Case Series: Evidence of Borderzone Ischemia in Critically-Ill COVID-19 Patients Who “Do Not Wake Up”
This article describes the clinical course, radiological findings, and outcome of two patients with the novel 2019 coronavirus disease (COVID-19) who remained comatose for a prolonged duration following discontinuation of all sedation. These two male patients, one aged 59-years and another aged 53-y...
| Main Authors: | , , , , , , , |
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| Format: | Article |
| Language: | English |
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Frontiers Media S.A.
2020-09-01
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| Series: | Frontiers in Neurology |
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| Online Access: | https://www.frontiersin.org/article/10.3389/fneur.2020.00964/full |
| _version_ | 1818655872900923392 |
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| author | Letitia Pirau Lauren Ottenhoff Lauren Ottenhoff Craig A. Williamson Craig A. Williamson Shahid N. Ahmad Shahid N. Ahmad Rafael Wabl Andrew Nguyen Laura Faiver Venkatakrishna Rajajee Venkatakrishna Rajajee |
| author_facet | Letitia Pirau Lauren Ottenhoff Lauren Ottenhoff Craig A. Williamson Craig A. Williamson Shahid N. Ahmad Shahid N. Ahmad Rafael Wabl Andrew Nguyen Laura Faiver Venkatakrishna Rajajee Venkatakrishna Rajajee |
| author_sort | Letitia Pirau |
| collection | DOAJ |
| description | This article describes the clinical course, radiological findings, and outcome of two patients with the novel 2019 coronavirus disease (COVID-19) who remained comatose for a prolonged duration following discontinuation of all sedation. These two male patients, one aged 59-years and another aged 53-years, both with a history of hypertension and neurologically intact on admission, developed worsening COVID-19 associated acute respiratory distress syndrome (ARDS). Both required benzodiazepine, opioid, neuromuscular blockade, therapeutic anticoagulation, and vasopressor infusions in addition to renal replacement therapy. Echocardiography demonstrated normal chamber size and systolic function in both cases. Each patient demonstrated only trace flexion to pain 7–10 days following discontinuation of all sedation. Magnetic Resonance Imaging on both patients demonstrated multifocal lesions on diffusion weighted imaging with apparent diffusion coefficient correlate in bilateral middle/anterior cerebral artery borderzones, and no large-vessel occlusion or severe stenosis. In both patients, continuous electroencephalography demonstrated no seizures. Neither patient had any documented period of sustained hypotension (mean arterial pressure <60 mmHg) or hypoxia (SpO2 <90%). Ninety days following initial presentation, the 59-years-old man was oriented, with fluent speech and able to ambulate with assistance, while the other 53-years-old man was at home and independent, undertaking the basic activities required by daily living. We conclude that critically-ill COVID-19 patients with prolonged coma following sedation discontinuation may demonstrate imaging features of ischemic injury in borderzone regions despite the absence of documented sustained hypotension or hypoxia. However, substantial neurological recovery is possible despite these findings. |
| first_indexed | 2024-12-17T03:16:36Z |
| format | Article |
| id | doaj.art-8495321d4efd4985a8808939248f94c2 |
| institution | Directory Open Access Journal |
| issn | 1664-2295 |
| language | English |
| last_indexed | 2024-12-17T03:16:36Z |
| publishDate | 2020-09-01 |
| publisher | Frontiers Media S.A. |
| record_format | Article |
| series | Frontiers in Neurology |
| spelling | doaj.art-8495321d4efd4985a8808939248f94c22022-12-21T22:05:38ZengFrontiers Media S.A.Frontiers in Neurology1664-22952020-09-011110.3389/fneur.2020.00964570218Case Series: Evidence of Borderzone Ischemia in Critically-Ill COVID-19 Patients Who “Do Not Wake Up”Letitia Pirau0Lauren Ottenhoff1Lauren Ottenhoff2Craig A. Williamson3Craig A. Williamson4Shahid N. Ahmad5Shahid N. Ahmad6Rafael Wabl7Andrew Nguyen8Laura Faiver9Venkatakrishna Rajajee10Venkatakrishna Rajajee11Department of Neurology, University of Michigan, Ann Arbor, MI, United StatesDepartment of Neurology, University of Michigan, Ann Arbor, MI, United StatesDepartment of Neurosurgery, University of Michigan, Ann Arbor, MI, United StatesDepartment of Neurology, University of Michigan, Ann Arbor, MI, United StatesDepartment of Neurosurgery, University of Michigan, Ann Arbor, MI, United StatesDepartment of Neurology, University of Michigan, Ann Arbor, MI, United StatesDepartment of Neurosurgery, University of Michigan, Ann Arbor, MI, United StatesDepartment of Neurology, University of Michigan, Ann Arbor, MI, United StatesDepartment of Neurology, University of Michigan, Ann Arbor, MI, United StatesDepartment of Neurology, University of Michigan, Ann Arbor, MI, United StatesDepartment of Neurology, University of Michigan, Ann Arbor, MI, United StatesDepartment of Neurosurgery, University of Michigan, Ann Arbor, MI, United StatesThis article describes the clinical course, radiological findings, and outcome of two patients with the novel 2019 coronavirus disease (COVID-19) who remained comatose for a prolonged duration following discontinuation of all sedation. These two male patients, one aged 59-years and another aged 53-years, both with a history of hypertension and neurologically intact on admission, developed worsening COVID-19 associated acute respiratory distress syndrome (ARDS). Both required benzodiazepine, opioid, neuromuscular blockade, therapeutic anticoagulation, and vasopressor infusions in addition to renal replacement therapy. Echocardiography demonstrated normal chamber size and systolic function in both cases. Each patient demonstrated only trace flexion to pain 7–10 days following discontinuation of all sedation. Magnetic Resonance Imaging on both patients demonstrated multifocal lesions on diffusion weighted imaging with apparent diffusion coefficient correlate in bilateral middle/anterior cerebral artery borderzones, and no large-vessel occlusion or severe stenosis. In both patients, continuous electroencephalography demonstrated no seizures. Neither patient had any documented period of sustained hypotension (mean arterial pressure <60 mmHg) or hypoxia (SpO2 <90%). Ninety days following initial presentation, the 59-years-old man was oriented, with fluent speech and able to ambulate with assistance, while the other 53-years-old man was at home and independent, undertaking the basic activities required by daily living. We conclude that critically-ill COVID-19 patients with prolonged coma following sedation discontinuation may demonstrate imaging features of ischemic injury in borderzone regions despite the absence of documented sustained hypotension or hypoxia. However, substantial neurological recovery is possible despite these findings.https://www.frontiersin.org/article/10.3389/fneur.2020.00964/fullCOVID-19 (2019-nCoV)encephalopathycomamagnetic resonance imagingcerebral ischemiaborderzone infarction |
| spellingShingle | Letitia Pirau Lauren Ottenhoff Lauren Ottenhoff Craig A. Williamson Craig A. Williamson Shahid N. Ahmad Shahid N. Ahmad Rafael Wabl Andrew Nguyen Laura Faiver Venkatakrishna Rajajee Venkatakrishna Rajajee Case Series: Evidence of Borderzone Ischemia in Critically-Ill COVID-19 Patients Who “Do Not Wake Up” Frontiers in Neurology COVID-19 (2019-nCoV) encephalopathy coma magnetic resonance imaging cerebral ischemia borderzone infarction |
| title | Case Series: Evidence of Borderzone Ischemia in Critically-Ill COVID-19 Patients Who “Do Not Wake Up” |
| title_full | Case Series: Evidence of Borderzone Ischemia in Critically-Ill COVID-19 Patients Who “Do Not Wake Up” |
| title_fullStr | Case Series: Evidence of Borderzone Ischemia in Critically-Ill COVID-19 Patients Who “Do Not Wake Up” |
| title_full_unstemmed | Case Series: Evidence of Borderzone Ischemia in Critically-Ill COVID-19 Patients Who “Do Not Wake Up” |
| title_short | Case Series: Evidence of Borderzone Ischemia in Critically-Ill COVID-19 Patients Who “Do Not Wake Up” |
| title_sort | case series evidence of borderzone ischemia in critically ill covid 19 patients who do not wake up |
| topic | COVID-19 (2019-nCoV) encephalopathy coma magnetic resonance imaging cerebral ischemia borderzone infarction |
| url | https://www.frontiersin.org/article/10.3389/fneur.2020.00964/full |
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