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McClelland AC, Benitez SJ, Burns J. COVID-19 neuroimaging update: pathophysiology, acute findings, and post-acute developments. Semin Ultrasound CT MR 2024:S0887-2171(24)00026-X. [PMID: 38518814 DOI: 10.1053/j.sult.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2024]
Abstract
COVID-19 has prominent effects on the nervous system with important manifestations on neuroimaging. In this review, we discuss the neuroimaging appearance of acute COVID-19 that became evident during the early stages of the pandemic. We highlight the underlying pathophysiology mediating nervous system effects and neuroimaging appearances including systemic inflammatory response such as cytokine storm, coagulopathy, and para/post-infections immune mediated phenomena. We also discuss the nervous system manifestations of COVID-19 and the role of imaging as the pandemic has evolved over time, including related to the development of vaccines and the emergence of post-acute sequalae such as long COVID.
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Affiliation(s)
| | | | - Judah Burns
- Albert Einstein College of Medicine; Bronx, NY, Department of Radiology, Montefiore Medical Center; Bronx, NY.
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Rezvani M, Sabouri M, Aminmansour B, Falahpour S, Sourani A, Sharafi M, Baradaran Mahdavi S, Foroughi M, Nik Khah R, Sourani A, Veisi S. Spontaneous spinal epidural haematoma following COVID-19 vaccination: a case report. Ann Med Surg (Lond) 2024; 86:612-619. [PMID: 38222759 PMCID: PMC10783308 DOI: 10.1097/ms9.0000000000001604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 11/29/2023] [Indexed: 01/16/2024] Open
Abstract
Introduction COVID-19 vaccination side effects are rare but important medical situations. Spine-affecting side effects are amongst the rarest, but exceedingly important. Haemorrhagic spinal manifestations of COVID-19 and its vaccines are less reported with little knowledge about them. Case presentation An 80-year-old male who received his first shot of the COVID-19 vaccine had developed COVID-19 pneumonia, weakness, and sensory problems in his legs followed by sphincter incontinence within 5 days period. MRI showed a spontaneous epidural spinal epidural haematoma (SSEDH) in T10-L1. He underwent laminectomy and haematoma evacuation. One month follow-up showed no clinical improvement. Discussion To our knowledge, this was the first post-vaccination SSEDH and second in haemorrhagic spinal complications following COVID-19 vaccination. Considering the neuropathogenesis pathway of COVID-19 and its vaccines, there are common mechanisms of action that could potentially justify post-vaccination SSEDH such as seen in COVID-19 infection, itself. Early Neurosurgical intervention and better preoperative neurological status could be a beneficial modifier for favourable clinical outcomes. Conclusion SSEDH and COVID-19 vaccine coincidence is a rare clinical event, still no solid association could be scientifically explained. Further studies are required for a reliable pathophysiologic association. Early diagnosis, interdisciplinary medical approach, and faster intervention are the cornerstone of the treatment paradigm.
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Affiliation(s)
| | | | | | | | - Arman Sourani
- Department of Neurosurgery, School of Medicine
- Environment Research Center
| | | | - Sadegh Baradaran Mahdavi
- Department of Physical Medicine and Rehabilitation, School of Medicine, Student Research Committee, Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-Communicable Disease
| | - Mina Foroughi
- Isfahan Medical Students’ Research Committee (IMSRC), Isfahan University of Medical Sciences, Isfahan, Iran
| | - Roham Nik Khah
- Isfahan Medical Students’ Research Committee (IMSRC), Isfahan University of Medical Sciences, Isfahan, Iran
| | - Armin Sourani
- Isfahan Medical Students’ Research Committee (IMSRC), Isfahan University of Medical Sciences, Isfahan, Iran
| | - Shaahin Veisi
- Isfahan Medical Students’ Research Committee (IMSRC), Isfahan University of Medical Sciences, Isfahan, Iran
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Weidauer S, Hattingen E, Arendt CT. Cervical myelitis: a practical approach to its differential diagnosis on MR imaging. ROFO-FORTSCHR RONTG 2023; 195:1081-1096. [PMID: 37479218 DOI: 10.1055/a-2114-1350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2023]
Abstract
BACKGROUND Differential diagnosis of non-compressive cervical myelopathy encompasses a broad spectrum of inflammatory, infectious, vascular, neoplastic, neurodegenerative, and metabolic etiologies. Although the speed of symptom onset and clinical course seem to be specific for certain neurological diseases, lesion pattern on MR imaging is a key player to confirm diagnostic considerations. METHODS The differentiation between acute complete transverse myelitis and acute partial transverse myelitis makes it possible to distinguish between certain entities, with the latter often being the onset of multiple sclerosis. Typical medullary MRI lesion patterns include a) longitudinal extensive transverse myelitis, b) short-range ovoid and peripheral lesions, c) polio-like appearance with involvement of the anterior horns, and d) granulomatous nodular enhancement prototypes. RESULTS AND CONCLUSION Cerebrospinal fluid analysis, blood culture tests, and autoimmune antibody testing are crucial for the correct interpretation of imaging findings. The combination of neuroradiological features and neurological and laboratory findings including cerebrospinal fluid analysis improves diagnostic accuracy. KEY POINTS · The differentiation of medullary lesion patterns, i. e., longitudinal extensive transverse, short ovoid and peripheral, polio-like, and granulomatous nodular, facilitates the diagnosis of myelitis.. · Discrimination of acute complete and acute partial transverse myelitis makes it possible to categorize different entities, with the latter frequently being the overture of multiple sclerosis (MS).. · Neuromyelitis optica spectrum disorders (NMOSD) may start as short transverse myelitis and should not be mistaken for MS.. · The combination of imaging features and neurological and laboratory findings including cerebrospinal fluid analysis improves diagnostic accuracy.. · Additional brain imaging is mandatory in suspected demyelinating, systemic autoimmune, infectious, paraneoplastic, and metabolic diseases..
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Affiliation(s)
- Stefan Weidauer
- Institute for Neuroradiology, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Elke Hattingen
- Institute for Neuroradiology, Goethe University Frankfurt, Frankfurt am Main, Germany
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Asano R, Hayashi K, Kawahara E, Sato M, Miura T. Three Types of Demyelination, Perivenous, Confluent, and Perineuronal Nets-Rich in a COVID-19 Patient With Meningoencephalomyelitis. Cureus 2023; 15:e51049. [PMID: 38269235 PMCID: PMC10805624 DOI: 10.7759/cureus.51049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2023] [Indexed: 01/26/2024] Open
Abstract
Neurologic symptoms are common in COVID-19, and a variety of neuropathological changes have been reported. One of the important neuropathological findings is demyelination. However, the underlying pathogenesis of demyelination remained poorly understood. We witnessed a case of COVID-19 with distinct types of demyelination in the cerebrum, medulla oblongata, and spinal canal, who died of sepsis. The postmortem examination showed the solitary massive demyelination in the medulla oblongata. The massive lesion was filled with components of perineuronal nets. In the spinal canal, confluent demyelination in bilateral lateral and dorsal funiculi was detected over the entire length from C1 to S5, which was maximum at the level of cervical spinal canal stenosis. Demyelination in the cerebrum was mainly perivenular, and augmented in the area of lacunar infarcts and dilated perivascular spaces. Considering the distribution patterns of the following three types of demyelination, the traces of viral spreading could be highlighted. Discontinuous perivenous demyelination in the cerebrum showed the result of hematogenous spreading. Longitudinal confluent demyelination of the spinal cord should be the picturesque of the trace of axonal spreading. The distribution of demyelination was possibly modified by the underlying diseases, diabetes mellitus, hypertension, and spinal canal stenosis.
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Affiliation(s)
- Rei Asano
- Department of Rehabilitation, Fukui General Hospital, Fukui, JPN
| | - Koji Hayashi
- Department of Rehabilitation, Fukui General Hospital, Fukui, JPN
| | - Ei Kawahara
- Department of Pathology, Fukui General Hospital, Fukui, JPN
| | - Mamiko Sato
- Department of Rehabilitation, Fukui General Hospital, Fukui, JPN
| | - Toyoaki Miura
- Department of Rehabilitation, Fukui General Hospital, Fukui, JPN
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Meiling JB, Ha CT, Garlanger KL, Snider BA, Flanagan EP, Reeves RK. Inpatient rehabilitation outcomes in patients with the new diagnosis of COVID-19 tractopathy: a case series. Spinal Cord Ser Cases 2023; 9:25. [PMID: 37393353 DOI: 10.1038/s41394-023-00586-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 06/20/2023] [Accepted: 06/23/2023] [Indexed: 07/03/2023] Open
Abstract
STUDY DESIGN Retrospective Case Series. OBJECTIVES Describe the inpatient rehabilitation outcomes of four patients with COVID-19 tractopathy. SETTING Olmsted County, Minnesota, United States of America. METHODS Retrospective review of medical records was performed to collect patient data. RESULTS Four individuals (n = 4, 3 men and 1 woman, mean age 58.25 years [range 56-61]) completed inpatient rehabilitation during the COVID-19 pandemic. All presented after COVID-19 infection and were admitted to acute care with progressive paraparesis. None were able to ambulate on admission to acute care. All received extensive evaluations which were largely negative except for mildly elevated CSF protein and MRI findings of longitudinally extensive T2 hyperintensity signal changes in the lateral (n = 3) and dorsal (n = 1) columns. All patients experienced incomplete spastic paraparesis. All patients experienced neurogenic bowel dysfunction; a majority experienced neuropathic pain (n = 3); half experienced impaired proprioception (n = 2); and a minority experienced neurogenic bladder dysfunction (n = 1). Between rehabilitation admission and discharge, the median improvement in lower extremity motor score was 5 (0-28). All patients were discharged home, but only one was a functional ambulator at time of discharge. CONCLUSION While the underlying mechanism is yet to be elucidated, in rare cases a COVID-19 infection can lead to a tractopathy, presenting as weakness, sensory deficits, spasticity, neuropathic pain, and neurogenic bladder/bowel. Patients with COVID-19 tractopathy would benefit from inpatient rehabilitation to enhance their functional mobility and independence.
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Affiliation(s)
- James B Meiling
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA.
| | - Christopher T Ha
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA
| | - Kristin L Garlanger
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA
| | | | | | - Ronald K Reeves
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA
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Grasso EA, Pozzilli V, Tomassini V. Transverse myelitis in children and adults. HANDBOOK OF CLINICAL NEUROLOGY 2023; 196:101-117. [PMID: 37620065 DOI: 10.1016/b978-0-323-98817-9.00020-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
Transverse myelitis is a noncompressive myelopathy of inflammatory origin. The causes are broad, ranging from infective or toxic to immuno-mediated etiology. They can be manifestations of systemic diseases, such as sarcoidosis and systemic lupus erythematous, or phenotypes of neuroinflammation; in a portion of cases, the etiology remains unknown, leading to the designation idiopathic. The clinical presentation of transverse myelitis depends on the level of spinal cord damage and may include sensorimotor deficits and autonomic dysfunction. The age of onset of the disorder can impact the symptoms and outcomes of affected patients, with differences in manifestation and prognosis between children and adults. Spinal cord magnetic resonance imaging and cerebrospinal fluid examination are the main diagnostic tools that can guide clinicians in the diagnostic process, even though the search for antibodies that target the structural components of the neural tissue (anti-aquaporin4 antibodies and anti-myelin-oligodendrocyte antibodies) helps in the distinction among the immune-mediated phenotypes. Management and outcomes depend on the underlying cause, with different probabilities of relapse according to the phenotypes. Hence, immunosuppression is often recommended for the immune-mediated diseases that may have a higher risk of recurrence. Age at onset has implications for the choice of treatment.
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Affiliation(s)
- Eleonora Agata Grasso
- Department of Neurosciences, Imaging and Clinical Sciences, Institute of Advanced Biomedical Technologies (ITAB), University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Valeria Pozzilli
- Department of Neurosciences, Imaging and Clinical Sciences, Institute of Advanced Biomedical Technologies (ITAB), University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Valentina Tomassini
- Department of Neurosciences, Imaging and Clinical Sciences, Institute of Advanced Biomedical Technologies (ITAB), University G. d'Annunzio of Chieti-Pescara, Chieti, Italy.
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Cacciaguerra L, Sechi E, Rocca MA, Filippi M, Pittock SJ, Flanagan EP. Neuroimaging features in inflammatory myelopathies: A review. Front Neurol 2022; 13:993645. [PMID: 36330423 PMCID: PMC9623025 DOI: 10.3389/fneur.2022.993645] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 08/16/2022] [Indexed: 11/15/2022] Open
Abstract
Spinal cord involvement can be observed in the course of immune-mediated disorders. Although multiple sclerosis (MS) represents the leading cause of inflammatory myelopathy, an increasing number of alternative etiologies must be now considered in the diagnostic work-up of patients presenting with myelitis. These include antibody-mediated disorders and cytotoxic T cell-mediated diseases targeting central nervous system (CNS) antigens, and systemic autoimmune conditions with secondary CNS involvement. Even though clinical features are helpful to orient the diagnostic suspicion (e.g., timing and severity of myelopathy symptoms), the differential diagnosis of inflammatory myelopathies is often challenging due to overlapping features. Moreover, noninflammatory etiologies can sometimes mimic an inflammatory process. In this setting, magnetic resonance imaging (MRI) is becoming a fundamental tool for the characterization of spinal cord damage, revealing a pictorial scenario which is wider than the clinical manifestations. The characterization of spinal cord lesions in terms of longitudinal extension, location on axial plane, involvement of the white matter and/or gray matter, and specific patterns of contrast enhancement, often allows a proper differentiation of these diseases. For instance, besides classical features, such as the presence of longitudinally extensive spinal cord lesions in patients with aquaporin-4-IgG positive neuromyelitis optica spectrum disorder (AQP4+NMOSD), novel radiological signs (e.g., H sign, trident sign) have been recently proposed and successfully applied for the differential diagnosis of inflammatory myelopathies. In this review article, we will discuss the radiological features of spinal cord involvement in autoimmune disorders such as MS, AQP4+NMOSD, myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD), and other recently characterized immune-mediated diseases. The identification of imaging pitfalls and mimics that can lead to misdiagnosis will also be examined. Since spinal cord damage is a major cause of irreversible clinical disability, the recognition of these radiological aspects will help clinicians achieve a correct and prompt diagnosis, treat early with disease-specific treatment and improve patient outcomes.
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Affiliation(s)
- Laura Cacciaguerra
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Elia Sechi
- Neurology Unit, Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Maria A. Rocca
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Filippi
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Neurorehabilitation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Neurophysiology Service, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sean J. Pittock
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
- Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Eoin P. Flanagan
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
- Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
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Cavallieri F, Sellner J, Zedde M, Moro E. Neurologic complications of coronavirus and other respiratory viral infections. HANDBOOK OF CLINICAL NEUROLOGY 2022; 189:331-358. [PMID: 36031313 PMCID: PMC9418023 DOI: 10.1016/b978-0-323-91532-8.00004-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
In humans, several respiratory viruses can have neurologic implications affecting both central and peripheral nervous system. Neurologic manifestations can be linked to viral neurotropism and/or indirect effects of the infection due to endothelitis with vascular damage and ischemia, hypercoagulation state with thrombosis and hemorrhages, systemic inflammatory response, autoimmune reactions, and other damages. Among these respiratory viruses, recent and huge attention has been given to the coronaviruses, especially the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic started in 2020. Besides the common respiratory symptoms and the lung tropism of SARS-CoV-2 (COVID-19), neurologic manifestations are not rare and often present in the severe forms of the infection. The most common acute and subacute symptoms and signs include headache, fatigue, myalgia, anosmia, ageusia, sleep disturbances, whereas clinical syndromes include mainly encephalopathy, ischemic stroke, seizures, and autoimmune peripheral neuropathies. Although the pathogenetic mechanisms of COVID-19 in the various acute neurologic manifestations are partially understood, little is known about long-term consequences of the infection. These consequences concern both the so-called long-COVID (characterized by the persistence of neurological manifestations after the resolution of the acute viral phase), and the onset of new neurological symptoms that may be linked to the previous infection.
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Affiliation(s)
- Francesco Cavallieri
- Neurology Unit, Neuromotor and Rehabilitation Department, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy,Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Johann Sellner
- Department of Neurology, Landesklinikum Mistelbach-Gänserndorf, Mistelbach, Austria,Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Marialuisa Zedde
- Neurology Unit, Neuromotor and Rehabilitation Department, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Elena Moro
- Division of Neurology, CHU of Grenoble, Grenoble Alpes University, Grenoble Institute of Neurosciences, Grenoble, France,Correspondence to: Elena Moro, Service de neurologie, CHU de Grenoble (Hôpital Nord), Boulevard de la Chantourne, 38043 La Tronche, France. Tel: + 33-4-76-76-94-52, Fax: +33-4-76-76-56-31
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