Teaching Case

A 37-year-old female patient presented an encephalopathic syndrome including an altered mental status in combination with a mild hemihypesthesia and a mild ataxia. She suffered from prolonged illness with respiratory failure, after having been diagnosed with COVID-19 through PCR-testing. Pre-existing conditions were asthma bronchiale and obesity.

MRI of the brain (3 Tesla) showed extensive oval and linear shaped cerebral microhemorrhages diffusely distributed throughout the brain parenchyma, predominantly affecting the corpus callosum and subcortical regions on axial susceptibility-weighted images without corresponding signal changes in FLAIR, T1w or diffusion-weighted images. There was no gadolinium enhancement.

Neurological symptoms associated with COVID-19 are various and the aetiologies range from ischemic und hemorrhagic stroke, acute demyelinating encephalomyelitis to microbleeds, as seen in this case. The pathophysiological mechanisms of these microhemorrhages remain unknown, but differential diagnoses include endotheliitis with thrombotic microangiopathy and prolonged respiratory failure and damage of the brain-blood-barrier due to hypoxemia [1].

Brain MRI in this young patient showed extensive atypically located intracerebral microbleeds, predominantely in the subcortical white matter and corpus callosum with an oval and linear shape, similar to the pattern reported in patients with non-COVID-19 related critical illness and other causes of severe hypoxia. It is often described after ECMO treatment, and even though this patient received invasive ventilation for 8 days, ECMO treatment was not necessary [2].  The prognosis remains unclear, interestingly the neurological symptoms in our patient improved shortly after the MRI. The patient was discharged five weeks after admission with improved symptoms and will be followed up.

Written informed patient consent for publication has been obtained.