Neuroimaging findings and neurological manifestations in hospitalized COVID-19 patients: Impact of cancer and ventilatory support status

INTRODUCTION

Coronavirus 2019 (COVID-19) is known to affect the central nervous system. Neurologic morbidity associated with COVID-19 is commonly attributed to sequelae of some combination of thrombotic and inflammatory processes. The aim of this retrospective observational study was to evaluate neuroimaging findings in hospitalized COVID-19 patients with neurological manifestations in cancer versus non-cancer patients, and in patients with versus without ventilatory support (with ventilatory support defined as including patients with intubation and noninvasive ventilation). Cancer patients are frequently in an immunocompromised or prothrombotic state with side effects from chemotherapy and radiation that may cause neurological issues and increase vulnerability to systemic illness. We wanted to determine whether neurological and/or neuroimaging findings differed between patients with and without cancer.

METHODS

Eighty adults (44 male, 36 female, 64.5 ±14 years) hospitalized in the Mount Sinai Health System in New York City between March 2020 and April 2021 with reverse-transcriptase polymerase chain reaction-confirmed COVID-19 underwent magnetic resonance imaging (MRI) during their admissions. The cohort consisted of four equal subgroups based on cancer and ventilatory support status. Clinical and imaging data were acquired and analyzed.

RESULTS

Neuroimaging findings included non-ischemic parenchymal T2/FLAIR signal hyperintensities (36.3%), acute/subacute infarcts (26.3%), chronic infarcts (25.0%), microhemorrhages (23.8%), chronic macrohemorrhages (10.0%), acute macrohemorrhages (7.5%), and encephalitis-like findings (7.5%). There were no significant differences in neuroimaging findings between cancer and non-cancer subgroups. Clinical neurological manifestations varied. The most common was encephalopathy (77.5%), followed by impaired responsiveness/coma (38.8%) and stroke (26.3%). There were significant differences between patients with versus without ventilatory support. Encephalopathy and impaired responsiveness/coma were more prevalent in patients with ventilatory support (p = 0.02). Focal weakness was more frequently seen in patients without ventilatory support (p = 0.01).

DISCUSSION

This study suggests COVID-19 is associated with neurological manifestations that may be visible with brain imaging techniques such as MRI. In our COVID-19 cohort, there was no association between cancer status and neuroimaging findings. Future studies might include more prospectively enrolled systematically characterized patients, allowing for more rigorous statistical analysis.

CT Perfusion collateral index in assessment of collaterals in acute ischemic stroke with delayed presentation: Comparison to single phase CTA

BACKGROUND & PURPOSE

Perfusion collateral index (PCI) has been recently defined as a promising measure of collateral status. We sought to compare collateral status assessed via CT-PCI in comparison to single-phase CTA and their relationship to outcome measures including final infarction volume, final recanalization status and functional outcome in ELVO patients.

METHODS

ELVO patients with anterior circulation large vessel occlusion who had baseline CTA and CT perfusion and underwent endovascular treatment were included. Collateral status was assessed on CTA. PCI from CT perfusion was calculated in each patient and an optimal threshold to separate good vs insufficient collaterals was identified using DSA as reference. The collateral status determined by CTA and PCI were assessed against 3 measured outcomes: 1) final infarction volume; 2) final recanalization status defined by TICI scores; 3) functional outcome measured by 90-day mRS.

RESULTS

A total of 53 patients met inclusion criteria. Excellent recanalization defined by TICI ≥2C was achieved in 36 (68%) patients and 23 patients (43%) had good functional outcome (mRS ≤2). While having good collaterals on both CTA and CTP-PCI was associated with significantly (p<0.05) smaller final infarction volume, only good collaterals status determined by CTP-PCI was associated with achieving excellent recanalization (p = 0.001) and good functional outcome (p = 0.003).

CONCLUSION

CTP-based PCI outperforms CTA collateral scores in determination of excellent recanalization and good functional outcome and may be a promising imaging marker of collateral status in patients with delayed presentation of AIS.

Neurovascular complications that can be seen in COVID-19 patients

Coronavirus disease 2019 (COVID-19), a clinical manifestation of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), was declared a global pandemic by the World Health Organization on March 11, 2020. Hypercoagulable state has been described as one of the hallmarks of SARS-CoV-2 infection and has been reported to manifest as pulmonary embolisms, deep vein thrombosis, and arterial thrombosis of the abdominal small vessels. Here we present cases of arterial and venous thrombosis pertaining to the head and neck in COVID-19 patients.

Addition of arterial spin-labelled MR perfusion to conventional brain MRI: clinical experience in a retrospective cohort study

OBJECTIVE

The usage of arterial spin labelling (ASL) perfusion has exponentially increased due to improved and faster acquisition time and ease of postprocessing. We aimed to report potential additional findings obtained by adding ASL to routine unenhanced brain MRI for patients being scanned in a hospital setting for various neurological indications.

DESIGN

Retrospective.

SETTING

Large tertiary hospital.

PARTICIPANTS

676 patients.

PRIMARY OUTCOME

Additional findings from ASL sequence compared with conventional MRI.

RESULTS

Our patient cohorts consisted of 676 patients with 257 with acute infarcts and 419 without an infarct. Additional findings from ASL were observed in 13.9% (94/676) of patients. In the non-infarct group, additional findings from ASL were observed in 7.4% (31/419) of patients, whereas in patients with an acute infarct, supplemental information was obtained in 24.5% (63/257) of patients.

CONCLUSION

The addition of an ASL sequence to routine brain MRI in a hospital setting provides additional findings compared with conventional brain MRI in about 7.4% of patients with additional supplementary information in 24.5% of patients with acute infarct.

4D-Dynamic Contrast-Enhanced MRI for Preoperative Localization in Patients with Primary Hyperparathyroidism

BACKGROUND AND PURPOSE

Our aim was to test the hypothesis that our recently introduced 4D-dynamic contrast-enhanced MR imaging with high spatial and temporal resolution has equivalent accuracy to 4D-CT for preoperative gland localization in primary hyperparathyroidism without requiring exposure to ionizing radiation.

MATERIALS AND METHODS

Inclusion criteria were the following: 1) confirmed biochemical diagnosis of primary hyperparathyroidism, 2) preoperative 4D-dynamic contrast-enhanced MR imaging, and 3) surgical cure with >50% decrease in serum parathyroid hormone intraoperatively. 4D-dynamic contrast-enhanced studies were reviewed independently by 2 neuroradiologists to identify the side, quadrant, and number of abnormal glands, and compared with surgical and pathologic results.

RESULTS

Fifty-four patients met the inclusion criteria: 37 had single-gland disease, and 17, multigland disease (9 with double-gland hyperplasia; 3 with 3-gland hyperplasia; and 5 with 4-gland hyperplasia). Interobserver agreement (κ) for the side (right versus left) was 0.92 for single-gland disease and 0.70 for multigland disease. Interobserver agreement for the quadrant (superior versus inferior) was 0.70 for single-gland disease and 0.69 for multigland disease. For single-gland disease, the gland was correctly located in 34/37 (92%) patients, with correct identification of the side in 37/37 (100%) and the quadrant in 34/37 (92%) patients. For multigland disease, the glands were correctly located in 35/47 (74%) patients, with correct identification of the side in 35/47 (74%) and the quadrant in 36/47 (77%).

CONCLUSIONS

The proposed high spatial and temporal resolution 4D-dynamic contrast-enhanced MR imaging provides excellent diagnostic performance for preoperative localization in primary hyperparathyroidism, with correct gland localization of 92% for single-gland disease and 74% in multigland disease, superior to 4D-CT studies.

Reduction of Radiation Dose and Scanning Time While Preserving Diagnostic Yield: A Comparison of Battery-Powered and Manual Bone Biopsy Systems

BACKGROUND AND PURPOSE

There is scarcity of data on the comparative efficacy between bone biopsy drill systems across various types of bone lesions. Our aim was to investigate differences in diagnostic yield, scanning time, and radiation dose between manual and battery-powered bone biopsy systems in CT-guided biopsies of lytic, sclerotic, and infectious bone lesions.

MATERIALS AND METHODS

This was a retrospective single-center institutional review board-approved study. A total of 585 CT-guided core needle biopsies were performed at 1 institution from May 2010 to February 2019. Classification of bone lesions, location, bone biopsy system, suspected origin of primary disease, final pathologic diagnosis, diagnostic yield, presence of crush artifacts, radiation dose, and scanning times were collected. For the battery-powered system, OnControl was used. For the manual drill system, Bonopty, Osteo-site, and Laurane drill systems were used. Comparisons in lytic and sclerotic lesions and suspected discitis/osteomyelitis were made using the Fisher exact test. Subgroup analysis of the drill systems for scanning time and radiation dose was performed by 1-way ANOVA.

RESULTS

Our patient cohorts consisted of a total of 585 patients with 422 lytic, 110 sclerotic, and 53 suspected infectious lesions. The mean age was 62 ± 13 years with a male/female ratio of 305:280 for all lesions. The diagnostic yield was 85.5% (362/422) for lytic, 82.7% (91/110) for sclerotic, 50.9% (27/53) for infectious lesions, and 82.1% (480/585) for all lesions. No statistical difference was found when comparing diagnostic yields of powered drills with the manual systems for lytic, sclerotic, and infectious lesions. However, in a subgroup analysis, radiation dose and scanning time were significantly lower for powered drill compared with manual drill systems in lytic (P = .001 for both) and sclerotic lesions (P = .028 and P = .012, respectively). No significant differences were seen between the drill systems for suspected infectious lesions.

CONCLUSIONS

Our findings demonstrate that there was no statistically significant difference in diagnostic yield when comparing battery-powered and manual bone biopsy systems for CT-guided bone biopsies; however, the use of the power drill system resulted in significantly reduced scanning time and radiation dose in lytic and sclerotic lesions.

Abstract WP68: CT Perfusion Collateral Index in Assessment of Collaterals in Patients With Acute Ischemic Stroke: A New Imaging Biomarker

Purpose: Perfusion collateral index (PCI) has been recently defined as a promising measure of collateral flow. We aim to evaluate the collateral status via CT-based PCI in association with outcome measures such as final infraction volume, recanalization status and functional outcome in patients presenting with acute ischemic stroke (AIS) and in a comparative analysis against CTA and DSA collateral scores.

Methods: AIS patients with anterior circulation large vessel occlusion who had baseline CTA and CT perfusion and underwent endovascular treatment were included. CTA collateral scores were calculated using modified Tan score and DSA collateral scores were evaluated by ASITN grading. In addition, previously described PCI defined as the volume of moderately hypoperfused tissue (ATD 2-6sec ) multiplied by its corresponding rCBV was calculated in each patient. The association of CTA and DSA collateral scores and PCI were assessed against 3 measured outcomes: 1) Final infarction volume obtained from follow up MRI; 2) Final recanalization status defined by TICI scores; 3) Functional outcome measured by 90-day mRS.

Results: A total of 53 patients met inclusion criteria (27F; mean/SD age: 70.1 ± 13 years; median NIHSS: 14). Final infarction volume (mean/SD: 30/40 mL), excellent recanalization defined by TICI >2C was achieved in 36 (68%) patients, and 23 patients (43%) had good functional outcome (mRS <2). Having good collaterals on all 3 modalities (CTA, DSA, CTP-PCI) were associated with significantly (p<0.05) smaller infarction volume. However only good collaterals determined by CTP-PCI was predictive of achieving excellent recanalization (p=0.001) or good functional outcome (p=0.01) ( Figure 1 ).

Conclusion: Collateral status assessed via CT-PCI outperforms CTA and DSA collateral scores in prediction of excellent recanalization and good functional outcome and may be a promising imaging biomarker of collateral status in patients with AIS.

Clinical outcome of vertebral compression fracture after single fraction spine radiosurgery for spinal metastases

Vertebral compression fracture (VCF) occurs after stereotactic body radiation therapy (SBRT) for spine metastasis. Recently, single fraction radiosurgery (sfSRS) is used more frequently. The aim of this study is to determine the clinical outcome of VCF after sfSRS. Spinal instability neoplastic score (SINS) criteria were used to retrospectively score 143 consecutive vertebral segments in 79 patients treated with SRS. Follow-up MRI, pain, and neurologic assessments obtained every 3-6 months. Pain also scored at 7, 14, and 30 days after sfSRS. Follow up was 16 ± 18 months ±SD, range 3-78. Long-term radiographic control occurred in 94 % of cases. Pain improvement resulted within 7 days in 100 % of cases with severe pain and sustained long-term in 95 %. VCF occurred in 21 % of segments: 30 % were de novo VCF. The overall 1 year fracture free probability (1yFFP) was 76 %. Pre-existing VCF resulted in higher probability to progress: 1yFFP 90 versus 60 %. Symptoms presented in 6 % of cases with de novo VCF and 39 % with progressive. The former were treated with vertebral augmentation (VA), the latter with open surgery. Surgery/VA prior to SRS did not change risk of progressive VCF. Univariate but not multivariate analysis identified histology (colorectal), pre-existing VCF, and pain (severe) as significant predictors of VCF. In conclusion, sfSRS compares favourably to SBRT for radiographic and pain control with similar VCF risk. Patients with pre-existing VCF have a higher probability to progress, become symptomatic, and require surgery. These results may help discussing risk and benefits with patients undergoing sfSRS for spinal metastasis and developing new treatment algorithms.