• Aileen O'Shea, Anushri Parakh, Sandeep Hedgire, and Susanna I Lee.
• Department of Radiology, Massachusetts General Hospital, White 270, 55 Fruit St, Boston 02114, MA.
• AJR Am J Roentgenol. 2021 Apr 1; 216 (4): 1088-1098.

AbstractBACKGROUND. Coronavirus disease (COVID-19) is known to be associated with a distinct form of coagulopathy. OBJECTIVE. The purpose of this study was to describe the imaging manifestations of COVID-19-associated coagulopathy across anatomic sites and modalities in hospitalized patients and to identify clinical variables associated with positive imaging findings. METHODS. We conducted a retrospective review of consecutive adult patients with COVID-19 admitted to our hospital over a 3-week period. Data on patient demographics, hematologic values, cross-sectional imaging examinations, and clinical outcomes (death and intubation) were collected. Imaging was reviewed for manifestations of coagulopathy. Multivariable logistic regression analyses were performed to assess associations of patient demographics, hematologic markers, and outcomes with the need for imaging and imaging manifestations of coagulopathy. RESULTS. Of 308 hospitalized patients with COVID-19, 142 (46%) underwent 332 cross-sectional imaging examinations. Of these, 37 (26%) had imaging results positive for coagulopathy. The most common imaging manifestations of coagulopathy were pulmonary embolus (n = 21) on contrast-enhanced CT or CTA, thrombus in the upper- or lower-extremity veins (n = 13) on Doppler ultrasound, 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 results positive for coagulopathy, eight (22%) had multisite involvement. Thrombi were multifocal in four of five patients with positive upper-extremity and three of eight patients with positive lower-extremity examination results and involved superficial veins, deep veins, or both. In multivariable analysis, intubation (p < .001) and prolonged prothrombin time (p = .04) were significantly associated with undergoing imaging. No patient variable was significantly associated with imaging results positive for coagulopathy (p > .05). CONCLUSION. Imaging commonly shows manifestations of coagulopathy in hospitalized patients with COVID-19. Over one-fifth of patients with such manifestations show multisite involvement. Clinical variables poorly predict which patients have positive imaging results, indicating a complementary role of imaging in detecting COVID-19-associated coagulopathy. CLINICAL IMPACT. In patients with COVID-19 with suspected systemic coagulopathy, pulmonary CTA, extremity Doppler ultrasound, contrast-enhanced abdominal CT, and contrast-enhanced brain MRI and MRA may all be appropriate in the absence of imaging contraindications.

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