MRI of Cerebrovascular Injury Associated With COVID-19 and Non-COVID-19 Acute Respiratory Distress Syndrome: A Matched Case-Control Study.

OBJECTIVES: Cerebrovascular injury associated with COVID-19 has been recognized, but the mechanisms remain uncertain. Acute respiratory distress syndrome (ARDS) is a severe pulmonary injury, which is associated with both ischemic and hemorrhagic stroke. It remains unclear if cerebrovascular injuries associated with severe COVID-19 are unique to COVID-19 or a consequence of severe respiratory disease or its treatment. The frequency and patterns of cerebrovascular injury on brain MRI were compared among patients with COVID-19 ARDS and non-COVID-19 ARDS. DESIGN: A case-control study. SETTING: A tertiary academic hospital system. PATIENTS: Adult patients (>18 yr) with COVID-19 ARDS (March 2020 to July 2021) and non-COVID-19 ARDS (January 2010-October 2018) who underwent brain MRI during their index hospitalization. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Cerebrovascular injury on MRI included cerebral ischemia (ischemic infarct or hypoxic ischemic brain injury) and intracranial hemorrhage (intraparenchymal, subarachnoid, or subdural, and cerebral microbleed [CMB]).Twenty-six patients with COVID-19 ARDS and sixty-six patients with non-COVID ARDS underwent brain MRI during the index hospitalization, resulting in 23 age- and sex-matched pairs. The frequency of overall cerebrovascular injury (57% vs 61%), cerebral ischemia (35% vs 43%), intracranial hemorrhage (43% vs 48%), and CMB (52% vs 41%) between COVID-19 ARDS and non-COVID-19 ARDS patients was similar (all p values >0.05). However, four of 26 patients (15%) with COVID-19 and no patients with non-COVID-19 ARDS had disseminated leukoencephalopathy with underlying CMBs, an imaging pattern that has previously been reported in patients with COVID-19. CONCLUSIONS: In a case-control study of selected ARDS patients with brain MRI, the frequencies of ischemic and hemorrhagic cerebrovascular injuries were similar between COVID-19 versus non-COVID-19 ARDS patients. However, the MRI pattern of disseminated hemorrhagic leukoencephalopathy was unique to the COVID-19 ARDS patients in this cohort.

Timing of Acute Stroke in COVID-19-A Health System Registry Study.

BACKGROUND AND PURPOSE: The association between SARS-CoV-2 infection and stroke remains unknown. We aimed to compare the characteristics of stroke patients who were hospitalized with Coronavirus Disease 2019 (COVID-19) based on the timing of stroke diagnosis. METHODS: We performed a retrospective analysis of adult patients in a health system registry of COVID-19 who were hospitalized and had imaging-confirmed acute stroke during hospitalization. Baseline characteristics and hospital outcomes were collected and analyzed. RESULTS: Out of 882 COVID-19 patients who were hospitalized between March 9 to May 17, 2020, 14 patients (2% of all COVID-19 patients and 21% of those who underwent imaging) presented with stroke or developed stroke during hospitalization. Eleven had acute ischemic stroke (AIS) and 3 had acute hemorrhagic stroke. Six patients (43%) presented to the hospital with acute stroke symptoms and were found to have SARS-CoV-2. Compared to patients who presented with AIS, more patients with AIS during hospitalization were male, of older age, had pneumonia and acute respiratory distress syndrome, were severely ill, and had high inflammatory and thrombotic markers (including C reactive protein, D dimer, ferritin, and fibrinogen). Among all patients, hospital mortality was high (50%) and the majority of patients who were discharged had poor neurological outcome. CONCLUSIONS: A distinction should be made between patients who present with acute stroke with concurrent SARS-CoV-2 infection and those who develop stroke as a complication of severe COVID-19. It is likely that a subset of stroke patients will incidentally test positive for the virus given the widespread pandemic.

Cerebral Microhemorrhage and Purpuric Rash in COVID-19: The Case for a Secondary Microangiopathy.

INTRODUCTION: Since the emergence of Coronavirus Disease 19 (COVID-19) pandemic, multiple neurologic complications in infected patients have been reported. Despite these reports, the mechanism of COVID-19 nervous system injury is not well understood. We report the case of a COVID-19 patient with diffuse microhemorrhages on brain MRI, positive anticardiolipin antibodies, and purpuric rash with biopsy showing a thrombotic vasculopathy, all features suggestive of secondary microangiopathy. CASE REPORT: A 69-year-old male with history of hypertension, chronic kidney disease, and hypothyroidism presented with one week of dyspnea, cough, diarrhea, and fevers. Chest x-ray demonstrated bibasilar consolidations and nasopharyngeal reverse transcriptase polymerase chain reaction confirmed SARS-CoV-2 infection. He had subsequent respiratory decline requiring intubation the day after admission. He developed a truncal morbilliform rash and diffuse purpura, a biopsy of which showed small dermal blood vessels with intraluminal microthrombi consistent with thrombotic vasculopathy. He was found to have elevated aCL IgM and IgG and equivocal lupus anticoagulant study. Brain MRI obtained for persistent encephalopathy showed innumerable areas of susceptibility weighted imaging changes throughout the bilateral juxtacortical white matter, corpus callosum, basal ganglia, and brainstem, as well as multiple small areas of FLAIR hyperintensities, consistent with microhemorrhage DISCUSSION: While there have been several reported cases of neurologic manifestations of COVID-19, the pathophysiology may not be related to neurotropism of the virus itself. The new development of antiphospholipid antibodies and thrombotic vasculopathy in dermal blood vessels in this patient suggest a secondary microangiopathy potentially related to a virally-induced inflammatory state.