Objectives To describe the extent and imaging findings of COVID-associated rhino-orbital-cerebral mucormycosis on magnetic resonance imaging and to evaluate the value of MRI severity score in grading the extent of involvement. Methods Proven cases of ROCM with a history of concurrent or recently (<6 weeks) treated COVID-19 underwent MRI at the initial presentation. Findings were charted for each anatomical structure and the extent of involvement was scored for sinonasal, extra-sinus soft tissues, orbits, and brain. MR severity score was defined by summing up the individual scores of each compartment (sinonasal 20, orbital 20, soft tissue 10, and brain 10) and a total score out of 60 was assigned. Results A total of 47 patients were included in our study with variable involvement of sinonasal compartment ( n = 43), extra-sinus soft tissue ( n = 25), orbits ( n = 23), and brain ( n = 17). In the sinonasal compartment, T2, DWI, and post-contrast T1 were the most useful sequences. A significantly higher mean sinonasal score was associated with mortality ( p = 0.007). In the orbits, a combination of STIR (orbital fat and extraconal muscles), DWI (optic nerves), and post-contrast images (superior ophthalmic vein) were the most accurate sequences. A higher mean orbital score was associated with vision loss ( p = 0.001). Patients with uncontrolled diabetes had greater extent of cranial involvement. Conclusion A combination of magnetic resonance sequences is required to correctly evaluate the involvement of individual structures and thus to assign the correct MR scoring. The proposed MR severity score can effectively and objectively evaluate the severity of COVID-associated ROCM.

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