse susceptibility weighted imaging (SWI) hypointense foci, infra and supratentorial, predominantly bithalamic, suggestive of microhemorrhage or alternatively microthrombi. Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) RNA was detected in the cerebrospinal fluid. Our findings suggest the occurrence of vascular damage, predominantly involving microvessels. The underlying mechanisms, which include direct and indirect penetration of the virus to the central nervous system and systemic cardiorespiratory complications, are yet to be elucidated, and a direct correlation with SARS-CoV-2 infection remains uncertain.

Keywords: Coagulopathy; Covid-19; Inflammation; Ischemia; Microthrombi; Neurological complications.

Fig. 1

Diffusion-weighted imaging (DWI) b1000 (a) and apparent diffusion coefficient map (b) show multiple areas of restricted diffusion, involving the bilateral fronto-parietal white matter and the genu of the corpus callosum, compatible with acute ischemic foci. Susceptibility-weighted imaging (SWI) (c) shows several millimetric hypointense areas, predominantly distributed in the thalami bilaterally, but also in the genu of the corpus callosum and in the parietal iuxtacortical white matter, consistent with microhemorrhages or alternatively microthrombi. T1-weighted post-contrast image (d) demonstrates the lack of parenchymal or meningeal enhancement at the level of these lesions (lack of enhancement was also observed in the rest of the brain, not shown)