Multifocal Necrotizing Leukoencephalopathy: Expanding the Clinicopathologic Spectrum

Premji, Sarah; Kang, Loveleen; Rojiani, Mumtaz V.; Kresak, Jesse; Rojiani, Amyn M.

doi:10.1093/jnen/nlz003

Cited by 5 publications

(3 citation statements)

References 17 publications

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“…One of our patients showed cavitary, necrotic-appearing lesions in regions with reduced diffusivity, suggestive of the MR imaging findings that accompany multifocal necrotizing leukoencephalopathy (Fig 3). 39 The anatomic distribution of these lesions resembled that of our other patients with leukoencephalopathy with reduced diffusivity; hence, this appearance may reflect a more advanced stage of white matter cellular injury, as was described in some early case reports of COVID-19-associated acute necrotizing encephalopathy. 39,40 This observational study has several limitations, including a small sample size, which could be affecting the potential effect of some clinical variables.…”

Section: Discussionsupporting

confidence: 78%

“…39 The anatomic distribution of these lesions resembled that of our other patients with leukoencephalopathy with reduced diffusivity; hence, this appearance may reflect a more advanced stage of white matter cellular injury, as was described in some early case reports of COVID-19-associated acute necrotizing encephalopathy. 39,40 This observational study has several limitations, including a small sample size, which could be affecting the potential effect of some clinical variables. The patients included in the study may reflect a proportion of those with severe COVID-19 in the ICU who were stable enough to have a brain MR imaging, potentially biasing this analysis.…”

Section: Discussionsupporting

confidence: 78%

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Clinical, Imaging, and Lab Correlates of Severe COVID-19 Leukoencephalopathy

Rapalino¹,

Pourvaziri²,

Maher³

et al. 2021

AJNR Am J Neuroradiol

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BACKGROUND AND PURPOSE: Patients infected with the Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) can develop a spectrum of neurological disorders, including a leukoencephalopathy of variable severity. Our aim was to characterize imaging, lab, and clinical correlates of severe coronavirus disease 2019 (COVID-19) leukoencephalopathy, which may provide insight into the SARS-CoV-2 pathophysiology.MATERIALS AND METHODS: Twenty-seven consecutive patients positive for SARS-CoV-2 who had brain MR imaging following intensive care unit admission were included. Seven (7/27, 26%) developed an unusual pattern of "leukoencephalopathy with reduced diffusivity" on diffusion-weighted MR imaging. The remaining patients did not exhibit this pattern. Clinical and laboratory indices, as well as neuroimaging findings, were compared between groups. RESULTS:The reduced-diffusivity group had a significantly higher body mass index (36 versus 28 kg/m 2 , P , .01). Patients with reduced diffusivity trended toward more frequent acute renal failure (7/7, 100% versus 9/20, 45%; P ¼ .06) and lower estimated glomerular filtration rate values (49 versus 85 mL/min; P ¼ .06) at the time of MRI. Patients with reduced diffusivity also showed lesser mean values of the lowest hemoglobin levels (8.1 versus 10.2 g/dL, P , .05) and higher serum sodium levels (147 versus 139 mmol/L, P ¼ .04) within 24 hours before MR imaging. The reduced-diffusivity group showed a striking and highly reproducible distribution of confluent, predominantly symmetric, supratentorial, and middle cerebellar peduncular white matter lesions (P , .001). CONCLUSIONS:Our findings highlight notable correlations between severe COVID-19 leukoencephalopathy with reduced diffusivity and obesity, acute renal failure, mild hypernatremia, anemia, and an unusual brain MR imaging white matter lesion distribution pattern. Together, these observations may shed light on possible SARS-CoV-2 pathophysiologic mechanisms associated with leukoencephalopathy, including borderzone ischemic changes, electrolyte transport disturbances, and silent hypoxia in the setting of the known cytokine storm syndrome that accompanies severe COVID-19.ABBREVIATIONS: BMI ¼ body mass index; COVID-19 ¼ coronavirus disease 2019; ICU ¼ intensive care unit; RT-PCR ¼ reverse transcription polymerase chain reaction; SARS-CoV-2 ¼ Severe Acute Respiratory Syndrome coronavirus 2; SOFA ¼ Sequential Organ Failure Assessment A mong the neurologic disorders associated with Severe Acute Respiratory Syndrome coronavirus-2 (SARS-CoV-2) 1-3 infection, there have been several reports of diffuse white matter abnormalities, including a "leukoencephalopathy with reduced diffusivity" on diffusion-weighted MR imaging. 4 This pattern of severe, bilateral white matter involvement appears to develop late in the course of coronavirus disease 2019 in critically ill patients and may be related to the prolonged hypoxemia that these patients experience, often even while asymptomatic. 5 Indeed, although leukoencephalopathy can result fr...

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Section: Discussionsupporting

confidence: 78%

Section: Discussionsupporting

confidence: 78%

Clinical, Imaging, and Lab Correlates of Severe COVID-19 Leukoencephalopathy

Rapalino¹,

Pourvaziri²,

Maher³

et al. 2021

AJNR Am J Neuroradiol

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“…Apoptosis (39) Axonal injury (15,39,81,86,103,119) Brain atrophy (67,68,74,93,110,112,126,127,129) Brain hyperplasia (120) Brain hypoplasia (55,57) Brain infarction (16,62,86,89,111,129,134) Cerebral abscesses (17,39,68,91,94,114,115) Demyelination (15,74,102,104,108,118,119,126,129,131) Edema (71,80,86,142,143) Hemorrhagic lesions (62, 63, 68-70, 72, 75, 88, 92, 93, 97, 99, 105, 143) Ischemic lesions (39,…”

Section: Injury Referencesmentioning

confidence: 99%

Postmortem Evidence of Brain Inflammatory Markers and Injury in Septic Patients: A Systematic Review

Barichello

Generoso

Dominguini

et al. 2021

Critical Care Medicine

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OBJECTIVES:Sepsis is a life-threatening organ dysfunction caused by a host's unregulated immune response to eliminate the infection. After hospitalization, sepsis survivors often suffer from long-term impairments in memory, attention, verbal fluency, and executive functioning. To understand the effects of sepsis and the exacerbated peripheral inflammatory response in the brain, we asked the question: What are the findings and inflammatory markers in the brains of deceased sepsis patients? To answer this question, we conducted this systematic review by the recommendations of Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

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