Brain MRI Findings in Patients in the Intensive Care Unit with COVID-19 Infection

Abstract

A novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), caused an outbreak of severe pneumonia (coronavirus disease 2019 ) in China that rapidly spread throughout the globe.Recent evidence highlights a relatively high percentage (36%) of central nervous system symptoms, including headache, altered mental status, acute cerebrovascular disease, and epilepsy, in patients with COVID-19 (1).The rate of neurologic symptoms is higher in patients with a more severe respiratory disease status (1).The relatively high percentage of neurologic symptoms is concordant with studies showing neurotropism of coronavirus (2).The current literature is limited regarding neuroimaging findings in patients with COVID-19, including acute hemorrhagic necrotizing encephalopathy and meningoencephalitis (3-5).The purpose of this study was to describe brain MRI findings in the evaluation of patients in the intensive care unit (ICU) with COVID-19 pneumonia. Materials and MethodsLocal institutional review board approval was obtained for this retrospective study for patients evaluated between March 1 and April 18, 2020.The requirement for informed consent was waived.The clinical course, neurologic findings, laboratory data (including cerebrospinal fluid analysis), and neuroimaging findings were retrospectively reviewed using a structured research form.Indications and timing for brain MRI in patients on mechanical ventilation were determined using a protocol established by ICU teams.Full details are in Appendix E1 (online).MRI scans were initially analyzed by neuroradiologists at the institution.Subsequently, all images were reviewed by two neuroradiologists (A.D., with 29 years of experience in neuroradiology and N.K., with 29 years of experience in neuroradiology) in consensus. ResultsOf 749 inpatients with COVID-19 infection at eight hospitals (two university hospitals and six university-affiliated hospitals), 235 patients (31%) required ICU admission during hospitalization.Fifty of the 235 ICU patients (21%; 95% confidence interval [CI]: 16%, 27%) developed neurologic symptoms.Brain MRI was performed in 27 of 50 patients (54%) with neurologic symptoms (Fig 1 , Table).The median age of patients who underwent MRI was 63 years (range, 34-87 years; 21 men).Twelve of 27 patients (44%, 95% CI: 25%, 65%) who underwent MRI had acute findings.In 10 of 27 patients (37%), cortical fluid-attenuated inversion recovery MRI scans showed signal intensity abnormality (Fig 2; Figures E1-E4 [online]).Accompanying subcortical and deep white matter signal intensity abnormality on fluid-attenuated inversion recovery images was seen in three patients.Abnormalities involved the frontal lobe in four patients, the parietal lobe in three patients, the occipital lobe in four patients, the temporal lobe in one patient, the insular cortex in three patients, and the cingulate gyrus in three patients.Cerobrospinal fluid was obtained in five of 10 patients with cortical signal intensity abnormalities.The total