Griffith, Brent

Noujaim, Daniel

Patel, Suresh C

Poyiadji, Neo

Shahin, Gassan

Stone, Michael

English

Henry Ford Health System Scholarly Commons

Henry Ford Health System Henry Ford Health System Scholarly Commons Diagnostic Radiology Articles Diagnostic Radiology 8-1-2020 COVID-19-associated Acute Hemorrhagic Necrotizing Encephalopathy: Imaging Features Neo Poyiadji Gassan Shahin Daniel Noujaim Michael Stone Suresh C. Patel See next page for additional authors Follow this and additional works at: https://scholarlycommons.henryford.com/radiology_articles Authors Neo Poyiadji, Gassan Shahin, Daniel Noujaim, Michael Stone, Suresh C. Patel, and Brent Griffith REVIEWS AND COMMENTARY • IMAGES IN RADIOLOGYCOVID-19–associated Acute Hemorrhagic Necrotizing Encephalopathy: Imaging FeaturesNeo Poyiadji, MD • Gassan Shahin, MD • Daniel Noujaim, MD • Michael Stone, MD • Suresh Patel, MD • Brent Griffith, MDFrom the Department of Radiology, Henry Ford Health System, 2799 W Grand Blvd, Detroit, MI 48202. Received March 24, 2020; revision requested March 26; revision received March 26; accepted March 27. Address correspondence to B.G. (e-mail: brentg@rad.hfh.edu).Conflicts of interest are listed at the end of this article.Radiology 2020; 296:E119–E120 • https://doi.org/10.1148/radiol.2020201187 • Content codes:   • © RSNA, 2020Unenhanced CT of the head demonstrated symmetric low at-tenuation within the bilateral medial thalami with a normal CT angiogram and CT venogram (Fig 1). Brain MRI demon-strated hemorrhagic rim-enhancing lesions within the bilateral thalami, medial temporal lobes, and subinsular regions (Fig 2). The patient was started on intravenous immunoglobulin. High-dose steroids were not initiated due to concern for respi-ratory compromise.Acute necrotizing encephalopathy is a rare complication of influenza and other viral infections and has been related to in-tracranial cytokine storms, which result in blood-brain barrier breakdown but without direct viral invasion or parainfectious demyelination (3). Accumulating evidence suggests that a sub-group of patients with severe COVID-19 might have cytokine storm syndrome (4). Although predominantly described in the pediatric population, acute necrotizing encephalopathy is known to occur in adults as well. The most characteristic im-aging feature includes symmetric, multifocal lesions with in-variable thalamic involvement (5). Other commonly involved locations include the brainstem, cerebral white matter, and cer-ebellum (5). Lesions appear hypoattenuating on CT images, and MRI demonstrates T2-weighted fluid-attenuated inver-sion recovery hyperintense signal with internal hemorrhage. Contrast material–enhanced images may demonstrate a ring of contrast enhancement (5).To our knowledge, this is the first reported case of CO-VID-19–associated acute necrotizing hemorrhagic encepha-lopathy. As the number of patients with COVID-19 increases Since its introduction to the human population in Decem-ber 2019, the coronavirus disease 2019 (COVID-19) pan-demic has spread across the world with more than 330 000 reported cases in 190 countries, areas, or territories (1). While patients typically present with fever, shortness of breath, and cough, neurologic manifestations have been reported, al-though to a much lesser extent (2). Herein, we report on the first presumptive case of COVID-19–associated acute nec-rotizing hemorrhagic encephalopathy, a rare encephalopathy that has been associated with other viral infections but has yet to be demonstrated as a result of COVID-19 infection.A 58-year-old female airline worker presented with a 3-day history of cough, fever, and altered mental status. The initial laboratory work-up was negative for influenza, with the diag-nosis of COVID-19 made by detection of severe acute respira-tory syndrome coronavirus 2 (SARS-CoV-2) viral nucleic acid in a nasopharyngeal swab specimen using the U.S. Centers for Disease Control and Prevention 2019 novel coronavirus real-time reverse-transcription polymerase chain reaction assay. The assay was performed using a Cobas Z 480 analyzer (Roche, Basel, Switzerland) at our institution following emergency use authorization from the U.S. Centers for Disease Control and Prevention. Cerebrospinal fluid analysis was limited due to a traumatic lumbar puncture. However, cerebrospinal fluid bacterial culture showed no growth after 3 days, and tests for herpes simplex virus 1 and 2, varicella zoster virus, and West Nile virus were negative. Testing for the presence of SARS-CoV-2 in the cerebrospinal fluid was unable to be performed. Figure 1: A, Unenhanced CT scan of head demonstrates symmetric low attenuation within the bilateral medial thalami (arrows). B, Axial CT venogram demonstrates patency of the cerebral venous vasculature, including the internal cerebral veins (arrows). C, Coronal reformation of CT an-giogram demonstrates normal appearance of the basilar artery and proximal posterior cerebral arteries.This copy is for personal use only. To order printed copies, contact reprints@rsna.orgE120 radiology.rsna.org n Radiology: Volume 296: Number 2—August 2020COVID-19–associated Acute Hemorrhagic Necrotizing Encephalopathyworldwide, clinicians and radiologists should watch for these findings among patients presenting with COVID-19 and altered mental status.Disclosures of Conflicts of Interest: N.P. disclosed no relevant relationships. G.S. disclosed no relevant relationships. D.N. disclosed no relevant relationships. M.S. disclosed no relevant relationships. S.P. disclosed no relevant relationships. B.G. disclosed no relevant relationships.References 1. Coronavirus disease (COVID-19) Pandemic. World Health Organization. https://www.who.int/emergencies/diseases/novel-coronavirus-2019. Pub-lished March 23, 2020. Accessed March 23, 2020. 2. Filatov A, Sharma P, Hindi F, et al. Neurological complications of coronavirus (COVID-19): encephalopathy. Cureus 2020;12(3):e7352. 3. Rossi A. Imaging of acute disseminated encephalomyelitis. Neuroimaging Clin N Am 2008;18(1):149–161, ix. 4. Mehta P, McAuley DF, Brown M, et al. COVID-19: consider cytokine storm syndromes and immunosuppression. Lancet 2020;395(10229):1033–1034, 20, 30628–0 https://doi.org/10.1016/S0140-6736(20)30628-0. 5. Wong AM, Simon EM, Zimmerman RA, Wang HS, Toh CH, Ng SH. Acute necrotizing encephalopathy of childhood: correlation of MR find-ings and clinical outcome. AJNR Am J Neuroradiol 2006;27(9):1919–1923.Figure 2: A, B, E, F, T2-weighted fluid-attenuated inversion recovery MRI scans demonstrate hyperintensity within the bilateral medial temporal lobes and thalami (ar-rows), with evidence of hemorrhage indicated by, C, G, hypointense signal (arrows) on susceptibility-weighted images and, D, H, rim enhancement (arrows) on contrast material–enhanced images.

COVID-19-associated Acute Hemorrhagic Necrotizing Encephalopathy: Imaging Features

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COVID-19-associated Acute Hemorrhagic Necrotizing Encephalopathy: Imaging Features

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