Neuro-imaging manifestations of COVID-19: Predilection for PICA infarcts

Abstract

COVID-19 has been an ever-evolving viral pandemic which can cause systemic disturbance especially in some of the critically ill patients. Neurologic or Neuro-imaging manifestations of COVID-19 are being increasingly reported in these patients and mainly consist of ischemic strokes, hypoxic ischemic injury and non-specific encephalopathy. Ischemic strokes as expected more commonly afflict major vascular territories, likely due to accentuated hypercoagulability in these patients. Certain vascular territories may be more susceptible to ischemic infarcts. We observed higher predilection for infarcts in posterior inferior cerebellar artery (PICA). This may represent another peculiarity of this pandemic.

Keywords: COVID-19; PICA infarct; Stroke.

Fig. 1

Frontal chest plain film (A) shows bilateral mid lung zones mild burden of ill-defined patchy but hazy opacities, equivalent to ground-glass changes on High resolution CT Chest. Initial Non-contrast CT Head (B) only demonstrated post traumatic changes of bifrontal large contusions with mild hemorrhage (arrows). Follow-up CT Head (C) demarcating small left PICA sub-acute infarct (arrow) with minimal petechial hemorrhage.

Fig. 2

Frontal chest plain film (A) showing bilateral mid to lung lung zones moderate burden of ill-defined patchy opacities. Follow-up MRI Brain demonstrates inferior medial left PICA sub-acute infarct (B,C-arrow) with FLAIR T2 hyperintensity of the cerebellar folia (B) and corresponding T1 hyperintensity representing cortical laminar necrosis (C) with out discernible enhancement. No petechial hemorrhage on susceptibility images (not shown).

Fig. 3

Coronal CT chest plain image (A) manifests bilateral confluent ground glass changes (arrows)- typical for COVID-19 with severe burden of disease (Score >18). Sub-acute PICA infarct is evident in the right inferior medial distribution with gyriform FLAIR T2 hyperintensity (arrow, B) and corresponding enhancement (arrow, C).

Fig. 4

Sagittal CT showing thick rind of hyper-density(A) in the entire PICA distribution due to hemorrhagic sub-acute PICA infarct with expected vasogenic edema (dark arrow, B) and effaced 4th ventricle due to mass effect. Obstructive hydrocephalus was present (not shown). Note dark T2 signal due to blood products (white arrow, B) and rim enhancement of the sub-acute infarct (arrow, C).