PMC8207268_01
Brain imaging (MRI/MRA/MRV). day #1 brain MRI (A) sagittal T1 image demonstrates downward herniation with decreased size of the suprasellar cistern, posterior fossa crowding causing brainstem compression against the clivus and developing tonsillar herniation. (B) MRV demonstrates patent jugular veins and transverse sinuses without thrombosis. The sagittal sinus and deep venous system are not visible. (C) T2 axial images reveal diffuse cortical swelling mild, global gray matter hyperintensity, and slit-like ventricles suggesting brain edema. (D) coronal MRA image demonstrates near complete or complete loss ACA, MCA, PCA and basilar flow. (E) susceptibility-weighted imaging shows exaggerated cortical veins consistent with engorgement vs thrombosis. the subsequent MRI sagittal T1 (F), day #2 demonstrates tonsillar herniation down to the level of C2. MRIs on day #1 and 2 revealed bilateral parotid cysts (G), suggesting parotitis, which has been reported in cases of COVID-19 infection.
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Also noted were mild, diffuse T2/FLAIR hyperintensities throughout both the deep and superficial gray matter suggesting a global, gray matter-focused process (Figure 1).