key: cord-0823873-m686d54d
authors: Jain, Rajan; Young, Matthew; Dogra, Siddhant; Kennedy, Helena; Nguyen, Vinh; Jones, Simon; Bilaloglu, Seda; Hochman, Katherine; Raz, Eytan; Galetta, Steven; Horwtiz, Leora
title: COVID-19 related neuroimaging findings: A signal of thromboembolic complications and a strong prognostic marker of poor patient outcome
date: 2020-05-19
journal: J Neurol Sci
DOI: 10.1016/j.jns.2020.116923
sha: 67f3c89540457efb8d9ded98a9a4936b447234a0
doc_id: 823873
cord_uid: m686d54d

OBJECTIVE: To investigate the incidence and spectrum of neuroimaging findings and their prognostic role in hospitalized COVID-19 patients in New York City. METHODS: This is a retrospective cohort study of 3218 COVID-19 confirmed patients admitted to a major healthcare system (three hospitals) in New York City between March 1, 2020 and April 13, 2020. Clinical data were extracted from electronic medical records, and particularly data of all neurological symptoms were extracted from the imaging reports. Four neuroradiologists evaluated all neuroimaging studies for acute neuroimaging findings related to COVID-19. RESULTS: 14.1% of admitted COVID-19 patients had neuroimaging and this accounted for only 5.5% of the total imaging studies. Acute stroke was the most common finding on neuro-imaging, seen in 92.5% of patients with positive neuro-imaging studies, and present in 1.1% of hospitalized COVID-19 patients. Patients with acute large ischemic and hemorrhagic stroke had much higher mortality risk adjusted for age, BMI and hypertension compared to those COVID-19 patients without neuroimaging. (Odds Ratio 6.02 by LR; Hazard Ratio 2.28 by CRR). CONCLUSIONS: Our study demonstrates acute stroke is the most common neuroimaging finding among hospitalized COVID-19 patients. Detection of an acute stroke is a strong prognostic marker of poor outcome. Our study also highlights the fact there is limited use of neuroimaging in these patients due to multiple logistical constraints.

Involvement of the nervous system with SARS-CoV-2 infection has been documented; [1] [2] [3] [4] however, the incidence of neurological complications based on use of neuroimaging and its prognostic role in hospital admitted COVID-19 patients is not well studied. Two mechanisms of virus injury are hypothesized: (1) direct-virus injury and (2) cytokine storm. Angiotensinconverting enzyme 2 (ACE2) is a human cell receptor with a strong binding affinity to the Spike protein of SARS-CoV-2. ACE2 is highly expressed in type II alveolar cells, intestinal epithelia, vascular endothelium, and cardiac muscle. ACE2 is also identified in the nervous system leading to direct-virus injury 1 . A subgroup of patients might have severe cytokine storm consistent with secondary hemophagocytic lymphohistiocytosis causing a fatal hypercytokinemia with multiorgan failure. Indirect mechanism of neurological injury mainly relates to increased coagulation activity, markedly increased D-dimer concentrations in these patients 5, 6 leading to increased risk of thromboembolic stroke 7 as well as compromised cardiac status due to associated cardiac injury 8 . We describe use of neuroimaging, incidence and spectrum of acute neuroimaging findings and their prognostic role in hospitalized COVID-19 patients in New York City. 38 patients had acute neuroimaging findings (8.4% of those who underwent neuroimaging and 1.2% of the total hospital admitted COVID-19 patients); and 35 patients had stroke (7.7% of those who had neuroimaging and 1.1% of COVID-19 inpatients) ( Table 1) .

Thromboembolic ischemic stroke comprised 68.5% of these 38 patients and hemorrhagic stroke was present in 24% (Fig 1) . Signs of acute stroke were the initial manifestation of COVID-19 in 63% of these 38 patients. (65% of all ischemic stroke and 44.5% of hemorrhagic strokes). 66.5% of all hemorrhagic stroke were on anti-coagulation therapy. Only 1 patient (2.5%) showed imaging findings consistent with encephalitis and 2 patients (5%) had hypoxic anoxic injury. The underdiagnosed. Finally, critically ill patients are often sedated, making it difficult to identify new neurologic complications. Hence, obtaining more expert neurology consultations, detailed neurological examinations and neuroimaging for early and accurate diagnosis of these often fatal neurological complications could improve our understanding of the disease and its neurological manifestations.

Community acquired pneumonias are known to be associated with hypercoaguability 5,6. It is no surprise that emerging evidence shows that COVID-19 may also predispose patients to both venous and arterial thromboembolism due to diffuse intravascular coagulation, hypoxia, cytokine storm and immobilization 6 . High D-dimer levels, a marker of inflammation, are known to be associated with poor outcome in COVID-19 8 . Acute strokes seen in the current study are also likely related to thromboembolic disease and majority were present at the initial admission. Most importantly, our data demonstrates for the first time, that when a neuroimaging shows acute large ischemic stroke or hemorrhagic stroke in admitted COVID-19 patients, it is one of the strongest prognostic markers of poor outcome, even more than age and other previously reported comorbidities such as hypertension and obesity 8 . COVID-19 patients who have a large ischemic or hemorrhagic stroke on imaging have a 50% mortality in the current study.

In conclusion, our study demonstrates that acute stroke is the most common COVID-19 related neuroimaging finding and its incidence is 1.1% in hospitalized COVID-19 patients. The discovery of acute stroke by neuroimaging is a strong prognostic marker of poor outcome. Our study also highlights the fact there is restricted use of neuroimaging in COVID-19 patients due to multiple logistical constraints including the severity of their illness and the concern of spread of infection by imaging. 

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Scoping review of prevalence of neurologic comorbidities in patients hospitalized for COVID-19

Neurological complications of coronavirus and COVID-19

Prevalence and significance of coagulation abnormalities in community-acquired pneumonia

Incidence of thrombotic complications in critically ill ICU patients with COVID-19

Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Persons for Coronavirus Disease

Healthcare Cost and Utilization Project (HCUP)

Collateral Effect of Covid-19 on Stroke Evaluation in the United States

Things We Do for No Reason: Neuroimaging for Hospitalized Patients with Delirium