Hemorrhagic and encephalopathy-related brain lesions were observed in patients who died from coronavirus disease 2019 (COVID-19), according to findings from a postmortem brain magnetic resonance imaging (MRI) study published in Neurology.

A cellular entry point for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the angiotensin-converting enzyme 2 (ACE 2) receptor, which is found in glial cells, neurons, and brain cell nuclei. This study, conducted by researchers from the Free University of Brussels in Belgium, was a prospective case series that included 19 consecutive patients who died from COVID-19 between March 31 and April 24, 2020. All patients tested positive for SARS-CoV-2 on nasopharyngeal swab and had chest computed tomographic scans suggestive of COVID-19.  Early postmortem structural brain MRI was performed on a 3 Tesla hybrid PET-MR scanner.

Overall, the mean age of decedents was 77 years (range, 49-94 years). Each patient had severe COVID-19 and between 1 to 5 comorbidities, including hypertension, body mass index >25, cardiac disorder, chronic obstructive pulmonary disorder, chronic kidney disease, and diabetes.


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The investigators found parenchymal brain abnormalities in 4 decedents, including subcortical micro- and macro-hemorrhages (n=2), cortico-subcortical edematous changes indicative of posterior reversible encephalopathy syndrome (PRES [n=1]), and nonspecific deep white matter changes (n=1). In 4 other decedents without downstream olfactory tract abnormalities, MRI revealed asymmetric olfactory bulbs. The investigators found no brainstem MRI signal abnormality in these patients. In participant D10, there was a midline pontine signal abnormality suggestive of capillary telangiectasia.

Limitations of this study included its virtopsy approach (eg the complications of post-mortem brain changes), the exclusion of 70% of COVID-19 patients who died during the inclusion period, lack of information regarding patients’ neurologic statuses, and the exclusion of COVID-19 survivors. These, the investigators suggested, may restrict the generalizability of the MRI findings across other clinical settings.

The investigators wrote that the “brainstem MRI findings do not support a brain-related contribution to respiratory distress in COVID-19.”

Editor’s note: Language in this article was edited for clarity on July 16, 2020.

Reference: Coolen T, Lolli V, Sadeghi N, et al. Early postmortem brain MRI findings in COVID-19 non-survivors [published online June 16, 2020]. Neurology. doi: 10.1212/WNL.0000000000010116