Increased Reports of Neurological Manifestations Among Patients With COVID-19, Brain Abnormalities

MOSCOW, RUSSIA DECEMBER 23, 2020: A patient undergoes a magnetic resonance imaging (MRI) scan before a surgery involving the use an upgraded stereotactic radiosurgery unit known as Gamma knife. Gamma knife uses Gamma radiation to treat benign and malignant tumours and vascular malformations in the cranial cavity. Surgeries are performed without any skin incisions or cranial trepanation. Readiosurgery does not require long stays in hospital and usually lasts for 4 to 12 hours. It is performed under local anaesthetic. Stanislav Krasilnikov/TASS (Photo by Stanislav KrasilnikovTASS via Getty Images)
Investigators described neurological manifestations of patients with COVID-19, analyzed cerebrospinal fluid, and assessed neuroimaging findings.

Researchers observed brain abnormalities in magnetic resonance imaging (MRI) data among patients with neurological manifestations who were positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). These findings were published in the Journal of Infectious Diseases.

Patients (N=58) hospitalized at Strasbourg University, France hospitals with confirmed SARS-CoV-2 and neurological manifestations were included in this study. Most patients underwent an MRI (91%) and all had a lumbar puncture to test their cerebrospinal fluid (CSF) for SARS-CoV-2.

Patients were 66% men aged a median of 62 years. The majority (81%) were admitted to the intensive care unit (ICU). The median between the onset of COVID-19 symptoms, primarily respiratory, to lumbar puncture was 30 days.

Patients presented with encephalopathy (81%), clinical signs of corticospinal tract involvement (16%), seizures (10%), headache (5%), binocular diplopia (2%), cerebellar syndrome (2%), and peripheral nervous system disorders (2%). Patients admitted to the ICU were more likely to have encephalopathy (87% vs 55%; P =.03).

Most patients (68%) had abnormal brain pathologies identified in their MRI. Brain abnormalities included focal leptomeningeal enhancement (38%), acute cerebrovascular injuries (23%), acute ischemic stroke (17%), white matter lesions (8%), and grey matter lesions (2%). Patients presented with a single (n=21), double (n=11), or triple (n=1) neuroimaging patterns.

A total of 4 patients (7%) had SARS-CoV-2 present in their CSF; of these, 3 patients had viral loads below the detection limit, and blood contamination could not be ruled out. The other patient had viral load of 4.3 log10/mL. All 4 patients were admitted to the ICU and presented with delirium.

Of the 4 patients with positive CSF, 2 had normal brain MRIs and 2 had abnormal brain MRI morphology (focal leptomeningeal enhancement).

This study was limited by its small sample size, retrospective design, and prevalence missing data.

The study authors concluded that although neurological manifestations due to a SARS-CoV-2 infection caused abnormal brain morphologies, there was little evidence to suggest a direct involvement of SARS-CoV-2 with CSF. Rather, it is more likely to be a systemic reaction, such as cytokine release syndrome or a hypercoagulable state.


Lersy F, Benotmane I, Helms J, et al. Cerebrospinal fluid features in COVID-19 patients with neurologic manifestations: correlation with brain MRI findings in 58 patients. J Infect Dis. Published online November 29, 2020. doi:10.1093/infdis/jiaa745.