Abstract: Objective To improve the diagnosis and treatment of SARS-CoV-2 associated necrotizing encephalopathy (ANE) of children by analyzing the clinical characteristics, imaging manifestations,and follow-up prognosis of 10 cases of children. Method The clinical and imaging data of 10 children with SARS-CoV-2 associated ANE diagnosed by Guangzhou Medical University Affiliated Women and Children's Medical Center from December 2022 to January 2023 were retrospectively collected. The clinical manifestations, laboratory indicators, treatment process and brain CT or MRI imaging characteristics were analyzed, and the surviving children were followed up for half a year and determine the prognosis. Result Out of 10 pediatric patients, 8 died and 2 survived. Fever was the first symptom in 9 patients, vomiting was the first symptom in 1 patient, and convulsions followed in 5 patients. Eight died children developed coma upon admission, with a median time from symptom onset to coma of 2 days. The Glasgow coma scale (GCS) scores upon admission were severe for 8 died cases, and the acute necrotizing encephalopathy severity scale (ANE-SS) indicated high risk. While the two surviving patients did not present symptoms of coma, with admission GCS ranging from mild to moderate, and ANE-SS indicated low to moderate risk. Laboratory indicators showed that among the dead children, 7 had elevated alanine aminotransferase upon admission, 8 had elevated alanine aminotransferase, and 7 had concomitant pulmonary infections. Among the surviving children, 1 case had normal alanine aminotransferase and glutamic oxalacetic transaminase, while the other case had elevated glutamic oxalacetic transaminase and normal alanine aminotransferase. No pulmonary infection was found in the two surving cases. All cases involved the thalamus and brainstem, with additional involvement of the basal ganglia, periventricular white matter, bilateral frontal and parietal lobes, and cerebellum. The imaging findings resembled those of ANE caused by other sources of infection, showing multifocal symmetric changes on CT and MRI. CT revealed areas of low density, with some showing signs of hemorrhage. Enhanced MRI scans demonstrated lesion enhancement, and diffusion-weighted imaging sequences indicated restricted diffusion. In patients with a poor prognosis, follow-up contrast-enhanced MRI did not show enhancement in the brain vessels, while in those with a favorable outcome, lesions gradually decreased and disappeared. Conclusions Children with acute necrotizing encephalopathy caused by SARS-CoV-2 infection should be identified in time and actively treated. CT and MRI can show symmetrical lesions, while MRI is more sensitive to early onset.

Key words: Severe acute respiratory syndrome coronavirus 2, Acute necrotizing encephalopathy, Children, Imaging, Prognosis