Cerebral vasculitis of medium-sized vessels as a possible mechanism of brain damage in COVID-19 patients

Abstract

Background and purpose: Cerebral complications related to COVID-19 were recently reported, and the underlying mechanisms of brain damage remain uncertain, probably multifactorial. Among various hypotheses suggested, a possible vasculitis was issued but never confirmed. Herein, we aimed to describe brain MRIs focused on the intracranial vessel wall in a population of COVID-19 patients with neurologic manifestations.

Materials and methods: Between March 1 and May 31, 2020, 69 consecutive COVID-19 patients with neurologic manifestations underwent a brain MRI allowing the study of the intracranial vessel wall at Strasbourg University hospitals and were retrospectively included. During the same period, 25 consecutive patients, without suspicion of SARS-CoV-2 infection, underwent a brain MRI urgently, with the same imaging protocols. A vasculitis seemed likely when imaging demonstrated vessel wall thickening with homogeneous and concentric enhancement.

Results: Among the 69 COVID-19 patients included, 11 (16%) presented arterial vessel wall thickening with homogeneous and concentric enhancement, compatible with cerebral vasculitis. These neuroimaging findings were not found among the 25 patients without SARS-CoV-2 infection, and the difference was statistically significant (p = 0.03). Middle cerebral arteries, basilar artery, and posterior cerebral arteries were the most frequent vessels involved. For nine of them, imaging demonstrated ischemic or hemorrhagic complications.

Conclusion: Cerebral vasculitis of medium-sized vessels seems to be one of the mechanisms at the origin of brain damage related to COVID-19.

Keywords: COVID-19; Magnetic Resonance Imaging (MRI); Vasculitis.

Graphical abstract

Fig. 1

69-year old man with pathological wakefulness after sedation. Axial unenhanced T1-weighted spin-echo (A), axial (B, E), and coronal (C, D) contrast-enhanced T1-weighted spin-echo, 3D TOF MR angiography (F). Basilar artery wall enhancement (B, C). Left middle cerebral artery (D), and right posterior cerebral artery (E) with concentric wall enhancement. Posterior cerebral arteries narrowing (F).