Saudi Arabia MRI Study Provide Further Evidence That SARS-CoV-2 Affects The Brain With 57.9% Of Severe COVID-19 Patients Having Brain Lesions!

SARS-CoV-2-Brain: A new MRI study by researchers from Saudi Arabia suggests pneumonia in COVID-19 patients is linked to viral-induced changes in the brain. MRI scans revealed that 57.9% of severe SARS-CoV-2 infected patients had recent brain lesions! The study findings provide further evidence that SAR-CoV-2 affects the brain and causes brain lesions and also generates various neurological manifestations.

 
According to the study abstract, “The increased frequency of neurological manifestations, including central nervous system (CNS) manifestations, in patients with COVID-19 is consistent with the virus's neurotropic nature. In most patients, brain magnetic resonance imaging (MRI) is a sensitive imaging modality in the diagnosis of viral encephalitides in the brain.”
 
The study team’s objectives were to determine the frequency of brain lesion patterns on brain MRI in SARS-CoV-2 pneumonia patients who developed focal and non-focal neurological manifestations. In addition, the stud was to compare the impact of the Glasgow Coma Scale (GCS) as an index of deteriorating cerebral function on positive brain MRIs in both neurological manifestations.
 
This retrospective study included an examination of SARS-CoV-2 pneumonia patients with real-time reverse transcription polymerase chain reaction (RT-PCR) confirmation, admitted with clinicoradiologic evidence of COVID-19 pneumonia, and who were candidates for brain MRI due to neurological manifestations suggesting brain involvement. Brain imaging was acquired on a 3.0 T MRI system (Skyra; Siemens, Erlangen, Germany) with a 20-channel receive head coil.
 
Brain MRI revealed lesions in 38 (82.6%) of the total 46 patients for analysis and was negative in the remaining eight (17.4%) of all finally enclosed patients with RT-PCR confirmed SARS-CoV-2 pneumonia. Twenty-nine (63%) patients had focal neurological manifestations, while the remaining 17 (37%) patients had non-focal neurological manifestations. The patients had a highly significant difference (p = 0.0006) in GCS, but no significant difference (p = 0.4) in the number of comorbidities they had.
 
In all, about 29 patients had focal neurological manifestations. The other 17 patients had non-focal neurological manifestations. The most significant lesions came from territorial infarcts or cerebral hemorrhaging.
 
The SARS-CoV-2-Brain study findings indicated that Brain MRI is a feasible and important imaging modality in patients with SARS-CoV-2 pneumonia who develop neurological manifestations suggestive of brain involvement, particularly in patients with non-focal manifestations and a decline in GCS.
 
The study findings were published in the peer reviewed journal: Scientific Reports. https://www.nature.com/articles/s41598-021-00064-5
 
Corresponding author, Dr Batil Alonazi from the Radiology and Medical Imaging Department, College of Applied Medical Sciences, Prince Sattam Bin Abdulaziz University told Thailand Medical News, “Brain MRI is a feasible and important imaging modality in selected patients with SARS-CoV-2 pneumonia on deve loping neurological manifestations, suggestive of brain involvement, particularly in patients with non-focal manifestations and decline in the Glasgow Coma Scale.”
 
Altogether, a total of 46 patients, 33 females and 13 males tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and later developed pneumonia.
 
Their SARS-CoV-2 infection suggested neurological manifestations, and they were invited to take an MRI scan of their brain.

Twenty-six-year-old male with no prior co-morbidities; admitted with severe RT-PCR proved SARS-CoV-2 pneumonia, (A) as shown on the chest radiogram. This patient, who was on mechanical ventilation, went into cardiac arrest. Brain MRI was performed 4 days post arrest due to low GCS (= 6), revealed global hypoxic-ischemic encephalopathy. (B) Axial FLAIR image, at the level of the BG, showed decreased signal intensity in the thalami, while (C) corresponding DWI image showed lack of hyperintensity in both thalami, in addition to the caudate and putamen nuclei, findings that represent pseudo normalization. (D) Also, corresponding ADC map showed hyperintensity in the locations cited in (B). (E) Reconstructed maximum intensity projection magnetic resonance angiography (MRA) image shows no large vessel occlusion.

It was noted that about 78.3% of patients had a secondary health condition, with 23.9% reporting over 3 comorbidities. On average, patients were 51.3 years old.
 
Alarmingly, the MRI scans showed brain lesions in 82.6% of patients. Additionally, about 57.9% of the identified brain legions were recent, suggesting the lesions were linked to SARS-CoV-2 infection. Only 41.1% of brain lesions were considered old.
 
Importantly, of the 57.9% with recent brain legions, 77.3% of these lesions were deemed “clinically significant.” These patients were the ones who had a stroke. Eight experienced a recent infarct, and five patients had a recent cerebral hemorrhage. In addition, four patients showed signs of global hypoxic-ischemic encephalopathy.
 
The study findings also showed that five patients had MRI scans positive for nonspecific subcortical changes, suggesting white matter microangiopathy. Of these 5 patients, 2 were below the age of 50 and had non-focal neurological manifestations and microangiopathic lesions.
 
Detailed laboratory evidence showed these patients had a history of viral infections, including MERS-CoV infection. The remaining 3 patients were older than 50 and had microangiopathic lesions associated with lacunar Infarcts.

Based on the MRI scans, the 46 patients were categorized into several groups.

group A composed of 63% of patients who had presented with neurological manifestations.
 
It was found that of the 22 patients in group A, ten had recent infarcts and seven had territorial infarcts. In addition, three patients had lacunar or microangiopathic infarcts in three patients, four with recent cerebral hemorrhage, three with old territorial infarcts, and five patients with variable sized old lacunar infarcts.
 
It was also noted that group B had the remaining 37% who did not have neurological manifestations at the time of the MRI scan.
 
Interestingly about 4 out of 5 patients in group B who had severe SARS-CoV-2 pneumonia underwent cardiac arrest. From this, brain MRI scans depicted signs of global hypoxic-ischemic encephalopathy. These five patients were eventually intubated from severe COVID-19–induced pneumonia. Therefore, this group was designated as group C.
 
The group D consisted of patients who did not have a cardiac arrest and had no signs of global hypoxic-ischemic encephalopathy.
 
The study findings showed that group A and group B showed a significant difference in the Glasgow Coma Scale (GCS) ie used to measure a person’s consciousness level after trauma. Group C also had a low GCS score
 
The study findings provide further evidence that SARS-CoV-2 affects the brain and generates neurological manifestations, including lesions.

This research is a retrospective study, indicating a small number of patients were non-randomized. Age, gender, and the type of comorbidity presented in each patient may weaken the association between SARS-CoV-2 and cerebrovascular disease.
 
According to the study team’s knowledge, there is no prior brain MRI study on SARS-CoV-2 infection. The lack of a baseline may decrease the accurateness in patterns between brain lesions and SARS-CoV-2 infection.
 
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