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2.
Neuroradiology ; 63(12): 2153-2156, 2021 Dec.
Article in English | MEDLINE | ID: covidwho-1473991

ABSTRACT

More than a year after the start of the COVID-19 pandemic, long-term neurological manifestations of COVID-19 are increasingly being reported. The long-term sequelae of COVID-19-related leukoencephalopathy, however, remain unclear. Here, we present long-term neuroimaging follow-up in two cases of COVID-19-related leukoencephalopathy. The two cases demonstrate the utility of brain MRI for evaluating neurologic symptoms in critically ill patients with COVID-19, for diagnosis of underlying neural injury and prognostication of future recovery. The presence of leukoencephalopathy may result in chronic neurologic manifestations and may represent a poor prognosticator of neurologic recovery. The presence of leukoencephalomalacia on follow-up neuroimaging is potentially an indicator of irreversible white matter damage, which may be associated with more severe chronic deficits.


Subject(s)
COVID-19 , Leukoencephalopathies , Follow-Up Studies , Humans , Leukoencephalopathies/chemically induced , Leukoencephalopathies/diagnostic imaging , Neuroimaging , Pandemics , SARS-CoV-2
3.
Pediatr Infect Dis J ; 40(12): e493-e496, 2021 12 01.
Article in English | MEDLINE | ID: covidwho-1416156

ABSTRACT

We present a case of a 14-year-old, previously healthy female, admitted with acute coronavirus disease 2019 infection and new-onset seizures secondary to virus-associated necrotizing disseminated acute leukoencephalopathy. Her symptoms resolved completely with intravenous immunoglobulin and steroids. Pathophysiology and prognosis of neurologic manifestations of coronavirus disease 2019 remain unclear.


Subject(s)
COVID-19/complications , Intracranial Hemorrhages/etiology , Leukoencephalopathies/etiology , Leukoencephalopathies/virology , SARS-CoV-2 , Adolescent , Anticonvulsants/administration & dosage , Anticonvulsants/therapeutic use , COVID-19/drug therapy , Female , Humans , Immunoglobulins, Intravenous/therapeutic use , Intracranial Hemorrhages/pathology , Leukoencephalopathies/pathology , Levetiracetam/administration & dosage , Levetiracetam/therapeutic use , Lorazepam/administration & dosage , Lorazepam/therapeutic use , Seizures/drug therapy
4.
Neurol Sci ; 42(12): 4899-4902, 2021 Dec.
Article in English | MEDLINE | ID: covidwho-1391891

ABSTRACT

OBJECTIVES: To provide new insights into neurological manifestations of COVID-19. We describe a patient with mild COVID-19 associated with diplopia from right sixth cranial nerve palsy and early diffuse leukoencephalopathy, successfully treated with intravenous methylprednisolone. METHODS: The patient was evaluated for diplopia that occurred 1 day after the onset of fever, myalgia, and headache. A complete neurological workup, including neurological examination, cerebrospinal fluid (CSF) analysis with viral polymerase chain reaction (PCR), serum autoimmune encephalitis, and anti-nerve antibodies and brain magnetic resonance imaging (MRI), was performed. RESULTS: Clinical examination revealed incomplete right sixth cranial nerve palsy. Brain MRI showed diffuse confluent fluid-attenuated inversion recovery (FLAIR) hyperintense white matter abnormalities, while CSF analysis showed mild hyperproteinorrachia (61 mg/dL) without pleocytosis. The patients were treated with high-dose intravenous methylprednisolone with rapid improvement of neurological symptoms and resolution of CSF and MRI abnormalities. DISCUSSION: Our report shows that COVID-19 may predominantly present with neurological symptoms; furthermore, it argues the notion of leukoencephalopathy as a typical feature of a severe case of the disease. Mechanisms underpinning neurological symptoms in COVID-19 still need to be elucidated; nonetheless, early recognition and prompt management may ensure their improvement or even complete recovery and are therefore recommended.


Subject(s)
Abducens Nerve Diseases , COVID-19 , Leukoencephalopathies , Abducens Nerve Diseases/drug therapy , Diplopia/drug therapy , Diplopia/etiology , Humans , Magnetic Resonance Imaging , SARS-CoV-2
6.
BMJ Case Rep ; 14(8)2021 Aug 11.
Article in English | MEDLINE | ID: covidwho-1354558

ABSTRACT

A 60-year-old patient presented with respiratory distress, after recently being tested COVID-19 positive and was mechanically ventilated for 15 days. After cessation of sedation, he remained in deep comatose state, without any reaction on pain stimuli (Glasgow Coma Score 3). MRI of the brain showed diffuse leukoencephalopathy and multiple (>50) microbleeds. Diffuse COVID-19-associated leukoencephalopathy with microhaemorrhages is associated with a poor prognosis. However, 3 months later, our patient showed a remarkable recovery and was able to walk independently. This case report shows COVID-related leukoencephalopathy and intracerebral microbleeds, even with persistent comatose state, may have a favourable clinical outcome and prolonged treatment should be considered in individual cases.


Subject(s)
COVID-19 , Leukoencephalopathies , Cerebral Hemorrhage/chemically induced , Cerebral Hemorrhage/diagnostic imaging , Coma/chemically induced , Glasgow Coma Scale , Humans , Leukoencephalopathies/diagnosis , Leukoencephalopathies/diagnostic imaging , Male , Middle Aged , SARS-CoV-2
9.
J Neurovirol ; 27(4): 656-661, 2021 08.
Article in English | MEDLINE | ID: covidwho-1260618

ABSTRACT

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) commonly results in a respiratory illness in symptomatic patients; however, those critically ill can develop a leukoencephalopathy. We describe two patients who had novel subacute MRI findings in the context of coronavirus disease 2019 (COVID-19) leukoencephalopathy, which we hypothesize could implicate a potent small-vessel vasculitis, ischemic demyelination and the presence of prolonged ischemia. Recent evidence of the direct neuroinvasiness of SARS-CoV-2 leading to ischemia and vascular damage supports this hypothesis.


Subject(s)
COVID-19/complications , Demyelinating Diseases/pathology , Leukoencephalopathies/pathology , Leukoencephalopathies/virology , Vasculitis, Central Nervous System/pathology , Demyelinating Diseases/virology , Female , Humans , Magnetic Resonance Imaging , Male , Middle Aged , SARS-CoV-2 , Vasculitis, Central Nervous System/virology
10.
J Trop Pediatr ; 67(2)2021 05 17.
Article in English | MEDLINE | ID: covidwho-1231046

ABSTRACT

COVID-19 pandemic is increasingly being recognized in infants and some develop cytokine storm mediated tissue damage. We report 5-month-old infant presenting with fever, refusal of feeds, developing altered sensorium and convulsions during the hospital course, tested positive for SARS-CoV2 RT-PCR in second week of illness. Her serology was also Dengue positive. She had features of cytokine storm and her MRI Brain suggested acute demyelinating encephalomyelitis (ADEM). She was treated with high-dose methylprednisolone followed oral prednisolone, under antibiotics cover. Infant improved gradually over 3 weeks duration following a stormy hospital course. On follow-up, infant showed delayed motor milestones with epileptic spasms and hysparrhthymia on EEG, progressing to develop secondary West syndrome. Features of acute encephalopathy, hypercytokinemia and restricted diffusion on DWI-MRI, with post-encephalopathic epilepsy, pointed to a differential of ADEM-acute leukoencephalopathy with restricted diffusion (ALERD) as the primary diagnosis; establishing ALERD as a possible neurological complication of COVID-19 infection in infants. Timeline of events. There is a demonstrable fall in the inflammatory markers with clinical improvement following the start of intravenous methylprednisolone. Epileptic spasms and developmental delay with hypsarrhthymia noted on follow-up, suggestive of secondary West syndrome.


Subject(s)
COVID-19 , Coinfection , Dengue , Leukoencephalopathies , Spasms, Infantile , Female , Humans , Infant , Pandemics , RNA, Viral , SARS-CoV-2 , Spasms, Infantile/diagnosis , Spasms, Infantile/drug therapy , Spasms, Infantile/etiology
11.
J Neurovirol ; 27(3): 514-518, 2021 06.
Article in English | MEDLINE | ID: covidwho-1225066

ABSTRACT

As the novel coronavirus, SARS-CoV-2, has enveloped the world in a pandemic, it has become clear that the symptoms extend far beyond the respiratory system and have particularly caused a wide range of neurologic CNS complications, including diffuse leukoencephalopathy. Here, we describe a case of a 59-year-old male with severe COVID-19 infection who developed severe encephalopathy, which persisted well after his acute infection had subsided and had begun to improve from his respiratory dysfunction. He was found to have diffuse leukoencephalopathy with concomitant diffusion restriction on MR imaging. This case represents a delayed onset of leukoencephalopathy secondary to hypoxia in a small but growing cohort of COVID-related leukoencephalopathy due to similarities in imaging features and lack of superior alternate diagnosis. Patient's clinical improvement suggests reversibility with likely pathology being demyelination rather than infarction.


Subject(s)
COVID-19/complications , Hypoxia, Brain/virology , Leukoencephalopathies/virology , Humans , Male , Middle Aged , SARS-CoV-2
12.
Clin Med (Lond) ; 21(2): 155-157, 2021 03.
Article in English | MEDLINE | ID: covidwho-1150983

ABSTRACT

Neurological manifestations associated with SARS-CoV-2 infection as well as its pathogenesis are insufficiently explained. We present two cases of severe COVID-19 who required hospitalisation in the intensive care unit with persistently depressed mental status and severe leukoencephalopathy. We discuss the clinical and radiological findings and also propose the possible pathogenesis involved.


Subject(s)
COVID-19 , Leukoencephalopathies , Humans , Leukoencephalopathies/diagnostic imaging , SARS-CoV-2
13.
AJR Am J Roentgenol ; 216(4): 1046-1047, 2021 04.
Article in English | MEDLINE | ID: covidwho-1088880

ABSTRACT

Among 2820 inpatients with coronavirus disease (COVID-19), 59 (2.1%) underwent brain MRI. Of them, six (10.2%) had MRI findings suspicious for COVID-19-related disseminated leukoencephalopathy (CRDL), which is characterized by extensive confluent or multifocal white matter lesions (with characteristics and locations atypical for other causes), microhemorrhages, diffusion restriction, and enhancement. CRDL is an uncommon but important differential consideration in patients with neurologic manifestations of COVID-19.


Subject(s)
Brain/diagnostic imaging , COVID-19/complications , Leukoencephalopathies/etiology , Magnetic Resonance Imaging/methods , Pandemics , SARS-CoV-2 , Adult , Aged , Aged, 80 and over , COVID-19/epidemiology , Female , Humans , Leukoencephalopathies/diagnosis , Male , Middle Aged , Retrospective Studies
15.
Neurol Neurochir Pol ; 54(4): 312-322, 2020.
Article in English | MEDLINE | ID: covidwho-1067910

ABSTRACT

AIM: To evaluate five illustrative cases and perform a literature review to identify and describe a working approach to adult-onset white matter diseases (WMD). STATE OF THE ART: Inherited WMD are a group of disorders often seen in childhood. In adulthood, progressive WMDs are rare, apart from the common nonspecific causes of hypertension and other cerebrovascular diseases. The pattern of WMDs on neuroimaging can be an important clue to the final diagnosis. Due to the adoption of a combined clinical-imaging-laboratory approach, WMD is becoming better recognised, in addition to the rapidly evolving field of genomics in this area. CLINICAL IMPLICATIONS: While paediatric WMDs have a well-defined and literature-based clinical-laboratory approach to diagnosis, adult-onset WMDs remain an important, pathologically diverse, radiographic phenotype, with different and distinct neuropathologies among the various subtypes of WMD. Adult-onset WMDs comprise a wide collection of both acquired and inherited aetiologies. While severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) neurological complications are emerging, we are as yet unaware of it causing WMD outside of post-anoxic changes. It is important to recognise WMD as a potentially undefined acquired or genetic syndrome, even when extensive full genome testing reveals variants of unknown significance. FUTURE DIRECTIONS: We propose a combined clinical-imaging-laboratory approach to WMD and continued exploration of acquired and genetic factors. Adult-onset WMD, even given this approach, can be challenging because hypertension is often comorbid. Therefore, we propose that undiagnosed patients with WMD be entered into multicentre National Organisation for Rare Diseases registries to help researchers worldwide make new discoveries that will hopefully translate into future cures.


Subject(s)
Leukoencephalopathies/diagnosis , Leukoencephalopathies/etiology , Adult , Betacoronavirus , COVID-19 , Coronavirus Infections , Humans , Pandemics , Pneumonia, Viral , SARS-CoV-2 , White Matter/pathology
16.
Brain ; 143(10): 3089-3103, 2020 10 01.
Article in English | MEDLINE | ID: covidwho-1066270

ABSTRACT

Since the appearance of the first case of coronavirus disease 2019 (COVID-19) a pandemic has emerged affecting millions of individuals worldwide. Although the main clinical manifestations are respiratory, an increase in neurological conditions, specifically acute cerebrovascular disease, has been detected. We present cerebrovascular disease case incidence in hospitalized patients with SARS-CoV-2 infection. Patients were confirmed by microbiological/serological testing, or on chest CT semiology. Available data on co-morbidity, laboratory parameters, treatment administered, neuroimaging, neuropathological studies and clinical evolution during hospitalization, measured by the modified Rankin scale, were analysed. A bivariate study was also designed to identify differences between ischaemic and haemorrhagic subtypes. A statistical model of binary logistic regression and sensitivity analysis was designed to study the influence of independent variables over prognosis. In our centre, there were 1683 admissions of patients with COVID-19 over 50 days, of which 23 (1.4%) developed cerebrovascular disease. Within this group of patients, cerebral and chest CT scans were performed in all cases, and MRI in six (26.1%). Histological samples were obtained in 6/23 cases (two brain biopsies, and four arterial thrombi). Seventeen patients were classified as cerebral ischaemia (73.9%, with two arterial dissections), five as intracerebral haemorrhage (21.7%), and one leukoencephalopathy of posterior reversible encephalopathy type. Haemorrhagic patients had higher ferritin levels at the time of stroke (1554.3 versus 519.2, P = 0.004). Ischaemic strokes were unexpectedly frequent in the vertebrobasilar territory (6/17, 35.3%). In the haemorrhagic group, a characteristic radiological pattern was identified showing subarachnoid haemorrhage, parieto-occipital leukoencephalopathy, microbleeds and single or multiple focal haematomas. Brain biopsies performed showed signs of thrombotic microangiopathy and endothelial injury, with no evidence of vasculitis or necrotizing encephalitis. The functional prognosis during the hospital period was unfavourable in 73.9% (17/23 modified Rankin scale 4-6), and age was the main predictive variable (odds ratio = 1.5; 95% confidence interval 1.012-2.225; P = 0.043). Our series shows cerebrovascular disease incidence of 1.4% in patients with COVID-19 with high morbidity and mortality. We describe pathological and radiological data consistent with thrombotic microangiopathy caused by endotheliopathy with a haemorrhagic predisposition.


Subject(s)
Brain Ischemia/diagnostic imaging , Brain Ischemia/epidemiology , Cerebral Hemorrhage/diagnostic imaging , Cerebral Hemorrhage/epidemiology , Coronavirus Infections/diagnostic imaging , Coronavirus Infections/epidemiology , Leukoencephalopathies/epidemiology , Pneumonia, Viral/diagnostic imaging , Pneumonia, Viral/epidemiology , Age Factors , Aged , Betacoronavirus , Brain/diagnostic imaging , Brain/pathology , Brain Ischemia/pathology , COVID-19 , Cerebral Hemorrhage/blood , Cerebral Hemorrhage/pathology , Comorbidity , Coronavirus Infections/blood , Coronavirus Infections/pathology , Female , Ferritins/blood , Humans , Incidence , Leukoencephalopathies/diagnostic imaging , Leukoencephalopathies/pathology , Magnetic Resonance Imaging , Male , Neuroimaging , Pandemics , Pneumonia, Viral/blood , Pneumonia, Viral/pathology , SARS-CoV-2 , Spain/epidemiology , Tomography, X-Ray Computed
17.
Am J Phys Med Rehabil ; 100(1): 39-43, 2021 01 01.
Article in English | MEDLINE | ID: covidwho-1066488

ABSTRACT

ABSTRACT: Apart from respiratory symptoms, encephalopathy and a range of central nervous system complications have been described in coronavirus disease 2019. However, there is a lack of published literature on the rehabilitative course and functional outcomes of severe coronavirus disease 2019 with encephalopathy. In addition, the presence of subclinical neurocognitive sequelae during postacute rehabilitation has not been described and may be underrecognized by rehabilitation providers. We report the rehabilitative course of a middle-aged male patient with severe coronavirus disease 2019 who required intensive care and mechanical ventilation. During postacute inpatient rehabilitation for severe intensive care unit-related weakness, an abnormal cognitive screen prompted brain magnetic resonance imaging, which revealed destructive leukoencephalopathy. Subsequently, detailed psychometric evaluation revealed significant impairments in the domains of processing speed and executive function. After 40 days of intensive inpatient rehabilitation, he was discharged home with independent function. This report highlights the need for an increased awareness of covert subclinical neurocognitive sequelae, the role of comprehensive rehabilitation, and value of routine cognitive screening therein and describes the neurocognitive features in severe COVID-19.


Subject(s)
COVID-19/complications , COVID-19/rehabilitation , Critical Care , Leukoencephalopathies/etiology , Leukoencephalopathies/rehabilitation , COVID-19/diagnosis , Humans , Leukoencephalopathies/diagnosis , Male , Middle Aged , Patient Discharge
18.
AJNR Am J Neuroradiol ; 42(4): 632-638, 2021 04.
Article in English | MEDLINE | ID: covidwho-1016049

ABSTRACT

BACKGROUND AND PURPOSE: Patients infected with the Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) can develop a spectrum of neurological disorders, including a leukoencephalopathy of variable severity. Our aim was to characterize imaging, lab, and clinical correlates of severe coronavirus disease 2019 (COVID-19) leukoencephalopathy, which may provide insight into the SARS-CoV-2 pathophysiology. MATERIALS AND METHODS: Twenty-seven consecutive patients positive for SARS-CoV-2 who had brain MR imaging following intensive care unit admission were included. Seven (7/27, 26%) developed an unusual pattern of "leukoencephalopathy with reduced diffusivity" on diffusion-weighted MR imaging. The remaining patients did not exhibit this pattern. Clinical and laboratory indices, as well as neuroimaging findings, were compared between groups. RESULTS: The reduced-diffusivity group had a significantly higher body mass index (36 versus 28 kg/m2, P < .01). Patients with reduced diffusivity trended toward more frequent acute renal failure (7/7, 100% versus 9/20, 45%; P = .06) and lower estimated glomerular filtration rate values (49 versus 85 mL/min; P = .06) at the time of MRI. Patients with reduced diffusivity also showed lesser mean values of the lowest hemoglobin levels (8.1 versus 10.2 g/dL, P < .05) and higher serum sodium levels (147 versus 139 mmol/L, P = .04) within 24 hours before MR imaging. The reduced-diffusivity group showed a striking and highly reproducible distribution of confluent, predominantly symmetric, supratentorial, and middle cerebellar peduncular white matter lesions (P < .001). CONCLUSIONS: Our findings highlight notable correlations between severe COVID-19 leukoencephalopathy with reduced diffusivity and obesity, acute renal failure, mild hypernatremia, anemia, and an unusual brain MR imaging white matter lesion distribution pattern. Together, these observations may shed light on possible SARS-CoV-2 pathophysiologic mechanisms associated with leukoencephalopathy, including borderzone ischemic changes, electrolyte transport disturbances, and silent hypoxia in the setting of the known cytokine storm syndrome that accompanies severe COVID-19.


Subject(s)
Acute Kidney Injury/diagnostic imaging , COVID-19/complications , Intensive Care Units , Leukoencephalopathies/complications , Acute Kidney Injury/complications , Adult , Diffusion Magnetic Resonance Imaging , Humans , Leukoencephalopathies/diagnostic imaging , Magnetic Resonance Imaging/methods , Male , Middle Aged , SARS-CoV-2 , White Matter/diagnostic imaging
19.
AJNR Am J Neuroradiol ; 42(1): 37-41, 2021 01.
Article in English | MEDLINE | ID: covidwho-895283

ABSTRACT

Brain multivoxel MR spectroscopic imaging was performed in 3 consecutive patients with coronavirus disease 2019 (COVID-19). These included 1 patient with COVID-19-associated necrotizing leukoencephalopathy, another patient who had a recent pulseless electrical activity cardiac arrest with subtle white matter changes, and a patient without frank encephalopathy or a recent severe hypoxic episode. The MR spectroscopic imaging findings were compared with those of 2 patients with white matter pathology not related to Severe Acute Respiratory Syndrome coronavirus 2 infection and a healthy control subject. The NAA reduction, choline elevation, and glutamate/glutamine elevation found in the patient with COVID-19-associated necrotizing leukoencephalopathy and, to a lesser degree, the patient with COVID-19 postcardiac arrest, follow a similar pattern as seen with the patient with delayed posthypoxic leukoencephalopathy. Lactate elevation was most pronounced in the patient with COVID-19 necrotizing leukoencephalopathy.


Subject(s)
COVID-19/diagnostic imaging , Aged , Humans , Leukoencephalopathies/diagnostic imaging , Magnetic Resonance Imaging , Magnetic Resonance Spectroscopy , Male , SARS-CoV-2 , White Matter
20.
AJNR Am J Neuroradiol ; 42(2): 279-284, 2021 01.
Article in English | MEDLINE | ID: covidwho-890309

ABSTRACT

BACKGROUND AND PURPOSE: Various patterns of leukoencephalopathy have been described in coronavirus disease 2019 (COVID-19). In this article, we aimed to describe the clinical and imaging features of acute disseminated leukoencephalopathy in critically ill patients with COVID-19 and the imaging evolution during a short-term follow-up. MATERIALS AND METHODS: We identified and reviewed the clinical data, laboratory results, imaging findings, and outcomes for 8 critically ill patients with COVID-19 with acute disseminated leukoencephalopathy. RESULTS: All patients demonstrated multiple areas of white matter changes in both cerebral hemispheres; 87.5% (7/8) of patients had a posterior predilection. Four patients (50%) had short-term follow-up imaging within a median of 17 days after the first MR imaging; they developed brain atrophy, and their white matter lesions evolved into necrotizing cystic cavitations. All (8/8) patients had inflammatory cytokine release syndrome as demonstrated by elevated interleukin-6, D-dimer, lactate dehydrogenase, erythrocyte sedimentation rate, C-reactive protein, and ferritin levels. Most (7/8; 87.5%) patients were on prolonged ventilator support (median, 44.5 days; interquartile range, 20.5 days). These patients had poor functional outcomes (6/8 [75%] patients were discharged with mRS 5) and high mortality (2/8, 25%). CONCLUSIONS: Critically ill patients with COVID-19 can develop acute disseminated leukoencephalopathy that evolves into cystic degeneration of white matter lesions with brain atrophy during a short period, which we dubbed virus-associated necrotizing disseminated acute leukoencephalopathy. This may be the result of COVID-19-related endothelial injury, cytokine storm, or thrombotic microangiopathy.


Subject(s)
COVID-19/diagnostic imaging , Leukoencephalopathies/diagnostic imaging , Adult , Aged , Atrophy , Brain/diagnostic imaging , COVID-19/complications , COVID-19/mortality , Critical Illness , Cytokine Release Syndrome/etiology , Female , Humans , Leukoencephalopathies/etiology , Leukoencephalopathies/mortality , Magnetic Resonance Imaging , Male , Middle Aged , Respiration, Artificial , Retrospective Studies , Thrombosis/diagnostic imaging , Thrombosis/etiology , Treatment Outcome , White Matter/diagnostic imaging
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