While neurological complications from COVID-19 are rare in children as opposed to adults, an international expert review of positive imaging results in children with acute and post-infectious COVID-19 found that the most common immune-mediated abnormalities resembled the brain, spine and nerves . Strokes, which are more commonly reported in adults with COVID-19, were much less common in children.
The study of 38 children, published in the journal Lancet, was the largest to date of COVID-19 imaging manifestations of the central nervous system in children.
Thanks to a large international collaboration, we found that the imaging manifestations of COVID-19 infection in children can range from mild to severe and that pre-existing illnesses are usually absent. Paying attention to the neurological effects of COVID-19 and detecting neuroimaging manifestations that may occur in children can facilitate correct and timely diagnosis, mitigate the spread of disease, and prevent significant morbidity and mortality.
Susan Palasis, co-senior writer, director of neuroradiology at Ann & Robert H. Lurie Children’s Hospital in Chicago, and associate professor of radiology at Northwestern University’s Feinberg School of Medicine.
To understand the imaging findings found in the clinical context, Dr. Palasis and colleagues classified the cases into four disease categories based on the children’s symptoms and laboratory findings. This enabled them to simultaneously assess large numbers of cases and identify recurring imaging patterns in the acute and post-infectious phases of the disease.
In many cases, abnormal enhancement of the spinal nerve roots on MRI has been observed. These neuroimaging findings typically occur in Guillain-Barré syndrome (GBS), a post-infectious autoimmune disease. The study showed that GBS associated with COVID-19 can occur as an acute parainfective process rather than as a typical post-infectious neuronal injury.
Another significant observation was that there was also frequent improvement in the cranial nerve.
We found that abnormal nerve enhancement did not always correlate with corresponding nerve symptoms. This indicates that neuroradiologists need to look specifically for any unexpected abnormalities, as this could be the clue that COVID-19 is the underlying cause of the disease.
DR. Palasis
Other findings that were commonly observed included areas of abnormality on MRI in a specific area of the brain, the splenium of the corpus callosum, and muscle inflammation. These have been more commonly identified with Multisystem Inflammatory Syndrome in Children (MIS-C), a serious complication of COVID-19.
Myelitis, an infectious or post-infectious demyelinating condition of the spinal cord, was also a common condition. Most cases fell within the spectrum of a post-infectious process and the children were either normal or had mild residual symptoms at follow-up. One child developed severe myelitis and eventually became paraplegic.
Our observations show that most children with COVID-19-related nervous system disorders are fine, but some can be severely affected. We have had four cases of atypical central nervous system infections in previously healthy children diagnosed with acute COVID-19 that were uniformly fatal. The results of our study underscore the importance of knowing the atypical and less common consequences of neurological COVID-19 disease in children with recent or concurrent COVID-19 infections. Neuroimaging patterns that we identified in our study should prompt the investigation of possible COVID-19 as an underlying etiological factor for disease.
DR. Palasis
Larry Kociolek, MD of Lurie Children’s co-authored the study and provided expertise on infectious diseases.
The study was funded by the American Society of Pediatric Neuroradiology.
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Research at Ann & The Robert H. Lurie Children’s Hospital in Chicago is directed by the Stanley Manne Children’s Research Institute. The Manne Research Institute is focused on improving children’s health, transforming pediatric medicine, and ensuring a healthier future through the relentless pursuit of knowledge. Lurie Children’s is ranked one of the best children’s hospitals in the country by US News & World Report. It is the pediatric training ground for Northwestern University’s Feinberg School of Medicine. Over the past year, the hospital has cared for more than 220,000 children from 48 states and 49 countries.
