COVID-19 complicated by leukoencephalopathy and cerebral microhemorrhages

Case contributed by Tom Elswood

Presentation

Admitted to critical care with severe COVID-19 pneumonitis. Difficulty weaning off ventilation with persistently low GCS.

Patient Data

Age: 35 years
Gender: Male

Diffuse bilateral alveolar opacities, most likely in keeping with COVID-19 viral pneumonitis.

Leukoencephalopathy with an almost global distribution, although some central white matter structures are spared. Additional bifrontal juxtacortical microhemorrhages. Possibly global sulcal effacement, but sulci are typically slim in young patients. 

COVID-19 is thought the main etiology.

Performed 1 week following initial CT.

As before, there is diffuse white matter low attenuation with sulcal effacement in keeping with diffuse brain swelling.  Preservation of grey-white matter differentiation.  The previously seen petechial hemorrhages are not well demonstrated on the current examination. 

Innumerable scattered micro-hemorrhages throughout the grey and white matter.
Very subtle petechial hemorrhages in the cerebellum.

There is a subtle focus of diffusion restriction in the left frontal lobe in the subcortical white matter.

No major territorial infarction. 

No evidence of cerebral edema. No enhancing lesions seen.

Normal outline of the CSF spaces.

Case Discussion

This young, previously fit and well, man presented to hospital 8 days into a COVID-19 illness. He was unvaccinated at the time of presentation. No medical history aside from childhood asthma. No regular medications.

He initially required high levels of non-invasive ventilatory support and ultimately required intubation. Attempts to extubate were complicated by reduced GCS, which prompted the initial CT. This shows a recognized complication of COVID-19 infection - leukoencephalopathy and cerebral microhemorrhages 1.

A subsequent CT venogram excluded cerebral venous sinus thrombosis.

After a week a second plain CT of the head showed resolving hemorrhagic foci but ongoing leukoencephalopathy.

An MRI at 3 weeks following the initial CT shows near-resolution of the leukoencephalopathy but well demonstrated foci of susceptibility change consistent with hemosiderin deposition and therefore resolved hemorrhagic foci - more widespread than initially thought.

The patient was discharged after 2 months in hospital and is recovering with rehabilitation input.

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