BackgroundAltered mentation in COVID-19 patients can be a function of any number of metabolic abnormalities associated with the infection. Here we present the case of an encephalopathic COVID-19 patient with bilateral globus pallidus lesions. While imaging abnormalities involving basal ganglia have been reported in encephalitis caused by neuroinvasive flaviviruses, the bipallidal lesions noted here likely resulted from hypoxic-ischemic brain injury.Case PresentationA 51-year-old African American woman was found unresponsive at home by her fiancé. She had been complaining of shortness of breath and cough for three days. She is a former smoker with past medical history of hypertension, nephropathy, and bipolar disorder. Upon examination, she was alert but nonverbal, following commands inconsistently, and unable to move extremities against gravity. After several minutes, she was able to state her name but kept repeating it in response to all questions. Chest radiograph revealed bilateral lung infiltrates. CT of the head showed hypodensities in bilateral globus pallidi. A non-contrast MRI of the brain showed symmetric restricted diffusion and FLAIR hyperintense signal changes in bilateral globus pallidi. Abnormal SWI signal seen in bilateral globus pallidi likely represents mineralization or hemosiderin. There were no striatal or thalamic lesions. Major intracranial arteries were widely patent.The patient later tested positive for 2019-nCoV using real-time PCR assay, and was transferred to our COVID-19 designated hospital campus. Thereafter, she had waxing and waning mentation. Repeat CT imaging 11 days after the first scan demonstrated resolution of the bipallidal hypodensities. The patient was recently discharged to a subacute rehab facility but is still experiencing confusion.ConclusionsAs we come across neurological manifestations of COVID-19, we believe neuroimaging is likely to play an important role in establishing if central nervous system involvement is invariably due to indirect mechanisms such as metabolic or hypoxic-ischemic brain injury or if direct neuroinvasive disease is a possibility, as with certain viruses.

Background: COVIDTrach is a UK multi-centre prospective cohort study project evaluating the outcomes of tracheostomy in patients with COVID-19 receiving mechanical ventilation. It also examines the incidence of SARS-CoV-2 infection among healthcare workers involved in the procedure. Method: An invitation to participate was sent to all UK NHS departments involved in tracheostomy in mechanically ventilated patients with COVID-19. Data was entered prospectively and clinical outcomes updated over time via an online database (REDCap). Clinical variables were compared with clinical outcomes using multivariable regression analysis, with logistic regression used to develop a prediction model for mortality. Participants recorded whether any of the operators tested positive for SARS-CoV-2 within two weeks of the procedure. Findings: The cohort comprised 1605 tracheostomy cases from 126 UK hospitals. The median time from intubation to tracheostomy was 15 days (IQR 11, 21). 285 (18%) patients died following the procedure. 1229 (93%) of the survivors had been successfully weaned from mechanical ventilation at censoring and 1049 (81%) had been discharged from hospital. Age, inspired oxygen concentration requirement on the day of tracheostomy, PEEP setting, pyrexia, number of days of ventilation before tracheostomy, C-reactive protein and the use of anticoagulation and inotropic support independently predicticted mortality. Six reports were received of operators testing positive for SARS-CoV-2 within two weeks following the procedure. Interpretation: Tracheostomy appears to be safe in mechanically ventilated patients with COVID-19 and to operators performing the procedure and we identified clinical indicators that are predictive of mortality. Optimal timing of the procedure remains to be determined. Funding: The COVIDTrach project is supported by the Wellcome Trust UCL COVID-19 Rapid Response Award and the National Institute for Health Research.