Reader Response: Critical Illness-Associated Cerebral Microbleeds in COVID-19 Acute Respiratory Distress Syndrome

We read with great interest the report by Cannac et al.,1 which adds to a rapidly growing body of evidence that severe COVID-19 is associated with cerebral microvascular lesions.2 However, we caution against the assumption that the observed lesions solely represent microhemorrhages. Although lesions showing a susceptibility effect on T2*-weighted gradient-recalled echo imaging often indicate microhemorrhages,3 the differential diagnosis for these lesions also includes microthrombi and air emboli, the latter being common in patients treated with extracorporeal membrane oxygenation (ECMO), as in the patient reported here. Indeed, in a patient with similar susceptibility lesions in the setting of H1N1 influenza treated with ECMO, postmortem histopathologic analysis revealed that many lesions corresponded to microinfarcts, not microhemorrhages.4

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