COVID-19-Associated Acute Asymmetric Hemorrhagic Necrotizing Encephalopathy: A Case Report

Abstract

Background: Coronavirus disease 2019 (COVID-19) has been associated with many neurological complications affecting the central nervous system. Purpose: Our aim was to describe a case of COVID-19 associated with a probable variant of acute necrotizing encephalopathy (ANE). Results: A 60-year-old man who presented with a 3-day history of dyspnea, fever, and cough tested positive for severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2). Five days following his admission, the patient was intubated secondary to respiratory failure. Following his extubation 16 days later, he was found to have a left-sided weakness. Magnetic resonance imaging (MRI) of the brain showed hemorrhagic rim-enhancing lesions involving the right thalamus, left hippocampus, and left parahippocampal gyrus. These lesions showed decreased relative cerebral blood flow on MR perfusion and restricted on diffusion-weighted imaging. These neuroimaging findings were consistent with ANE. The left-sided weakness gradually improved over the subsequent weeks. Conclusions: We concluded that COVID-19 can be associated with ANE, a condition believed to be the result of an immune-mediated process with activation of the innate immune system. Future studies must address whether biological drugs targeting the pro-inflammatory cytokines could prevent the development of this condition.

Keywords: COVID-19; acute necrotizing encephalopathy; case report; magnetic resonance imaging.

Figure 1.

I: (A) Initial head computed tomography showed a bleed in the right thalamus with a hypodensity extending to the posterior limb of the internal capsule. (B) Coronal T1 section of initial gadolinium-enhanced brain MRI showing 2 ring-enhancing lesions over the right thalamus and left mesial temporal lobe. (C) Coronal FLAIR section showing increased signal in the right thalamus, and left hippocampus, and parahippocampal gyrus. II: (A) Axial T1 section of initial gadolinium-enhanced brain MRI showing a ring-enhancing lesion involving the right thalamus. (B) Axial FLAIR section showing increased signal surrounding an area of decreased signal consistent with acute or early subacute bleed. (C) Axial T2 FFE cut showing the right thalamic hemorrhage. III: MR angiogram showing normal intracranial vasculature. IV: (A) Axial FLAIR section of follow-up brain MRI at 1 week showing partial resolution of the right thalamic hemorrhage. (B) DWI and (C) apparent diffusion coefficient showing restricted diffusion of the right thalamic lesion. MRI, magnetic resonance imaging.

Figure 2.

(A) Brain MR perfusion targeting the selected areas over the thalami showing (B) decreased cerebral blood flow and (C) decreased cerebral blood volume over the right thalamic lesion.

Figure 3.

MR spectroscopy over right thalamic lesion showing inverted N-acetylaspartate/choline ratio.

Figure 4.

I: (A) Axial FLAIR section of the follow-up MRI at 5 months showing resolution of the right thalamic lesion. (B) Axial DWI showing no restricted diffusion over the right thalamus. (C) Axial T2 FFE showing near complete resolution of the right thalamic hemorrhage. II: (A) Coronal gadolinium-enhanced T1 section and (B) coronal FLAIR of the follow-up brain MRI at 5 months showing resolution of the right thalamic lesion and development of a cystic encephalomalacia in the left mesial temporal lobe. MRI, magnetic resonance imaging.