Brain autopsies in fatal COVID-19 and postulated pathophysiology: more puzzling than a Rubik’s cube

A little over century after the 1918 influenza pandemic, the world is witnessing another pandemic of similar magnitude, caused by SARS-CoV-2 and affecting nearly 215 countries. Although SARS-CoV-2 primarily affects the lungs, neurological presentations are being recognised with increasing frequency. Recently, Ellul and colleagues1 have elaborated a spectrum of neurological diseases in 901 patients of COVID-19. Here, we describe three case series of brain autopsies2–4 that have revealed distinctly different pathologies, failing to explain the common pathobiological mechanism of central nervous system (CNS) involvement in severe COVID-19. Solomon et al 2 reported histopathological changes in autopsies of 18 patients with COVID-19 from a teaching hospital. Gross inspection showed no changes suggestive of acute stroke, herniation or olfactory bulb damage. Microscopic examination revealed changes of acute hypoxia in the cerebrum and cerebellum in 100% of patients with COVID-19, with neuronal loss in various structures like cerebral cortex, hippocampus and cerebellar Purkinje cell layer. There were no findings of thrombosis or vasculitis. Focal …