Brain MRI in SARS-CoV-2 pneumonia patients with newly developed neurological manifestations suggestive of brain involvement

Abstract

The increased frequency of neurological manifestations, including central nervous system (CNS) manifestations, in patients with coronavirus disease 2019 (COVID-19) pandemic is consistent with the virus's neurotropic nature. In most patients, brain magnetic resonance imaging (MRI) is a sensitive imaging modality in the diagnosis of viral encephalitides in the brain. The purpose of this study was to determine the frequency of brain lesion patterns on brain MRI in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia patients who developed focal and non-focal neurological manifestations. In addition, it will compare the impact of the Glasgow Coma Scale (GCS) as an index of deteriorating cerebral function on positive brain MRIs in both neurological manifestations. This retrospective study included an examination of SARS-CoV-2 pneumonia patients with real-time reverse transcription polymerase chain reaction (RT-PCR) confirmation, admitted with clinicoradiologic evidence of COVID-19 pneumonia, and who were candidates for brain MRI due to neurological manifestations suggesting brain involvement. Brain imaging acquired on a 3.0 T MRI system (Skyra; Siemens, Erlangen, Germany) with a 20-channel receive head coil. Brain MRI revealed lesions in 38 (82.6%) of the total 46 patients for analysis and was negative in the remaining eight (17.4%) of all finally enclosed patients with RT-PCR confirmed SARS-CoV-2 pneumonia. Twenty-nine (63%) patients had focal neurological manifestations, while the remaining 17 (37%) patients had non-focal neurological manifestations. The patients had a highly significant difference (p = 0.0006) in GCS, but no significant difference (p = 0.4) in the number of comorbidities they had. Brain MRI is a feasible and important imaging modality in patients with SARS-CoV-2 pneumonia who develop neurological manifestations suggestive of brain involvement, particularly in patients with non-focal manifestations and a decline in GCS.

Figure 1

Depicts the descriptive selection of RT-PCR confirmed SARS-CoV-2 pneumonia patients, presented with neurological manifestations and subjected to brain MRI, that are enclosed in this study analysis.

Figure 2

Frequency of patients with recent (A) and old (B) diagnostic findings on positive brain MRI of 38 among 46 patients with RT-PCR confirmed SARS-CoV-2 pneumonia and presented with neurological manifestations.

Figure 3

Fifty-eight-year-old male with RT-PCR proved SARS-CoV-2 pneumonia, (A) as revealed on chest CT. The patient also had right-sided weakness, right hemihyposthesia, and aphasia (stroke). Brain MRI was performed 4 days after the onset of the focal neurological manifestations as brain CT scanning was performed at the onset of such manifestations. (B) Axial FLAIR image showed increased signal intensity in the left parieto-occipital lobe (C) DW-MRI and (D) corresponding apparent diffusion coefficient (ADC) map showed diffusion restriction of the early sub-acute left parieto-occipital infarction. (E) No blooming was seen on two-dimensional (2D) T₂* gradient-echo sequences (GRE), signifying no hemorrhage.

Figure 4

The distribution of patients, revealing brain MRI findings, in RT-PCR proved SARS-CoV-2 pneumonia, and presented with focal neurological manifestations.

Figure 5

Twenty-six-year-old male with no prior co-morbidities; admitted with severe RT-PCR proved SARS-CoV-2 pneumonia, (A) as shown on the chest radiogram. This patient, who was on mechanical ventilation, went into cardiac arrest. Brain MRI was performed 4 days post arrest due to low GCS (= 6), revealed global hypoxic-ischemic encephalopathy. (B) Axial FLAIR image, at the level of the BG, showed decreased signal intensity in the thalami, while (C) corresponding DWI image showed lack of hyperintensity in both thalami, in addition to the caudate and putamen nuclei, findings that represent pseudo normalization. (D) Also, corresponding ADC map showed hyperintensity in the locations cited in (B). (E) Reconstructed maximum intensity projection magnetic resonance angiography (MRA) image shows no large vessel occlusion.

Figure 6

Thirty-three-year-old male, admitted with RT-proved SARS-CoV-2 pneumonia, (A) as noted on the chest radiogram. With GCS = 15, this patient developed headache and blurred vision. Brain MRI showed nonspecific scattered deep and sub-cortical small foci, in bilateral frontal and right parietal lobes with (B) hyperintense signals on axial FLAIR image. (C) DW-MRI, and (D) corresponding ADC map showed no diffusion restriction. (E) Also, no blooming was depicted on 2D T₂* GRE image.