Multisystem assessment of the imaging manifestations of coagulopathy in hospitalized patients with COVID-19.

O'Shea, Aileen; Parakh, Anushri; Hedgire, Sandeep; Lee, Susanna I

Background: COVID-19 is known to be associated with a distinct form of coagulopathy. Objective: To describe the imaging manifestations of COVID-19 associated coagulopathy in hospitalized patients, across anatomic sites and modalities, and to identify clinical variables associated with positive imaging findings. Methods: We conducted a retrospective review of a consecutive series of adult patients with COVID-19 admitted to our hospital over a 3-week period. Patient demographics, hematologic values, cross-sectional imaging examinations, and clinical outcomes (death and intubation) were collected. Imaging was reviewed for imaging manifestations of coagulopathy. Multivariable logistic regression analyses were performed to assess for associations of patient demographics, hematologic markers, and outcomes, with the conduct of imaging and imaging manifestations of coagulopathy. Results: Among 308 hospitalized patients with COVID-19, 46% underwent cross-sectional imaging for a total of 332 included cross-sectional imaging examinations. A total of 26% (37/142) of patients demonstrated imaging positive for coagulopathy. The most common such imaging manifestations were pulmonary embolus (n=21) on contrast-enhanced CT or CTA, thrombus in the upper or lower extremity veins (n=13) on Doppler US, end organ infarction in the bowel (n=4) and kidney (n=4) on contrast-enhanced CT, and thrombus or parenchymal infarction in the brain (n=2) on contrast-enhanced CTA or MRI with MRA. Among patients with imaging positive for coagulopathy, 22% (8/37) had multi-site involvement. Thrombi were multifocal in 4 of 5 patients with positive upper and 3 of 8 patients with positive lower extremity examinations and involved both superficial and/or deep veins. In multivariable analysis, intubation (p<0.001) and prolonged prothrombin time (p=0.04) showed a significant association with undergoing imaging; no patient variable was significantly associated with imaging positive for coagulopathy (p>0.05). Conclusion: Imaging commonly demonstrates manifestations of coagulopathy in hospitalized patients with COVID-19. In patients with such manifestations, over a fifth demonstrate multi-site involvement. Clinical variables poorly predict which patients have positive imaging, indicating a complementary role of imaging in detecting COVID-19 associated coagulopathy. Clinical Impact: In patients with COVID-19, CT pulmonary angiogram, extremity Doppler US, contrast-enhanced abdomen CT, and contrast-enhanced brain MRI and MRA may all be appropriate if systemic coagulopathy is suspected, in the absence of imaging contraindications.