Query: coved 19 CT BRAIN

title: Covid 19 related encephalopathy: a case series with brain FDG PET/CT findings
abstract: A variety of neurological manifestations have been reported in association with Covid 19. Covid 19 related encephalopathy has seldom been reported and studied.  We report four cases of Covid 19 related encephalopathy. The diagnosis was made in patients with confirmed Covid 19 who presented with new onset cognitive disturbances, central focal neurological signs or seizures. All patients underwent cognitive screening, brain MRI, lumbar puncture, and brain FDG PET/CT.  The four patients were 60 years of age or older, and presented with various degrees of cognitive impairment, with predominant frontal lobe impairment. Two patients presented with cerebellar syndrome, one had myoclonus, one had psychiatric manifestations, and one patient had status epilepticus. The delay between first Covid 19 symptoms and onset of neurological symptoms was between 0 and 12 days. None of the patients had MRI features of encephalitis nor significant CSF abnormalities. SARS CoV 2 RT PCR in the CSF was negative for all patients. All patients presented with a consistent brain FDG PET/CT pattern of abnormalities, namely frontal hypometabolism and cerebellar hypermetabolism. All patients improved after immunotherapy.  Despite varied clinical presentations, all patients presented with a consistent FDG PET pattern which may reflect an immune mechanism.

title: Neuroimaging findings of brain MRI and CT in patients with COVID 19: A systematic review and meta analysis
abstract: To comprehensively evaluate the incidences of abnormal neuroimaging findings in patients with COVID 19 via a systematic review and meta analysis.  PubMed MEDLINE and EMBASE were searched for original articles reporting imaging findings of the brain in adult patients with COVID 19 between January 1, 2020 and October 9, 2020. Abnormal neuroimaging findings were categorized as (1) cerebral microhemorrhages, (2) acute spontaneous intracranial hemorrhage (ICH) (3) acute to subacute infarcts, and (4) encephalitis or encephalopathy. Pooled incidences of neuroimaging findings were assessed using random effects modeling. Between study heterogeneity was explored by using the kh2 statistic for pooled incidences and the inconsistency index I 2. The quality of the studies was evaluated using the Risk of Bias Assessment Tool for Nonrandomized Studies. Subgroup meta regression analysis was performed to identify potential sources of heterogeneity.  Twenty one eligible papers, including 2125 patients, were identified. The pooled incidences of cerebral microhemorrhages, acute spontaneous ICH, acute/subacute infarcts, and encephalitis/encephalopathy were 6.9 (95 confidence interval [CI] 4.9 8.9 5.4 (95 CI, 3.1 7.6 24.0 (95 CI, 16.1 31.8 and 3.3 (95 CI, 1.9 4.7 respectively. Substantial heterogeneities were noted for all neuroimaging findings (I 2 87 97 Significant publication biases were present in the pooled incidences. In the subgroup meta regression analysis, patients with mean or median ages over 65 years showed a significantly lower incidence of encephalitis/encephalopathy (P 0.001) Furthermore, studies reported that patients in ICU had significantly higher incidences of cerebral microhemorrhages (P 0.001) and encephalitis/encephalopathy (P 0.001)  Considerable incidences of abnormal neuroimaging findings have been reported in patients with COVID 19. Acute to subacute cerebral infarction was the most prevalent neuroimaging finding.

title: COVID 19 associated acute cerebral venous thrombosis: clinical, CT, MRI and EEG features
abstract: Dear editor, Many recent COVID 19 series have reported arterial or venous thrombosis (stroke, pulmonary embolism, etc.  Here, we report a case of COVID 19 associated cerebral venous thrombosis (CVT) with dramatic evolution. On April 3, 2020, a 63 year old female presented to the emergency department because of aphasia and right hemiplegia. She had a 12 day history of fever, cough, and anosmia. Her husband was hospitalized in intensive care for confirmed COVID 19 acute respiratory distress syndrome (ARDS) Brain MRI showed a large left temporal brain hemorrhage and a suspicion of CVT confirmed on a venous brain CT scan and chest CT showed typical COVID 19 patchy ground glass opacities in both lungs  The patient suddenly suffered a clinical status epilepticus and was administered i.v. lacosamide. Laboratory results showed hyperfibrinogenemia (7.2 g/L) and high ferritin levels (1427 mg/L) The nasopharyngeal and bronchial samples were negative for SARS CoV 2. Most common causes of genetic thrombotic disorders and antiphospholipid antibody syndrome were excluded. The patient was started on an intravenous curative dose of heparin anticoagulation. Electroencephalograpy (EEG) showed background theta activity unreactive to nociceptive stimulus, with pseudo periodic activity of a short period composed of slow di phasic waves irradiating towards the anterior regions  Although subtle status epilepticus could not be excluded, the aspect was not typical and other successive EEG traces would confirm this non epileptic paroxystic pseudo periodic pattern. The patient eventually underwent surgical intracranial hematoma evacuation followed by decompressive craniectomy. On April 17th, brain CT scan revealed a new intracranial contralateral bleeding most likely following contralateral venous thrombosis despite being properly treated with intravenous heparin. Venous angiography showed persistent left thrombosis  On April 25th, the patient was tested positive for SARS CoV 2 plasmatic IgG and IgM (ELISA test) On April 29th, the patient died following therapeutic limitation after ethical consultation group expertise. Although both samples were negative for SARS CoV2, we considered the patient infected by it, given the initial symptomatology, the confirmed infection in one relative, the specific aspect of the thoracic CT scan [3] and the positive serology. Furthermore, in this case, the thrombotic event occurred 12 days after the first

title: Admission Perfusion CT for Classifying Early In Hospital Mortality of Patients With Severe Traumatic Brain Injury: A Pilot Study.
abstract: The purposes of this study were to assess the feasibility and safety of perfusion CT of patients with severe traumatic brain injury (TBI) at hospital admission and to examine whether early in hospital mortality could be characterized with perfusion CT (PCT) The hypothesis was that PCT can be used to characterize brain death, when present, in patients with severe TBI at hospital admission.  In this prospective cohort pilot study, PCT was performed on patients with severe TBI at first imaging workup at hospital admission. PCT images were processed at the end of the study and assessed for features of brain death. The PCT features were then compared with the clinical outcome of in hospital mortality.  A total of 19 patients (13 men [68.4% six women [31.6% mean age, 36.4 years; median, 27.5 years) had a mean hospital stay longer than 1 month. No complications of PCT were found. In the first 48 hours after admission, four patients (21% died. Admission PCT changes suggesting brainstem death were sensitive (75% and specific (100% and had high positive (100% and negative (93.75% predictive value for correct classification early in hospital mortality.  Admission PCT of patients with severe TBI was feasible and safe. Admission PCT findings helped in correctly classifying early in hospital mortality in the first 48 hours of hospital admission.

title: Early postmortem brain MRI findings in COVID 19 non survivors
abstract: The severe acute respiratory syndrome coronavirus 2 (SARS CoV 2) is considered to have potential neuro invasiveness that might lead to acute brain disorders or contribute to respiratory distress in patients with coronavirus disease 2019 (COVID 19) Brain magnetic resonance imaging (MRI) data in COVID 19 patients are scarce due to difficulties to obtain such examination in infected unstable patients during the COVID 19 outbreak.  To investigate the occurrence of structural brain abnormalities in non survivors of COVID 19 in a virtopsy framework.  Prospective, case series study with postmortem brain MRI obtained early <24h) after death.  Monocentric study.  From 31/03/2020 to 24/04/2020, consecutive decedents who fulfilled the following inclusion criteria were included: death <24 hours, SARS CoV 2 detection on nasopharyngeal swab specimen, chest computerized tomographic (CT) scan suggestive of COVID 19, absence of known focal brain lesion, and MRI compatibility.  Signs of acute brain injury and MRI signal abnormalities along the olfactory tract and brainstem were searched independently by 3 neuroradiologists, then reviewed with neurologists and clinicians.  Among the 62 patients who died from COVID 19 during the inclusion period, 19 decedents fulfilled inclusion criteria. Subcortical micro and macro bleeds (2 decedents) cortico subcortical edematous changes evocative of posterior reversible encephalopathy syndrome (PRES, one decedent) and nonspecific deep white matter changes (one decedent) were observed. Asymmetric olfactory bulbs were found in 4 other decedents without downstream olfactory tract abnormalities. No brainstem MRI signal abnormality.  Postmortem brain MRI demonstrates hemorrhagic and PRES related brain lesions in non survivors of COVID 19 that might be triggered by the virus induced endothelial disturbances. SARS CoV 2 related olfactory impairment seems to be limited to olfactory bulbs. The absence of brainstem MRI abnormalities does not support a brain related contribution to respiratory distress in COVID 19.

title: COVID 19 related acute necrotizing encephalopathy with brain stem involvement in a patient with aplastic anemia
abstract: To describe a novel case of coronavirus disease 2019 (COVID 19) associated acute necrotizing encephalopathy (ANE) in a patient with aplastic anemia where there was early brain stem predominant involvement.  Evaluation of cause, clinical symptoms, and treatment response.  A 59 year old woman with a background of transfusion dependent aplastic anemia presented with seizures and reduced level of consciousness 10 days after the onset of subjective fever, cough, and headache. Nasopharyngeal swab testing for severe acute respiratory syndrome coronavirus (SARS CoV 2) was positive, and CT during admission demonstrated diffuse swelling of the brain stem. She required intubation and mechanical ventilation for airway protection, given her reduced level of consciousness. The patient's condition deteriorated, and MRI on day 6 demonstrated worsening brain stem swelling with symmetrical hemorrhagic lesions in the brain stem, amygdalae, putamina, and thalamic nuclei. Appearances were consistent with hemorrhagic ANE with early brain stem involvement. The patient showed no response to steroid therapy and died on the eighth day of admission.  COVID 19 may be associated with an acute severe encephalopathy and, in this case, was considered most likely to represent an immune mediated phenomenon. As the pandemic continues, we anticipate that the spectrum of neurologic presentation will broaden. It will be important to delineate the full clinical range of emergent COVID 19 related neurologic disease.

title: COVID 19 in the act: incidental 18F FDG PET/CT findings in asymptomatic patients and those with symptoms not primarily correlated with COVID 19 during the United Kingdom coronavirus lockdown
abstract: The emergence of the novel SARS CoV 2 pathogen and lethal COVID 19 disease pandemic poses major diagnostic challenges. The study aims to describe the spectrum and prevalence of thoracic and extrathoracic incidental findings in patients who have undergone 18F FDG PET/CT during the first 3 weeks of the COVID 19 UK lockdown.  This is a single centre retrospective controlled observational study. 18F FDG PET/CT scans n 160) acquired from 23/3/2020 to 9/4/2020 were retrospectively reviewed for incidental findings in the lungs and extrapulmonary sites (heart, nasal sinuses, parotid and salivary glands, colon, large vessels, renal cortex, brain, spleen and testes) A date matched control group n 205) of patients from 2019 was used for comparison.  The total prevalence of suspicious findings was 26/160 (16.25% Fifteen patients presented with incidental findings in the lungs, while eleven patients had only non pulmonary incidental findings. There was a significant increase in the appearance of incidental 18F FDG PET/CT findings during the 2nd week (OR 3.8) and 3rd week (OR 7.6) in relation to the 1st week. There was a significant increase in the average maximum standardised uptake values (SUVmax) in the parotid/salivary glands of patients scanned during week 2 in relation to week 1 p 0.036) There was no significant difference in the prevalence of incidental findings compared to the control group, but the number of pulmonary vs. extrathoracic findings was different between the two populations.  The study provides a novel base of evidence to identify asymptomatic patients and those without symptoms strongly associated with COVID 19 with incidental 18F FDG PET/CT findings suspicious of SARS CoV 2 infection during the initial stages of the pandemic.

title: Early postmortem brain MRI findings in COVID 19 non survivors
abstract: The severe acute respiratory syndrome coronavirus 2 (SARS CoV 2) is considered to have potential neuroinvasiveness that might lead to acute brain disorders or contribute to respiratory distress in patients with coronavirus disease 2019  This study investigates the occurrence of structural brain abnormalities in non survivors of COVID 19 in a virtopsy framework.  In this prospective, monocentric, case series study, consecutive patients who fulfilled the following inclusion criteria benefited from an early postmortem structural brain MRI: death <24 hours, SARS CoV 2 detection on nasopharyngeal swab specimen, chest CT scan suggestive of COVID 19, absence of known focal brain lesion, and MRI compatibility.  Among the 62 patients who died of COVID 19 from March 31, 2020, to April 24, 2020, at our institution, 19 decedents fulfilled the inclusion criteria. Parenchymal brain abnormalities were observed in 4 decedents: subcortical microbleeds and macrobleeds (2 decedents) cortico subcortical edematous changes evocative of posterior reversible encephalopathy syndrome (PRES; 1 decedent) and nonspecific deep white matter changes (1 decedent) Asymmetric olfactory bulbs were found in 4 other decedents without downstream olfactory tract abnormalities. No brainstem MRI signal abnormality was observed.  Postmortem brain MRI demonstrates hemorrhagic and PRES related brain lesions in non survivors of COVID 19. SARS CoV 2 related olfactory impairment seems to be limited to olfactory bulbs. Brainstem MRI findings do not support a brain related contribution to respiratory distress in COVID 19.

title: Brain Imaging Use and Findings in COVID 19: A Single Academic Center Experience in the Epicenter of Disease in the United States
abstract: Coronavirus disease 2019 (COVID 19) is a serious public health crisis and can have neurologic manifestations. This is a retrospective observational case series performed March 1 31, 2020, at New York University Langone Medical Center campuses. Clinical and imaging data were extracted, reviewed, and analyzed. Two hundred forty two patients with COVID 19 underwent CT or MRI of the brain within 2 weeks after the positive result of viral testing (mean age, 68.7 16.5 years; 150 men/92 women [62.0%/38.0% The 3 most common indications for imaging were altered mental status (42.1% syncope/fall (32.6% and focal neurologic deficit (12.4% The most common imaging findings were nonspecific white matter microangiopathy (134/55.4% chronic infarct (47/19.4% acute or subacute ischemic infarct (13/5.4% and acute hemorrhage (11/4.5% No patients imaged for altered mental status demonstrated acute ischemic infarct or acute hemorrhage. White matter microangiopathy was associated with higher 2 week mortality (P .001) Our data suggest that in the absence of a focal neurologic deficit, brain imaging in patients with early COVID 19 with altered mental status may not be revealing.

title: Letter to editor: Severe brain haemorrhage and concomitant COVID 19 Infection: A neurovascular complication of COVID 19
abstract: Beyond pulmonary infection, SARS CoV can cause dysfunction of multiple other organs and systems. Cardiovascular complications after COVID 19 have now been reported very often but the knowledge on neurovascular complications especially brain haemorrhage is scars. Here, we report the first case of COVID 19 positive patient presenting with a concomitant subarachnoid haemorrhage from an intracranial aneurysm. A 60 year old woman was admitted to our emergency department due to loss of consciousness. The patient was intubated due to reduced Glasgow Coma Scale (GCS) and respiratory insufficiency. A computer tomography (CT) with CT angiography revealed left frontal haemorrhage with ventricle bleeding  from a ruptured pericallosal artery aneurysm around 5 mm in size (Fig. 1C, F) Oropharyngeal swab with PCR based testing was COVID 19 positive. A chest CT confirmed pneumonia predominantly of left lung  On admission laboratory diagnostic showed elevated troponin 45 ng/ ml (normal 14 ng/ ml) and creatine kinase 4920 U/l (normal 145 U/l) Elevated CRP 1.1 mg /dl and leukocytes 14.2X1000 ml. Slightly elevated lactate dehydrogenase 360 U/l (normal 247 U/l) and elevated liver enzyme GOT 103 U/I (normal 31 U/l) The aneurysm was clipped microsurgically immediately after admission. After clipping of the aneurysm, due to positive COVID 19 PCR, the patient was transferred to a COVID 19 specialized ward for the treatment of infection and for the further intensive medical care. Cerebrospinal fluid (CSF) diagnostic revealed no viral genome in the CSF. Initially elevated troponin was normalized in the further course and no cardiac complication occurred. CT perfusion studies on day 3, 6, 9 and 12 showed no signs of cerebral vasospasm. Until last imaging on day 12 post ictus no delayed cerebral ischemia was detected. Patient still needs the treatment of pneumonia. Due to poor grade subarachnoid haemorrhage (WFNS grad 4) the patient is completely cured from COVID 19 and now transferred for rehabilitation. Involvement of other organs especially the brain and the cardiovascular system increase additional morbidity and mortality in COVID19 infected patients. The elderly patients with chronic medical conditions are particularly at risk to develop neurological complications including olfactory and gustatory disturbances (Vavougios, 2020) and in some cases an encephalitis (Ye et al. 2020) showing the possible accessibility of the virus to the brain and involvement of central nervous system (Duong et al. 2020) Moreover, COVID 19 infection can pose emotional and psychological stress in affected patients (Chew et al. 2020) This is the first case of COVID19 infection and concomitant aneurysmal subarachnoid haemorrhage from a ruptured pericallosal artery aneurysm. Whether COVID 19 infection led to aneurysm formation or rupture of an already existing aneurysm is still unexplored. There are however, multiple mechanisms, how an intracranial aneurysm can possibly lead to vascular wall instability during systemic inflammation due to viral infection. Viral infections including influenza A and COVID19 are known to induce cytokine storm (hypercytokinemia) leading to elevated systemic inflammation with high levels of IL 6, IL 1b and TNFa (Muhammad et al. 2011; Qin et al. 2020) Systemic inflammation is known to cause vascular injury including breakdown of collagen and permeability of blood brain barrier. Influenza A virus infection for example disturbs BBB through involvement of systemic elevated MMP 9 that breaks collagen present in the basal membrane of every arterial wall and a high collagen turnover in the systemic circulation is a sign of instability of existing intracranial aneurysm (Hackenberg et al. 2020) in patients with unruptured intracranial aneurysms. Moreover, COVID19 infection has been reported to increase systemic inflammation through dysbalance of T helper cells with exaggerated Th1 response (Huang et al. 2020) Similar kind of alterations in T helper cells populations have been found in patients with intracranial aneurysms (Zhang et al. 2016) Moreover, a disturbed balance of macrophages and other inflammatory markers has been found in the wall of ruptured intracranial aneurysms (Hasan et al. 2012) showing that inflammation is an important component of instable aneurysms. In our patient, we found elevated systemic leukoctyes as a sign of systemic inflammation that is probably due to both infection and SAH. We however could not analyse subpopulations of different leukocytes in systemic circulation that might be altered. Another possibility could be a direct invasion of virus in the brain as previously reported (Duong et al. 2020) However, we did not find virus genome in the cerebrospinal fluid and consequently it is highly unlikely that virus had any direct influence. Taken together, aneurysm instability partially due to systemic inflammation after virus infection might be one possible reason leading to SAH. This is however a single case report with concomitant SAH and COVID 19. Therefore, further epidemiological/clinical studies are needed to confirm the relationship and animal experiments in controlled conditions are required to find out exact mechanism.