Neuroimaging Should Be Considered for Severe COVID-19 Patients with Neurologic Symptoms
Key findings
- This retrospective study investigated the frequency of neuroimaging findings in patients with COVID-19 and potential associations between acute abnormalities on neuroimaging and measures of disease severity
- Between March 3 and May 6, 2020, 641 patients received medical care at Massachusetts General Hospital for COVID-19, and 150 underwent neuroimaging
- Twenty-six patients had abnormalities on neuroimaging: infarction (n=13), intracranial hemorrhage (n=11), leukoencephalopathy (n=7) and both infarction and intracranial hemorrhage (n=4)
- There was a significant association between the severity of COVID-19, as indicated by the requirement for ICU admission, need for intubation and development of acute kidney injury and neuroimaging abnormalities
- Clinicians should pursue neuroimaging studies for any neurological concern in the COVID-19 population, particularly if COVID-19 manifestations are severe. A range of imaging abnormalities may be expected
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Small cohort studies have demonstrated numerous neuroimaging abnormalities in patients with COVID-19. However, it remains unknown exactly which clinical parameters are associated with these abnormalities, partly because patients with COVID-19 present with such a wide spectrum of laboratory and clinical findings.
In a retrospective study, Massachusetts General Hospital researchers were able to link neuroimaging manifestations of COVID-19 to several markers of disease severity. Byung C. Yoon, MD, PhD, and Sandra P. Rincon, MD, staff neuroradiologists in the Department of Radiology, with Thabele Leslie-Mazwi, MD, director of Endovascular Stroke Services in the Departments of Neurosurgery and Neurology; and colleagues report the findings in the American Journal of Neuroradiology.
Study Methods
Between March 3 and May 6, 2020, 641 patients received medical care at Mass General for COVID-19, of which 150 (23%) underwent CT and/or MRI for evaluation of neurologic symptoms. The patients were followed until May 19, 2020. 141 patients had a CT scan, 21 had an MRI and 31 had both.
Imaging Findings
Twenty-six patients (17%) had cerebrovascular abnormalities on imaging:
- Infarction, 13 (50%)—5 middle cerebral artery, 2 posterior cerebral artery, 1 posterior inferior cerebellar artery, 1 borderzone, 2 multi-territorial
- Intracranial hemorrhage, 11 patients (42%)—2 subarachnoid hemorrhage, 2 intraparenchymal hemorrhage, 7 diffuse microhemorrhages
- Leukoencephalopathy—7 (27%)
- Hemorrhage + infarction—4 (15%)
Markers of Disease Severity
The researchers found significant associations between positive neuroimaging studies and:
- Requirement for ICU admission (P = 0.039)
- Need for intubation (P = 0.004)
- Development of acute kidney injury (P = 0.03)
There were no significant differences between patients with positive versus negative neuroimaging in terms of age, body mass index, length of stay or mortality.
Recommendation
Clinicians should pursue neuroimaging studies for any neurological concern in the COVID-19 population, particularly if COVID-19 manifestations are severe. A range of imaging abnormalities may be expected.
The true incidence of neuroimaging abnormalities in COVID-19 may be underestimated by this study. Most of the patients had indications for imaging making the incidence of asymptomatic neuroimaging abnormalities is unknown. Further, CT imaging predominated, which is less sensitive than MRI to assess for leukoencephalopathy, low-volume infarction and other subtle cerebrovascular abnormalities.
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