Neuropathological Features of Covid-19 after Autopsy

With this hypoxia shown as a result of COVID-19 I'm getting anti-coagulation immediately, before I become acute or critical. But I'm not medically trained so you can't use this to inform your doctor. My reading of this is that the micro-capillaries are plugged but not large enough dead areas to consider it a stroke. It still can kill you but it is not a stroke.

Brain hypoxia is when the brain isn’t getting enough oxygen. This can occur when someone is drowning, choking, suffocating, or in cardiac arrest. Brain injury, stroke, and carbon monoxide poisoning are other possible causes of brain hypoxia. The condition can be serious because brain cells need an uninterrupted flow of oxygen to function properly.

Neuropathological Features of Covid-19 after Autopsy

To the Editor:

Neurologic symptoms, including headache, altered mental status, and anosmia, occur in many patients with Covid-19.^1-3 We report the neuropathological findings from autopsies of 18 consecutive patients with SARS-CoV-2 infection who died in a single teaching hospital between April 14 and April 29, 2020.

All the patients had nasopharyngeal swab samples that were positive for SARS-CoV-2 on qualitative reverse-transcriptase–polymerase-chain-reaction (RT-PCR) assays. The median age was 62 years (interquartile range, 53 to 75), and 14 patients (78%) were men. The presenting neurologic symptoms were myalgia (in 3 patients), headache (in 2), and decreased taste (in 1). Coexisting conditions included diabetes mellitus (in 12 patients), hypertension (in 11), cardiovascular disease (in 5), hyperlipidemia (in 5), chronic kidney disease (in 4), prior stroke (in 4), dementia (in 4), and treated anaplastic astrocytoma (in 1) (see Tables S1 and S2 in the Supplementary Appendix, available with the full text of this letter at NEJM.org).

The patients had presented a median of 2 days (interquartile range, 0 to 5) after the onset of the first symptoms of SARS-CoV-2 infection and were hospitalized for a median of 6 days (interquartile range, 2 to 9) before death (Fig. S1A); 11 received mechanical ventilation. According to a retrospective chart review by neurologists, all the patients had a confusional state or decreased arousal from sedation for ventilation. Brain magnetic resonance imaging, electroencephalographic imaging, and cerebrospinal fluid examinations were not performed. Cranial computed tomography without contrast was performed in 3 patients and showed no acute abnormalities; the tumor resection cavity in the patient with a known anaplastic astrocytoma was seen.

Table 1. Gross Findings and Results of Histologic Analysis to Detect SARS-CoV-2.

Death occurred 0 to 32 days after the onset of symptoms (median, 8 days; mean, 10 days). Autopsies were performed in a uniform manner with sampling of 10 standard brain areas. Specimens were fixed in formalin and stained with hematoxylin and eosin, as described in the Materials and Methods section in the Supplementary Appendix. Gross inspection showed atherosclerosis in 14 brain specimens but no acute stroke, herniation, or olfactory bulb damage. Residual anaplastic astrocytoma was seen in the patient who had received a diagnosis of anaplastic astrocytoma previously (Table 1). Microscopic examination (Fig. S1B) showed acute hypoxic injury in the cerebrum and cerebellum in all the patients, with loss of neurons in the cerebral cortex, hippocampus, and cerebellar Purkinje cell layer, but no thrombi or vasculitis. Rare foci of perivascular lymphocytes were detected in 2 brain specimens, and focal leptomeningeal inflammation was detected in 1 brain specimen. No microscopic abnormalities were observed in the olfactory bulbs or tracts (Fig. S2).

Testing of brain tissue was performed with quantitative RT-PCR (qRT-PCR) for the SARS-CoV-2 nucleocapsid protein (techniques are described in the Materials and Methods section in the Supplementary Appendix). As shown in Table S3, for 2 patients, all 10 sections were tested, and for the remaining 16 patients, 2 sections were tested (1 from the frontal lobe and olfactory nerve and 1 from the medulla). The results were equivocal (defined as a viral load of <5.0 copies per cubic millimeter) in 5 of 10 brain sections from 1 patient and in 4 of 10 sections from another patient (Table S3); the remaining 11 sections obtained from these 2 patients were negative. In 32 sections obtained from the remaining 16 patients, 3 sections from the medulla and 3 sections from the frontal lobes and olfactory nerves were positive (5.0 to 59.4 copies per cubic millimeter); the results were equivocal in 20 sections and negative in 6 sections. The test results in relation to the interval between the onset of symptoms and death were inconsistent (Fig. S1).

Immunohistochemical analysis (as described in the Supplementary Appendix) was performed to detect SARS-CoV-2 in the same tissue blocks analyzed by qRT-PCR (in 52 blocks from 18 patients). There was no staining in the neurons, glia, endothelium, or immune cells. Nonspecific staining in the choroid plexus was observed in 8 sections obtained from 7 patients; however, this signal was present in negative control brains and did not correlate with the qRT-PCR results (Figs. S1 and S3). The tumor blocks obtained from the patient with anaplastic astrocytoma were not tested by qRT-PCR or immunohistochemical analysis to detect SARS-CoV-2.

In conclusion, histopathological examination of brain specimens obtained from 18 patients who died 0 to 32 days after the onset of symptoms of Covid-19 showed only hypoxic changes and did not show encephalitis or other specific brain changes referable to the virus. There was no cytoplasmic viral staining on immunohistochemical analysis. The virus was detected at low levels in 6 brain sections obtained from 5 patients; these levels were not consistently related to the interval from the onset of symptoms to death. Positive tests may have been due to in situ virions or viral RNA from blood.

Isaac H. Solomon, M.D., Ph.D.
Brigham and Women’s Hospital, Boston, MA
ihsolomon@bwh.harvard.edu

Erica Normandin, B.A.
Broad Institute, Cambridge, MA

Shamik Bhattacharyya, M.D.
Brigham and Women’s Hospital, Boston, MA

Shibani S. Mukerji, M.D., Ph.D.
Kiana Keller, B.S.
Massachusetts General Hospital, Boston, MA

Ahya S. Ali, M.B., B.S.
Brigham and Women’s Hospital, Boston, MA

Gordon Adams, B.A.
Broad Institute, Cambridge, MA

Jason L. Hornick, M.D., Ph.D.
Robert F. Padera, Jr., M.D., Ph.D.
Brigham and Women’s Hospital, Boston, MA

Pardis Sabeti, M.D., D.Phil.
Broad Institute, Cambridge, MA

Supported by a grant (2U19AI110818, to Ms. Normandin and Dr. Sabeti) from the National Institutes of Health (NIH), a grant (to Ms. Normandin and Dr. Sabeti) from the Howard Hughes Medical Institute, and a grant (K23MH115812, to Dr. Mukerji) from the NIH.

Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org.

This letter was published on June 12, 2020, at NEJM.org.