Increase in Ventricle Size and the Evolution of White Matter Changes on Serial Imaging in Critically Ill Patients with COVID-19

Abstract

Background: Evolution of brain magnetic resonance imaging (MRI) findings in critically ill patients with coronavirus disease 2019 (COVID-19) is unknown.

Methods: We retrospectively reviewed 4530 critically ill patients with COVID-19 admitted to three tertiary care hospitals in New York City from March 1 to June 30, 2020 to identify patients who had more than one brain MRI. We reviewed the initial and final MRI for each patient to (1) measure the percent change in the bicaudate index and third ventricular diameter and (2) evaluate changes in the presence and severity of white matter changes.

Results: Twenty-one patients had two MRIs separated by a median of 22 [Interquartile range (IQR) 14-30] days. Ventricle size increased for 15 patients (71%) between scans [median bicaudate index 0.16 (IQR 0.126-0.181) initially and 0.167 (IQR 0.138-0.203) on final imaging (p < 0.001); median third ventricular diameter 6.9 mm (IQR 5.4-10.3) initially and 7.2 mm (IQR 6.4-10.8) on final imaging (p < 0.001)]. Every patient had white matter changes on the initial and final MRI; between images, they worsened for seven patients (33%) and improved for three (14%).

Conclusions: On serial imaging of critically ill patients with COVID-19, ventricle size frequently increased over several weeks. White matter changes were often unchanged, but in some cases they worsened or improved, demonstrating there is likely a spectrum of pathophysiological processes responsible for these changes.

Keywords: COVID-19; Leukoencephalopathy; SARS-CoV-2; Ventricle.

Fig. 1

Patient selection flowchart. This diagram illustrates the process by which we identified 21 patients for inclusion in this study from the 4530 patients hospitalized between March 1 and June 30, 2020, with COVID-19 at the three tertiary care hospitals of our academic medical center

Fig. 2

White matter changes and increase in ventricle size from initial to final MRI. a, b Patient 6, a 61-year-old man with a history of hypertension, had an initial MRI a 17 days after admission and a final MRI b 24 days later. There were confluent posterior juxtacortical white matter changes present on the initial MRI which improved on the final MRI, consistent with posterior reversible encephalopathy syndrome. There was a notable increase in ventricular size between the MRIs (increase in the bicaudate index by 36.59% and in the third ventricular diameter by 44.64%). His course was complicated by a cardiac arrest with return of spontaneous circulation after 15 min prior to the initial MRI and renal failure requiring dialysis both prior to the initial MRI and between the initial and final MRI. He was ultimately declared brain dead following multifocal intracranial hemorrhage. c, d Patient 8, a 50-year-old man with a history of hypertension and diabetes (whose initial imaging was also described by Radmanesh et al. [12]) had an initial MRI c 21 days after admission and a final MRI d 11 days later. There were prominent symmetric confluent white matter changes present on the initial MRI which worsened on the final MRI and demonstrated progressive development of necrosis/cystic changes. His course was complicated by renal failure requiring dialysis prior to the initial MRI and a cardiac arrest with return of spontaneous circulation after 2.5 min between the initial and final MRI. He was discharged to a subacute rehab after 52 days with GCS score of 3 and mRS score of 5

Fig. 3

Large number of microhemorrhages on serial imaging. Patient 16, a 72-year-old man with a history of hypertension and hyperlipidemia, had an initial MRI 42 days after admission and a final MRI 7 days later. There were many bilateral globi pallidi and centrum semiovale microhemorrhages in a watershed distribution on both the initial and final MRI. His course was complicated by renal failure requiring dialysis prior to the initial MRI. He was on a heparin drip for 15 days prior to the initial MRI (started empirically for elevated D-Dimer), but this was stopped because of thrombocytopenia (lowest platelet count was 28,000/ul before the initial MRI and 50,000/ul between the initial and final MRI). Highest systolic blood pressure was 190 mm Hg prior to the initial MRI and 140 mm Hg between the initial and final MRI. His highest INR was 1.4 before the initial MRI and 1.1 between the initial and final MRI. Highest D-Dimer was 2527 ng/mL before the initial MRI and 1350 ng/mL between the initial and final MRI. He had a cardiopulmonary arrest 95 days after admission and died