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DOI: 10.1055/a-1265-7209
Cerebral Imaging in Patients with COVID-19 and Neurological Symptoms: First Experience from two University Hospitals in Northern Germany
Article in several languages: English | deutschAbstract
Purpose To describe findings on cerebral imaging in patients with COVID-19 and neurological symptoms at two German university hospitals.
Materials and Methods Patients with COVID-19 and neurological symptoms and cerebral imaging (CT or MRI) were included. A chart review regarding neurological symptoms, COVID-19 and imaging findings was conducted.
Results 12 patients (4 females, age 68 ± 12 years) could be included. Three patients had acute findings. Two patients had acute and subacute cerebral ischemia, one patient had additional intracranial hemorrhages and presumed central pontine myelinolysis. One patient had presumed COVID-19-associated pansinusitis.
Conclusion Findings on cerebral imaging in patients with COVID-19 are uncommon and nonspecific. However, cerebral ischemia is regularly encountered and patients should be evaluated for stroke symptoms.
Key Points:
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Approx. 20 % of patients with COVID-19 develop neurological symptoms.
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Findings on cerebral imaging in patients with COVID-19 are heterogeneous and nonspecific.
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The most common findings are cerebral ischemia and hemorrhages.
Citation Format
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Jensen-Kondering U, Neumann A, Margraf N et al. Cerebral Imaging in Patients with COVID-19 and Neurological Symptoms: First Experience from two University Hospitals in Northern Germany. Fortschr Röntgenstr 2021; 193: 667 – 671
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Introduction
In December 2019, the first cases of pneumonia caused by a novel coronavirus (SARS-CoV2) were identified in Wuhan/China. The virus has since spread around the globe. The disease caused by SARS-CoV2, known as COVID-19, is typically characterized by a respiratory infection with cough and fever. However, other organ systems can also be infected at an early stage in some cases [1] [2]. According to an initial large retrospective analysis from Wuhan, approximately one third (36.4 %) of COVID-19 patients exhibit neurological manifestations [3]. The neuroinvasive potential of coronaviruses is already known. Neurological symptoms were able to be observed in SARS-CoV1 and MERS-CoV patients [4] [5]. At the end of June 2020, 193 243 cases in Germany and 3146 (108.6 per 100 000 inhabitants were reported in Schleswig-Holstein) (https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Fallzahlen.html, as of 6/27/2020). In total, 68 patients had been hospitalized at both sites of the University Hospital of Schleswig-Holstein. We report on our first experience with cerebral imaging in COVID-19 patients with neurological symptoms.
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Materials and Methods
All patients infected with SARS-CoV2 who underwent clinically indicated cerebral imaging were retrospectively included. Imaging findings were evaluated with respect to primary and secondary findings. The following were categorized as primary findings: acute pathologies that were the presumably cause of symptoms or presumably occurred during the infection or as a result of the infection. All pathological findings classified as preexisting were considered secondary findings. In addition, demographic data and clinical information regarding SARS-CoV2 infection were recorded.
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Results
12 patients (4 women, 8 men, average age 68 + 12 years) were able to be included ([Table 1a]). Two of the patients were examined after the infection had resolved. Three COVID-19 cases were mild, five were moderate, and four were severe (mild: no hospitalization, hospitalization without oxygen supply, moderate: oxygen supply, severe: intensive care). MRI examination was performed in two patients, CT examination in seven patients (including additional CT angiography in one case), and three additional patients underwent both CT and MRI. All MRI examinations were performed with IV contrast agent.
In one severe case of COVID-19, a brain stem lesion was detected and classified as presumed central pontine myelinolysis ([Fig. 1]). Two patients had acute and subacute cerebral ischemia ([Fig. 2]). One patient additionally had a combination of subarachnoid and parenchymal hemorrhages ([Fig. 3]). One patient had presumed COVID-19-associated sinusitis based on headache, imaging finding, and a positive PCR for SARS-CoV2 from a nasal swab ([Fig. 4]). None of the patients had acute inflammatory intracranial changes. No acute findings could be identified on imaging in the remaining patients. The most common secondary findings were preexisting microangiopathic white matter damage (n = 4) and old embolic and microangiopathic stroke (n = 2). The neurological symptoms occurred with the start of the other symptoms in six patients, over the course of hospitalization in four cases, and weeks later in two patients. Eight patients experienced complete resolution of their neurological symptoms, one patient was discharged in soporose state, and three patients died ([Table 1b]).
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Discussion
Initial imaging results in a series of 58 patients with severe cases of COVID-19 were published by Helms et al. [6]. Meningeal contrast enhancement was seen in 8 of 13 patients (62 %) and cerebral ischemia in 3 patients (23 %).
Kandemili et al. report on patients with severe cases of COVID-19 in Turkey [7]. Cortical signal changes in FLAIR weighting accompanied by cortical diffusion impairment, leptomeningeal enhancement, or cortical blooming artifacts were seen in 10/27 patients (37 %).
Radmanesh report on 242 patients (of a total of 3661 patients, 6.6 %) with neurological symptoms in New York, who were examined primarily with CT. 13 patients (4.5 %) had acute or subacute ischemic infarct and 11 patients (3.8 %) intracranial hemorrhages. The majority of patients had no specific changes, particularly no meningeal contrast enhancement [8].
The high prevalence of cases of cerebral ischemia occurring in association with COVID-19 is noteworthy. Case series from France [9], the USA [10], and Italy [11] show a significantly worse clinical neurological outcome and a greater mortality rate in patients with COVID-19 and cerebral ischemia compared to patients without COVID-19 and cerebral ischemia. In addition, COVID-19 was identified as an independent risk factor for cerebral ischemia [12].
As in other collectives, the frequency of neurological symptoms (approx. 18 %) in our cohort is lower than that reported by Mao et al. One reason for this is that we only included patients with neurological symptoms resulting in cerebral imaging. Two patients in our cohort had cerebral ischemia (approx. 17 %) and one patient (approx. 8 %) had intracranial hemorrhages. However, most patients did not have any acute pathologies which corresponds with the literature.
Various damage mechanisms of the CNS have been discussed. 1) Direct neuroinvasion by SARS-CoV; 2) Secondary cerebral damage caused by ischemia and bleeding due to possible endothelial dysfunction and systemic hypercoagulability and possibly due to thromboses of the small cerebral veins caused by cerebral hemorrhages [13]. 3) Indirect damage due to cytokines and post-infection antibodies [14]. To date, it has not been possible to clearly define the damage pattern and the clarify which mechanisms are most prevalent and how frequently they occur. Neuropathological correlation studies are necessary to answer these questions and to identify a causality between the infection and damage patterns [15].
We present the first German case series from a minimally affected region. Our study includes COVID-19 patients with mild, moderate, and severe disease courses who underwent neuroradiological imaging and includes post-infection data and data regarding newly occurring neurological symptoms. In summary, these findings are currently still heterogeneous and nonspecific. Further long-term studies are needed to detect potential residual and late effects of COVID-19. In this regard, we initiated a population-based cohort study www.covidom.de.
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References
- 1 Guan W, Ni Z, Hu Y. et al. Clinical characteristics of coronavirus disease 2019 in China. New England Journal of Medicine 2020; 382: 1708-1720
- 2 Puelles VG, Lütgehetmann M, Lindenmeyer MT. et al. Multiorgan and Renal Tropism of SARS-CoV-2. N Engl J Med 2020;
- 3 Mao L, Jin H, Wang M. et al. Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China. JAMA Neurol 2020; 77 (06) 683-690
- 4 Tsai LK, Hsieh ST, Chang YC. Neurological manifestations in severe acute respiratory syndrome. Acta Neurol Taiwan 2005; 14: 113-119
- 5 Kim JE, Heo JH, Kim HO. et al. Neurological Complications during Treatment of Middle East Respiratory Syndrome. J Clin Neurol 2017; 13: 227-233
- 6 Helms J, Kremer S, Merdji H. et al. Neurologic Features in Severe SARS-CoV-2 Infection. N Engl J Med 2020; 382 (23) 2268-2270
- 7 Kandemirli SG, Dogan L, Sarikaya ZT. et al. Brain MRI Findings in Patients in the Intensive Care Unit with COVID-19 Infection. Radiology 2020; 297: 201697
- 8 Radmanesh A, Raz E, Zan E. et al. Brain Imaging Use and Findings in COVID-19: A Single Academic Center Experience in the Epicenter of Disease in the United States. AJNR Am J Neuroradiol 2020;
- 9 Escalard S, Maïer B, Redjem H. et al. Treatment of Acute Ischemic Stroke due to Large Vessel Occlusion With COVID-19: Experience From Paris. Stroke 2020;
- 10 Yaghi S, Ishida K, Torres J. et al. SARS-CoV-2 and Stroke in a New York Healthcare System. Stroke 2020; 51 (07) 2002-2011
- 11 Benussi A, Pilotto A, Premi E. et al. Clinical characteristics and outcomes of inpatients with neurologic disease and COVID-19 in Brescia, Lombardy, Italy. Neurology 2020;
- 12 Belani P, Schefflein J, Kihira S. et al. COVID-19 Is an Independent Risk Factor for Acute Ischemic Stroke. AJNR Am J Neuroradiol 2020;
- 13 Wu Y, Xu X, Chen Z. et al. Nervous system involvement after infection with COVID-19 and other coronaviruses. Brain Behav Immun 2020;
- 14 Nicholson P, Alshafai L, Krings T. Neuroimaging Findings in Patients with COVID-19. AJNR Am J Neuroradiol 2020;
- 15 Solomon IH, Normandin E, Bhattacharyya S. et al. Neuropathological Features of COVID-19. N Engl J Med 2020;
Correspondence
Publication History
Received: 18 July 2020
Accepted: 04 September 2020
Article published online:
19 November 2020
© 2020. Thieme. All rights reserved.
Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany
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References
- 1 Guan W, Ni Z, Hu Y. et al. Clinical characteristics of coronavirus disease 2019 in China. New England Journal of Medicine 2020; 382: 1708-1720
- 2 Puelles VG, Lütgehetmann M, Lindenmeyer MT. et al. Multiorgan and Renal Tropism of SARS-CoV-2. N Engl J Med 2020;
- 3 Mao L, Jin H, Wang M. et al. Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China. JAMA Neurol 2020; 77 (06) 683-690
- 4 Tsai LK, Hsieh ST, Chang YC. Neurological manifestations in severe acute respiratory syndrome. Acta Neurol Taiwan 2005; 14: 113-119
- 5 Kim JE, Heo JH, Kim HO. et al. Neurological Complications during Treatment of Middle East Respiratory Syndrome. J Clin Neurol 2017; 13: 227-233
- 6 Helms J, Kremer S, Merdji H. et al. Neurologic Features in Severe SARS-CoV-2 Infection. N Engl J Med 2020; 382 (23) 2268-2270
- 7 Kandemirli SG, Dogan L, Sarikaya ZT. et al. Brain MRI Findings in Patients in the Intensive Care Unit with COVID-19 Infection. Radiology 2020; 297: 201697
- 8 Radmanesh A, Raz E, Zan E. et al. Brain Imaging Use and Findings in COVID-19: A Single Academic Center Experience in the Epicenter of Disease in the United States. AJNR Am J Neuroradiol 2020;
- 9 Escalard S, Maïer B, Redjem H. et al. Treatment of Acute Ischemic Stroke due to Large Vessel Occlusion With COVID-19: Experience From Paris. Stroke 2020;
- 10 Yaghi S, Ishida K, Torres J. et al. SARS-CoV-2 and Stroke in a New York Healthcare System. Stroke 2020; 51 (07) 2002-2011
- 11 Benussi A, Pilotto A, Premi E. et al. Clinical characteristics and outcomes of inpatients with neurologic disease and COVID-19 in Brescia, Lombardy, Italy. Neurology 2020;
- 12 Belani P, Schefflein J, Kihira S. et al. COVID-19 Is an Independent Risk Factor for Acute Ischemic Stroke. AJNR Am J Neuroradiol 2020;
- 13 Wu Y, Xu X, Chen Z. et al. Nervous system involvement after infection with COVID-19 and other coronaviruses. Brain Behav Immun 2020;
- 14 Nicholson P, Alshafai L, Krings T. Neuroimaging Findings in Patients with COVID-19. AJNR Am J Neuroradiol 2020;
- 15 Solomon IH, Normandin E, Bhattacharyya S. et al. Neuropathological Features of COVID-19. N Engl J Med 2020;