Study Reveals Wide Spectrum of COVID-19 Brain Complications – Including Stroke, Hemorrhage, and Other Fatal Complications

The largest multi-institutional international study to date of brain complications from COVID-19 has found that approximately one in 100 patients hospitalized with COVID-19 is likely to develop central nervous system complications. These can include stroke, bleeding, and other potentially fatal complications. The study will be presented tomorrow at the annual meeting of the Radiological Society of North America (RSNA).

“Much has been written about the common lung problems associated with COVID-19, but we don’t often talk about the other organs that can be affected,” said lead author Scott H. Faro, MD, FASFNR, professor of radiology and neurology. and director of the Department of Neuroradiology/Head & Neck Imaging at Thomas Jefferson University in Philadelphia. “Our study shows that central nervous system complications are a leading cause of morbidity and mortality in this devastating pandemic.”

49-year-old female with a medical history of mitral valve disease and tricuspid valve regurgitation who developed headache followed by cough and fever, presented to the ED with ptosis of the right upper eyelid (drooping). Credit: Radiological Society of North America and Scott H. Faro, MD

dr. Faro initiated the study after discovering that the existing literature on central nervous system complications in hospitalized COVID-19-infected patients was based on a relatively small number of cases.

To get a more complete picture, he and his colleagues analyzed nearly 40,000 cases of hospitalized COVID-19-positive patients from seven U.S. and four Western European university hospitals. The patients were admitted between September 2019 and June 2020. Their average age was 66 years and there were twice as many men as women.

Bleeding seen in 56-year-old female with COVID-19 infection and no other significant past medical history. Credit: RSNA and Scott H. Faro, MD

The most common cause of admission was confusion and altered mental status, followed by fever. Many of the patients had co-morbidities such as hypertension, heart disease and diabetes.

There were 442 acute neuroimaging findings most likely related to the viral infection. The overall incidence of central nervous system complications in this large patient group was 1.2%.

“Of all the included patients who had imaging, such as MRI or a CT scan of the brain, the examination was positive about 10% of the time,” said Dr. Faro. “The 1.2% incidence means that just over one in 100 patients hospitalized with COVID-19 will have some kind of brain problem.”

65-year-old male smoker, presented with acute hypoxic respiratory failure secondary to COVID-19 pneumonia, requiring intubation. Hospitalization was complicated by seizures associated with cerebral edema and hemorrhagic posterior reversible encephalopathy syndrome. Credit: RSNA and Scott H. Faro, MD

The most common complication was ischemic stroke, with an incidence of 6.2%, followed by intracranial hemorrhage (3.72%) and encephalitis (0.47%), inflammation of the brain.

The researchers also found a small percentage of unusual findings, such as acute diffuse encephalomyelitis, an inflammation of the brain and spinal cord, and posterior reversible encephalopathy syndrome, a syndrome that mimics many of the symptoms of stroke.

“It’s important to know an accurate incidence of all major central nervous system complications,” said Dr. Faro. “There should probably be a low threshold to ordering brain scans for patients with COVID-19.”

Co-authors are Arichena Manmatharayan, MBBS, Benjamin Leiby, Ph.D., Neelu Jain, MD, Feroze B. Mohamed, Ph.D., Kiran S. Talekar, MD, Amish Doshi, MD, MBBS, Ivan Jambor, MD , Ph.D., Chang Sanders, MD, Mark Finkelstein, MD, Stephane Kremer, MD, Ph.D., Francois Lercy, MD, Brenden Lindgren, DO, Nathalia M. Figueidero, MD, Varun Sethi, MD, Simonetta Gerevini , MD, Angela Napolitano, MD, Rajan Jain, MD, Siddhanth Dogra, BS, Jay Pillai, MD, Dan Ryan, MD, Rolf Jager, FRCR, Francesco Carletti, MD, Ph.D., Asim Mian, MD, Artem Kaliev , Priya Anand, MD, Courtney Takahashi, MD, AK Murat, MD, Rivka Colen, MD, and Francesca Pizzini, MD, Ph.D.