Reader Response: Early Postmortem Brain MRI Findings in COVID-19 Non-survivors

I read the article by Coolen et al.¹ with interest. The wide range of manifestations of the coronavirus disease 2019 (COVID-19) pandemic is not yet known. In their article, Coolen et al. reported 2 patients presenting with subcortical micro- and macrobleeds, 1 patient with cortico-subcortical edematous changes evocative of PRES, and the last patient presenting with nonspecific deep white matter changes. Multiple neuroradiologic patterns attributable to the coronavirus have been reported.^2,3 Recently, various cerebral hemorrhagic disorders have been reported, including both intraparenchymal hemorrhages and diffuse microhemorrhages of the white matter. Extensive and isolated white matter microhemorrhages are found in patients hospitalized in intensive care units for various causes.⁴ Regarding PRES, it has been suggested that SARS-CoV-2 could act as a triggering factor for the development of rapid autoimmune and/or autoinflammatory dysregulation and lead to the endothelial dysfunction. The neuropathologic findings from the autopsies of 18 patients with COVID-19 infection from a recent article showed only hypoxic changes and did not show encephalitis or other specific brain changes referable to the virus.⁵ Considering this, the radiologic abnormalities reported by the authors do not appear to be related to encephalitis or vasculitis due to coronavirus but appear to be related to hypoxemia or autoinflammatory dysregulation.