Teaching NeuroImage: Imaging and Pathologic Findings in SARS-CoV-2-Related Acute Demyelinating Encephalomyelitis

A 41-year-old woman with type 1 diabetes admitted with SARS-CoV-2 PCR confirmed respiratory failure developed altered mental status. EEG was unrevealing, and CSF showed an elevated protein (110 mg/dL) and normal glucose (159 mg/dL), without pleocytosis or oligoclonal bands and normal IgG index. MRI demonstrated FLAIR hyperintensities in the corpus callosum and periventricular white matter (Figure 1). She was treated with plasmapheresis for presumed SARS-CoV-2-related acute demyelinating encephalomyelitis (ADEM) but succumbed to cardiopulmonary arrest. Postmortem histology revealed irregular zones of demyelination with axonal sparing and perivascular inflammatory infiltrate, consistent with ADEM (Figure 2). There was no inflammation within the vessel walls as is seen in vasculitis. SARS-CoV-2 ADEM has variable clinical presentations. Involvement of deep white matter and the corpus callosum has been previously reported, as well as hemorrhagic leukoencephalopathy, although only minimal microhemorrhage was present for this patient.(1) ADEM can be difficult to diagnose, and outcomes are often poor.(2)