Neuroimaging Manifestations of COVID-19 in Children

Doctor’s hands in protection gloves putting COVID-19 test swab into kid’s mouth in hospital.
A team of researchers made an international call for cases of children with encephalopathy linked to SARS-CoV-2 infection in order to investigate abnormal neuroimaging findings.

In children with coronavirus disease 2019 (COVID-19) secondary to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), neuroimaging manifestations of the infection can range from mild to fatal changes. The most common brain manifestations were acute disseminated encephalomyelitis (ADEM)-like in appearance, with patchy or confluent areas of T2 hyperintensity in grey and white matter, according to study results published in The Lancet Child & Adolescent Health.

Although children seemed to be largely unaffected during the early stages of the COVID-19 pandemic, more severe manifestations of the viral infection in children emerged as the pandemic progressed, including a Kawasaki-like syndrome termed multisystem inflammatory syndrome in children (MIS-C).

As data on the neurological manifestations of COVID-19 in children are based mainly on case reports, the objective of the current study was to describe the neuroimaging manifestations of the disease in children by placing an international call for cases of children with encephalopathy secondary to SARS-CoV-2 infection.

The retrospective study included 38 children with neurological manifestations related to SARS-CoV-2. Most patients were from France (13 cases), the UK (8 cases) and the US (5 cases), with additional cases from Brazil and Argentina (4 cases each), India (2 cases), and Saudi Arabia and Peru (1 case each).

The study researchers identified recurring patterns of disease, along with more unusual imaging manifestations and reported that the neuroimaging manifestations of COVID-19 infection in children can range from mild to fatal. The most common neuroimaging patterns were postinfectious, immune-mediated ADEM-like changes (16 patients), myelitis in isolation or in combination with brain abnormalities (8 patients), and neural enhancement (13 patients), including cauda equina enhancement (8 patients).

Cranial neuritis was reported in 9 cases, including 7 in which there was involvement of at least 1 specific cranial nerve without corresponding nerve palsy. This indicated that cranial nerve enhancement did not always correlate with cranial nerve deficits.

The dominant findings in children with MIS-C were splenial lesions (7 patients) and enhancing myositis of the face and neck (4 patients).

Cerebrovascular manifestations were less common in children compared with prior reports of SARS-CoV-2 CNS complications in adults. Significant pre-existing conditions were absent and outcomes were usually favorable. However, fulminant atypical co-infections were found in previously healthy children with acute symptomatic SARS-CoV-2 infections and were fatal in all cases.

The study had several limitations, including its retrospective design, potential selection bias secondary to identification of cases through voluntary submissions, missing long-term follow-up in some cases, and variability in diagnostic, treatment and imaging strategies at different institutions.

“This international collaboration has revealed that children can present with positive neuroimaging findings with or without the classic symptoms of COVID-19. Knowledge of the neuroimaging patterns of COVID-19 is important, as these patterns could be the first indication of SARS-CoV-2 infection in children with neurological abnormalities,” concluded the study researchers.


Lindan CE, Mankad K, Ram D, et al. Neuroimaging manifestations in children with SARS-CoV-2 infection: a multinational, multicentre collaborative study. Lancet Child Adolesc Health. Published online December 15, 2020. doi: 10.1016/S2352-4642(20)30362-X