Case report: COVID-19 associated acute necrotizine hemorrhagic encephalopathy – ANE – associated iwth other viral infections. Female, late 50s, 3-day cough, fever, altered mental status.
Work-up NEG for influenza, nasopharyngeal swab (+) coronavirus, CSF limited – traumatic LP, CSF bacterial culture NG, HSV HSV 1 and 2, varicella, WNV NEG; unable to test CSF for SARSCoV-2.
CT head: symmetric hypoattenuation within the bilateral medial thalami with a normal CT angiogram and CT venogram
MRI: hemorrhagic rim enhancing lesions within the bilateral thalami, medial temporal lobes, and subinsular regions
Acute necrotizing encephalopathy
- rare complication of influenza / viral infections
- related to intracranial cytokine storms –> BBB breakdown
- no direct viral invasion or parainfecitous demyelination
- reported mostly in pediatric population but occurs in adults as well
- symmetric, multifocal lesions with invariable thalamic involvement
- Other commonly involved locations include the brain stem, cerebral white matter, and cerebellum
- hypoattenuating on CT
- MRI shows T2 FLAIR hyperintense signal with internal hemorrhage
- Postcontrast images may demonstrate a ring of contrast enhancement
Image from noncontrast head CT demonstrates symmetric hypoattenuation within the bilateral medial thalami (arrows). B, Axial CT venogram demonstrates patency of the cerebral venous vasculature, including the internal cerebral veins (arrows). C, Coronal reformat of aCT angiogram demonstrates normal appearance of the basilar artery and proximal posterior cerebral arteries.
MRI images demonstrate T2 FLAIR hyperintensity within the bilateral medial
temporal lobes and thalami (A, B, E, F) with evidence of hemorrhage indicated by hypointense signal intensity on susceptibility-weighted images (C, G) and rim enhancement on postcontrast
images (D, H).
Poyiadji, N., Shahin, G., Noujaim, D., Stone, M., Patel, S., & Griffith, B. (2020). COVID-19–associated Acute Hemorrhagic Necrotizing Encephalopathy: CT and MRI Features. Radiology, 201187. doi: 10.1148/radiol.2020201187