Multiple Microbleeds: A Serious Neurological Manifestation in a Critically Ill COVID-19 Patient

Abstract

Coronavirus disease 2019 (COVID-19) is a viral illness caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). There is worldwide emerging evidence of multisystem involvement including different neurological manifestations in COVID-19 patients. As a result, healthcare systems worldwide are not only experiencing diagnostic but also therapeutic and prognostic challenges with COVID-19-related complications. Cerebral microbleeds and leukoencephalopathy have been described in COVID-19 patients; although the mechanism remains unknown, possibilities include endotheliitis with thrombotic microangiopathy, excessive inflammation, prolonged respiratory failure, and hypoxemia. We describe here the clinical, radiological, and laboratory findings as well as the 90-day outcome of a 72-year-old gentleman who presented with severe SARS-CoV-2 infection, leading to diffuse cerebral microhemorrhages and ischemic infarct causing severe morbidity. He was tested positive for COVID-19 confirmed by reverse transcriptase polymerase chain reaction.

Modeling SARS-CoV-2: Comparative Pathology in Rhesus Macaque and Golden Syrian Hamster Models

“… 37 - 39 In humans, COVID-19-associated brain pathologies, such as encephalitis, cerebral microbleeds, stroke, and diffuse leukoencephalopathy are described, and it is hypothesized that inflammation of blood vessels secondary to virus binding of endothelium (rich in ACE2) results in subsequent breaks and leaks. 37 , 38 Another potential route for viral entry into the brain following intranasal inoculation could be through the olfactory nerve that provides a pathway between the olfactory bulb, located near the nasal cavity, and the brain; however, a recent review suggests a weak case for infection through this route. 40 There are little data on SARS-CoV-2-related encephalitis in nonhuman primates.…”

Cerebral small vessel disease pathology in COVID-19 patients: A systematic review

“… 49 y/o Acute No No n/a MRI sequence: FLAIR, DWI, ADC, SWAN No large vessel occlusion; 2 small cortical acute ischemic lesions in pre and postcentral gyrus. ( Haroon et. al., 2020 ) Case-report COVID-19 positive patient admitted to ICU.…”

“…Twenty-nine case reports were included detailing patients with COVID-19-induced cerebromicrovascular complications with neuroimaging indicative of MB and/or small vessel ischemic lesions or infarctions ( Table 1 ). Eighteen out of twenty-nine case reports presented patients who were admitted to the ICU due to respiratory failure/distress and required one or more of the following: intubation, mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) ( Ahmed et al, 2022 , Backman et al, 2022 , Cannac et al, 2020 , De Stefano et al, 2020 , Elshereye and Erdinc, 2020 , Gupta et al, 2020 , Hanafi et al, 2020 , Haroon et al, 2020 , Neppala et al, 2021 , Petersson et al, 2022 , Planinc et al, 2020 , Reichard et al, 2020 , Rudilosso et al, 2020 , Shoskes et al, 2020 , Toeback et al, 2021 , Tristán-Samaniego et al, 2022 , Vattoth et al, 2020 , Witvoet et al, 2021 ). MB were seen in 17/29 case reports ( Backman et al, 2022 , Cannac et al, 2020 , De Stefano et al, 2020 , Finsterer, 2022 , Fraiman et al, 2020 , Gupta et al, 2020 , Hanafi et al, 2020 , Haroon et al, 2020 , Liang et al, 2021 , Petersson et al, 2022 , Planinc et al, 2020 , Reichard et al, 2020 , Rudilosso et al, 2020 , Shoskes et al, 2020 , Toeback et al, 2021 , Tristán-Samaniego et al, 2022 , Vattoth et al, 2020 , Witvoet et al, 2021 ) with 14/17 being in patients with severe pulmonary/respiratory complications.…”

“…Eighteen out of twenty-nine case reports presented patients who were admitted to the ICU due to respiratory failure/distress and required one or more of the following: intubation, mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) ( Ahmed et al, 2022 , Backman et al, 2022 , Cannac et al, 2020 , De Stefano et al, 2020 , Elshereye and Erdinc, 2020 , Gupta et al, 2020 , Hanafi et al, 2020 , Haroon et al, 2020 , Neppala et al, 2021 , Petersson et al, 2022 , Planinc et al, 2020 , Reichard et al, 2020 , Rudilosso et al, 2020 , Shoskes et al, 2020 , Toeback et al, 2021 , Tristán-Samaniego et al, 2022 , Vattoth et al, 2020 , Witvoet et al, 2021 ). MB were seen in 17/29 case reports ( Backman et al, 2022 , Cannac et al, 2020 , De Stefano et al, 2020 , Finsterer, 2022 , Fraiman et al, 2020 , Gupta et al, 2020 , Hanafi et al, 2020 , Haroon et al, 2020 , Liang et al, 2021 , Petersson et al, 2022 , Planinc et al, 2020 , Reichard et al, 2020 , Rudilosso et al, 2020 , Shoskes et al, 2020 , Toeback et al, 2021 , Tristán-Samaniego et al, 2022 , Vattoth et al, 2020 , Witvoet et al, 2021 ) with 14/17 being in patients with severe pulmonary/respiratory complications. Regarding the three MB cases in which patients did not require intubation, mechanical ventilation or ECMO, patients presented with early onset Alzheimer’s Disease ( Fraiman et al, 2020 ), CAA ( Liang et al, 2021 ), or pre-existing microangiopathy ( Finsterer, 2022 ), all of which are independent risk factors for cerebral MB ( Cordonnier and van der Flier, 2011 , Woerdeman et al, 2014 ).…”

“…Regarding the three MB cases in which patients did not require intubation, mechanical ventilation or ECMO, patients presented with early onset Alzheimer’s Disease ( Fraiman et al, 2020 ), CAA ( Liang et al, 2021 ), or pre-existing microangiopathy ( Finsterer, 2022 ), all of which are independent risk factors for cerebral MB ( Cordonnier and van der Flier, 2011 , Woerdeman et al, 2014 ). All but one report (7/8) presenting with both MB and ischemic lesions/infarctions required pulmonary/respiratory intervention in the ICU ( Hanafi et al, 2020 , Haroon et al, 2020 , Petersson et al, 2022 , Shoskes et al, 2020 , Toeback et al, 2021 , Tristán-Samaniego et al, 2022 , Witvoet et al, 2021 ). Cases of small vessel ischemic lesion/infarct without MB ( Abdi et al, 2020 , Ahmed et al, 2022 , Elshereye and Erdinc, 2020 , Frisullo et al, 2020 , Neppala et al, 2021 , Piazza et al, 2021 , Pinzon et al, 2021 , Rajendran et al, 2021 , Rudilosso et al, 2020 , Trifan et al, 2020 , Williams et al, 2020 , Zhang et al, 2021 ) were less dependent on ICU status with 8/12 patients not requiring intubation, mechanical ventilation or ECMO.…”