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COVID-19 neuroimaging update: pathophysiology, acute findings, and post-acute developments

McClelland, Andrew C; Benitez, Steven J; Burns, Judah
COVID-19 has prominent effects on the nervous system with important manifestations on neuroimaging. In this review, we discuss the neuroimaging appearance of acute COVID-19 that became evident during the early stages of the pandemic. We highlight the underlying pathophysiology mediating nervous system effects and neuroimaging appearances including systemic inflammatory response such as cytokine storm, coagulopathy, and para/post-infections immune mediated phenomena. We also discuss the nervous system manifestations of COVID-19 and the role of imaging as the pandemic has evolved over time, including related to the development of vaccines and the emergence of post-acute sequalae such as long COVID.
PMID: 38518814
ISSN: 1558-5034
CID: 5640902

Health Systems Science - A Primer for Radiologists

Felsen, Amanda; McClelland, Andrew; Kobi, Mariya; Bello, Jacqueline A; Burns, Judah
Health systems science (HSS) is an educational framework designed to promote improved care through enhanced citizenship and the training of systems-fluent individuals trained in the science of health care delivery.  HSS education in residency builds upon foundations established during medical school, emphasizing practical skills development, and fostering a growth mindset among trainees.  The HSS framework organizes elements of system-based practice for radiology trainees, promoting practice-readiness for providing safe, timely, effective, efficient, equitable and patient centered radiological care. This paper serves as a primer for radiologists to understand and apply the HSS framework. Additionally, we highlight radiology-specific curricular elements aligned with the HSS framework, and provide teaching resources both for classroom education and for resident self-study.
PMID: 36966069
ISSN: 1878-4046
CID: 5463032

Radiographic and cross-sectional imaging of the airway

Chapter by: McClelland, Andrew C; Chi, TL; Mirsky, DM; Bello, JA; Ferson, DZ; Shifteh, K
in: Hagberg and Benumof's Airway Management by Hagberg, Carin A (Ed)
pp. ?-
ISBN: 9780323795388
CID: 5262722

Brain MRI findings in COVID-19 patients with PRES: A systematic review

Yeahia, Rubaya; Schefflein, Javin; Chiarolanzio, Patrick; Rozenstein, Anna; Gomes, William; Ali, Sana; Mehta, Hasit; Al-Mufti, Fawaz; McClelland, Andrew; Gulko, Edwin
BACKGROUND:Numerous case reports and case series have described brain Magnetic Resonance Imaging (MRI) findings in Coronavirus disease 2019 (COVID-19) patients with concurrent posterior reversible encephalopathy syndrome (PRES). PURPOSE/OBJECTIVE:We aim to compile and analyze brain MRI findings in patients with COVID-19 disease and PRES. METHODS:PubMed and Embase were searched on April 5th, 2021 using the terms "COVID-19", "PRES", "SARS-CoV-2" for peer-reviewed publications describing brain MRI findings in patients 21 years of age or older with evidence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and PRES. RESULTS:Twenty manuscripts were included in the analysis, which included descriptions of 30 patients. The average age was 57 years old. Twenty-four patients (80%) required mechanical ventilation. On brain MRI examinations, 15 (50%) and 7 (23%) of patients exhibited superimposed foci of hemorrhage and restricted diffusion respectively. CONCLUSIONS:PRES is a potential neurological complication of COVID-19 related disease. COVID-19 patients with PRES may exhibit similar to mildly greater rates of superimposed hemorrhage compared to non-COVID-19 PRES patients.
PMID: 34700172
ISSN: 1873-4499
CID: 5244932

Review of COVID-19, part 1: Abdominal manifestations in adults and multisystem inflammatory syndrome in children

Kanmaniraja, Devaraju; Kurian, Jessica; Holder, Justin; Gunther, Molly Somberg; Chernyak, Victoria; Hsu, Kevin; Lee, Jimmy; Mcclelland, Andrew; Slasky, Shira E; Le, Jenna; Ricci, Zina J
The coronavirus disease 2019 (COVID -19) pandemic caused by the novel severe acute respiratory syndrome coronavirus (SARS-CoV-2) has affected almost every country in the world, resulting in severe morbidity, mortality and economic hardship, and altering the landscape of healthcare forever. Although primarily a pulmonary illness, it can affect multiple organ systems throughout the body, sometimes with devastating complications and long-term sequelae. As we move into the second year of this pandemic, a better understanding of the pathophysiology of the virus and the varied imaging findings of COVID-19 in the involved organs is crucial to better manage this complex multi-organ disease and to help improve overall survival. This manuscript provides a comprehensive overview of the pathophysiology of the virus along with a detailed and systematic imaging review of the extra-thoracic manifestation of COVID-19 with the exception of unique cardiothoracic features associated with multisystem inflammatory syndrome in children (MIS-C). In Part I, extra-thoracic manifestations of COVID-19 in the abdomen in adults and features of MIS-C will be reviewed. In Part II, manifestations of COVID-19 in the musculoskeletal, central nervous and vascular systems will be reviewed.
PMID: 34298343
ISSN: 1873-4499
CID: 5244912

Review of COVID-19, part 2: Musculoskeletal and neuroimaging manifestations including vascular involvement of the aorta and extremities

Kanmaniraja, Devaraju; Le, Jenna; Hsu, Kevin; Lee, Jimmy S; Mcclelland, Andrew; Slasky, Shira E; Kurian, Jessica; Holder, Justin; Gunther, Molly Somberg; Chernyak, Victoria; Ricci, Zina J
The coronavirus disease 2019 (COVID-19) pandemic caused by the novel severe acute respiratory syndrome coronavirus (SARS-CoV-2) has affected almost every country in the world resulting in severe morbidity, mortality and economic hardship, altering the landscape of healthcare forever. Its devastating and most frequent thoracic and cardiac manifestations have been well reported since the start of the pandemic. Its extra-thoracic manifestations are myriad and understanding them is critical in diagnosis and disease management. The role of radiology is growing in the second wave and second year of the pandemic as the multiorgan manifestations of COVID-19 continue to unfold. Musculoskeletal, neurologic and vascular disease processes account for a significant number of COVID-19 complications and understanding their frequency, clinical sequelae and imaging manifestations is vital in guiding management and improving overall survival. The authors aim to provide a comprehensive overview of the pathophysiology of the virus along with a detailed and systematic imaging review of the extra-thoracic manifestation of COVID-19. In Part I, abdominal manifestations of COVID-19 in adults and multisystem inflammatory syndrome in children will be reviewed. In Part II, manifestations of COVID-19 in the musculoskeletal, central nervous and vascular systems will be reviewed.
PMID: 34388683
ISSN: 1873-4499
CID: 5244922

Neurologic Syndromes Predict Higher In-Hospital Mortality in COVID-19

Eskandar, Emad Nader; Altschul, David J; de La Garza Ramos, Rafael; Cezayirli, Phillip; Unda, Santiago R; Benton, Joshua; Dardick, Joseph; Toma, Aureliana; Patel, Nikunj; Malaviya, Avinash; Flomenbaum, David; Fernandez-Torres, Jenelys; Lu, Jenny; Holland, Ryan; Burchi, Elisabetta; Zampolin, Richard; Hsu, Kevin; McClelland, Andrew; Burns, Judah; Erdfarb, Amichai; Malhotra, Rishi; Gong, Michelle; Semczuk, Peter; Ferastraoaru, Victor; Rosengard, Jillian; Antoniello, Daniel; Labovitz, Daniel; Esenwa, Charles; Milstein, Mark; Boro, Alexis; Mehler, Mark F
OBJECTIVE:The SARS-Cov2 virus is protean in its manifestations, affecting nearly every organ system. However, nervous system involvement and its impact on disease outcome are poorly characterized. The objective of the study is to determine if neurological syndromes are associated with increased risk of inpatient mortality. METHODS:581 hospitalized patients with confirmed SARS-Cov2 infection, neurological involvement and brain-imaging were compared to hospitalized non-neurological COVID-19 patients. Four patterns of neurological manifestations were identified -acute stroke, new or recrudescent seizures, altered mentation with normal imaging, and neuro-COVID-19 complex. Factors present on admission were analyzed as potential predictors of in-hospital mortality, including sociodemographic variables, pre-existing comorbidities, vital-signs, laboratory values, and pattern of neurological manifestations. Significant predictors were incorporated into a disease-severity score. Patients with neurological manifestations were matched with patients of the same age and disease severity to assess the risk of death. RESULTS:4711 patients with confirmed SARS-Cov2 infection were admitted to one medical system in New York City during a 6-week period. Of these, 581 (12%) had neurological issues of sufficient concern to warrant neuro-imaging. These patients were compared to 1743 non-neurological COVID-19 patients matched for age and disease-severity admitted during the same period. Patients with altered mentation (n=258, p =0.04, OR 1.39, CI 1.04 - 1.86) or radiologically confirmed stroke (n=55, p = 0.001, OR 3.1, CI 1.65-5.92) had a higher risk of mortality than age and severity-matched controls. CONCLUSIONS:The incidence of altered mentation or stroke on admission predicts a modest but significantly higher risk of in-hospital mortality independent of disease severity. While other biomarker factors also predict mortality, measures to identify and treat such patients may be important in reducing overall mortality of COVID-19.
PMID: 33443111
ISSN: 1526-632x
CID: 4776982

Cerebrospinal Fluid in Posterior Reversible Encephalopathy Syndrome: Implications of Elevated Protein and Pleocytosis

Ellis, Colin A; McClelland, Andrew C; Mohan, Suyash; Kuo, Emory; Kasner, Scott E; Zhang, Cen; Khankhanian, Pouya; Balu, Ramani
Background and Purpose/UNASSIGNED:Patients with posterior reversible encephalopathy syndrome (PRES) sometimes undergo analysis of cerebrospinal fluid (CSF) to exclude alternative diagnoses. This study's objectives were to describe the CSF characteristics in patients with PRES and to identify clinical and radiologic findings associated with distinct CSF abnormalities. Methods/UNASSIGNED:We identified a retrospective cohort of patients with PRES. We compared clinical and radiographic characteristics of those who did versus did not undergo lumbar puncture, described the observed range of CSF findings, and analyzed clinical and radiographic features associated with specific CSF abnormalities. Results/UNASSIGNED:= .0058) but not with seizure, time from symptom onset, radiographic evidence of diffusion restriction, or contrast enhancement. Five (7%) patients had elevated CSF white blood cells, all of whom had infarction and/or hemorrhage on neuroimaging, and 4 of whom had eclampsia. Conclusion/UNASSIGNED:The CSF of most patients with PRES shows a mild protein elevation commensurate with radiographic severity. Cerebrospinal fluid pleocytosis may mark a distinct subtype of PRES with predisposition toward infarction and/or hemorrhage. These findings help clinicians interpret CSF findings in these patients and generate new hypotheses about the pathophysiology of this syndrome.
PMID: 30915182
ISSN: 1941-8744
CID: 3778842

White matter microstructural abnormalities in blast-exposed combat veterans: accounting for potential pre-injury factors using consanguineous controls

McClelland, Andrew C; Fleysher, Roman; Mu, Weiya; Kim, Namhee; Lipton, Michael L
PURPOSE/OBJECTIVE:Assess the prevalence of white matter microstructural changes in combat veterans, within the context of a highly matched control group comprising unexposed close relatives. METHODS:This prospective study had institutional review board approval, included written informed consent, and is HIPAA-compliant. Diffusion tensor imaging was analyzed in 16 male blast-exposed combat veterans of Operation Iraqi Freedom/Operation Enduring Freedom (mean age 31.0 years) and 18 unexposed males (mean age 30.4 years) chosen on the basis of a consanguineous relationship to a member of the subject group. Whole-brain voxel-based comparison of fractional anisotropy (FA) was performed using both group and individual analyses. Areas where effects on FA were detected were subsequently characterized by extracting radial diffusivity (RD), axial diffusivity (AD), and mean diffusivity (MD) from the regions of abnormal FA. RESULTS:Controls did not differ from veterans on any background demographic factor. In voxel-based group comparison, we identify high fractional anisotropy (FA) in veterans compared to controls (p < 0.01). Within individual veterans, we find multiple areas of both abnormally high and low FA (p < 0.01) in a heterogeneous distribution, consistent with multifocal traumatic axonal injury. In individualized analyses, low FA areas demonstrate high radial diffusivity, whereas high FA areas demonstrate low RD in both group and individual analyses. CONCLUSIONS:Combat-related blast exposure is associated with microstructural white matter abnormalities, and the nature of the control group decreases the likelihood that the findings reflect underlying background differences. Abnormalities are heterogeneously distributed across patients, consistent with TAI, and include areas of low and high FA.
PMID: 30116841
ISSN: 1432-1920
CID: 5244872

Quantitative Evaluation of Medial Temporal Lobe Morphology in Children with Febrile Status Epilepticus: Results of the FEBSTAT Study

McClelland, A C; Gomes, W A; Shinnar, S; Hesdorffer, D C; Bagiella, E; Lewis, D V; Bello, J A; Chan, S; MacFall, J; Chen, M; Pellock, J M; Nordli, D R; Frank, L M; Moshé, S L; Shinnar, R C; Sun, S
BACKGROUND AND PURPOSE:The pathogenesis of febrile status epilepticus is poorly understood, but prior studies have suggested an association with temporal lobe abnormalities, including hippocampal malrotation. We used a quantitative morphometric method to assess the association between temporal lobe morphology and febrile status epilepticus. MATERIALS AND METHODS:Brain MR imaging was performed in children presenting with febrile status epilepticus and control subjects as part of the Consequences of Prolonged Febrile Seizures in Childhood study. Medial temporal lobe morphologic parameters were measured manually, including the distance of the hippocampus from the midline, hippocampal height:width ratio, hippocampal angle, collateral sulcus angle, and width of the temporal horn. RESULTS:Temporal lobe morphologic parameters were correlated with the presence of visual hippocampal malrotation; the strongest association was with left temporal horn width (P < .001; adjusted OR, 10.59). Multiple morphologic parameters correlated with febrile status epilepticus, encompassing both the right and left sides. This association was statistically strongest in the right temporal lobe, whereas hippocampal malrotation was almost exclusively left-sided in this cohort. The association between temporal lobe measurements and febrile status epilepticus persisted when the analysis was restricted to cases with visually normal imaging findings without hippocampal malrotation or other visually apparent abnormalities. CONCLUSIONS:Several component morphologic features of hippocampal malrotation are independently associated with febrile status epilepticus, even when complete hippocampal malrotation is absent. Unexpectedly, this association predominantly involves the right temporal lobe. These findings suggest that a spectrum of bilateral temporal lobe anomalies are associated with febrile status epilepticus in children. Hippocampal malrotation may represent a visually apparent subset of this spectrum.
PMID: 27633809
ISSN: 1936-959x
CID: 5262702