European Radiology

, Volume 28, Issue 9, pp 3893–3901 | Cite as

Is the brain spared in Crimean-Congo haemorrhagic fever? An MR-SWI study to reveal CNS involvement

  • Bilge Öztoprak
  • İbrahim Öztoprak
  • Aynur Engin
Magnetic Resonance



The aim of this prospective study is to investigate the central nervous system involvement in Crimean-Congo haemorrhagic fever (CCHF) with magnetic resonance imaging (MRI) in conjunction with clinical and laboratory findings.


Between July 2015 and August 2016, 36 patients with CCHF were undergone brain MRI including SWI. Two MRIs, one at the time of admission and the second in the convalescent period, were performed for each patient in order to see if there is any sign of central nervous system (CNS) involvement, especially in terms of intracranial haemorrhage or viral encephalitis. Clinical severity scoring was also done and laboratory findings were noted in order to correlate with clinical and imaging findings.


None of the 36 patients showed any MRI findings of an acute intracranial event during the course of the disease. There was a significant difference between mild cases and moderate cases in terms of some laboratory parameters (p < 0.05).


Although CCHF is a highly lethal disease which involves multiple organs and systems, CNS involvement seems to be extremely rare in mild and moderate cases.

Key Points

• MRI is the imaging method of choice to diagnose microbleeds and encephalitis

• Although CCHF causes multisystem bleeding, intracranial haemorrhage seems to be very rare

• CNS complications are uncommon, even in the setting of suggestive symptoms

• Death usually results from extracranial bleeding and multiorgan failure

• Severity scoring is associated with some laboratory abnormalities in CCHF


Central nervous system Haemorrhage Magnetic resonance imaging Nairovirus Viral encephalitis 



The authors thank the Scientific Research Projects Committee of Cumhuriyet University for their support.


This study has received funding by Scientific Research Projects program of Cumhuriyet University (CUBAP), Sivas, Turkey.

Compliance with ethical standards


The scientific guarantor of this publication is Prof. Dr. İbrahim Öztoprak, M.D., the head of the Department of Neuroradiology, Cumhuriyet University School of Medicine.

Conflict of interest

The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was obtained from all patients in this study.

Ethical approval

Institutional Ethics Committee approval was obtained (Decided on 12th May 2015; Decision No: 2015-05/09).


• prospective

• diagnostic or prognostic study

• performed at one institution


  1. 1.
    Shayan S, Bokaean M, Shahrivar MR, Chinikar S (2015) Crimean-Congo hemorrhagic fever. Lab Med 46:180–189CrossRefPubMedGoogle Scholar
  2. 2.
    Ergönül Ö (2006) Crimean-Congo haemorrhagic fever. Lancet Infect Dis 6:203–214CrossRefPubMedGoogle Scholar
  3. 3.
    Andersen LK, Davis MD (2017) Climate change and epidemiology of selected tick-borne and mosquito-borne diseases: update from the International Society of Dermatology Climate Change Task Force. Int J Dermatol 56:252–259CrossRefPubMedGoogle Scholar
  4. 4.
    Ergonul O (2012) Crimean-Congo hemorrhagic fever virus: new outbreaks, new discoveries. Curr Opin Virol 2:215–220CrossRefPubMedGoogle Scholar
  5. 5.
    Barr DA, Aitken C, Bell DJ et al (2013) First confirmed case of Crimean-Congo haemorrhagic fever in the UK. Lancet 382:1458CrossRefPubMedGoogle Scholar
  6. 6.
    Tülek N (2014) Kırım-Kongo Kanamalı Ateşi: Tanı ve Tedavi. Turkiye Klinikleri J Inf Dis-Special Topics 7(2):19–28Google Scholar
  7. 7.
    Bente DA, Forrester NL, Watts DM, McAuley AJ, Whitehouse CA, Bray M (2013) Crimean-Congo hemorrhagic fever: history, epidemiology, pathogenesis, clinical syndrome and genetic diversity. Antiviral Res 100:159–189CrossRefPubMedGoogle Scholar
  8. 8.
    Alavi-Naini R, Moghtaderi A, Metanat M (2004) An unusual intracerebral hemorrhage. Can J Infect Dis Med Microbiol 15:175–177PubMedPubMedCentralGoogle Scholar
  9. 9.
    Swanepoel R, Shepherd AJ, Leman PA, Shepherd SP, Miller GB (1985) A common-source outbreak of Crimean-Congo haemorrhagic fever on a dairy farm. S Afr Med J 68:635–637PubMedGoogle Scholar
  10. 10.
    Whitley RJ, Gnann JW (2002) Viral encephalitis: familiar infections and emerging pathogens. Lancet 359:507–513CrossRefPubMedGoogle Scholar
  11. 11.
    Venter M, Zaayman D, van Niekerk S et al (2014) Macroarray assay for differential diagnosis of meningoencephalitis in southern Africa. J Clin Virol 60:50–56CrossRefPubMedGoogle Scholar
  12. 12.
    Osborn AG (2013) Osborn’s brain: imaging, pathology, and anatomy, 1st edn. Amirsys, Friesens, AltonaGoogle Scholar
  13. 13.
    Spengler JR, Keating MK, McElroy AK et al (2017) Crimean-Congo hemorrhagic fever in humanized mice reveals glial cells as primary targets of neurological infection. J Infect Dis.
  14. 14.
    Butenko A (1971) Data from studying etiology, laboratory diagnosis and immunology of Crimean hemorrhagic fever: questions of ecology of the viral agent. Inst Polio Virusn Entsefalitov Akad Med Nauk SSSR Moskva [article in Russian]. (English version, US Naval Medical Research Unit No. 3–T1152)Google Scholar
  15. 15.
    Dilcher M, Koch A, Hasib L, Dobler G, Hufert FT, Weidmann M (2012) Genetic characterization of Erve virus, a European Nairovirus distantly related to Crimean-Congo hemorrhagic fever virus. Virus Genes 45:426–432CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Chastel C (1998) Erve and Eyach: two viruses isolated in France, neuropathogenic for man and widely distributed in Western Europe. Bull Acad Natl Med 182(4):801–809 discussion 809-10PubMedGoogle Scholar
  17. 17.
    Kleib AS, Salihy SM, Ghaber SM, Sidiel BW, Sidiya KC, Bettar ES (2016) Crimean-Congo hemorrhagic fever with acute subdural hematoma, Mauritania, 2012. Emerg Infect Dis 22:1305–1306CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Cheng AL, Batool S, McCreary CR et al (2013) Susceptibility-Weighted Imaging is more reliable than T2*-weighted gradient-recalled echo MRI for detecting microbleeds. Stroke 44:2782–2786CrossRefPubMedGoogle Scholar
  19. 19.
    Hermier M, Nighoghossian N (2004) contribution of susceptibility-weighted imaging to acute stroke assessment. Stroke 35:1989–1994CrossRefPubMedGoogle Scholar
  20. 20.
    Bakır M, Engin A, Gozel MG, Elaldi N, Kilickap S, Cinar Z (2012) A new perspective to determine the severity of cases with Crimean-Congo hemorrhagic fever. J Vector Borne Dis 49:105–110PubMedGoogle Scholar
  21. 21.
    Bakır M, Gözel MG, Köksal I et al (2015) Validation of a severity grading score (SGS) system for predicting the course of disease and mortality in patients with Crimean-Congo hemorrhagic fever (CCHF). Eur J Clin Microbiol Infect Dis 34:325–330CrossRefPubMedGoogle Scholar
  22. 22.
    Rausher A, Sedlacik J, Barth M, Mentzel HJ, Reichenbach JR (2005) Magnetic susceptibility-weighted MR phase imaging of the human brain. AJNR Am J Neuroradiol 26:736–742Google Scholar
  23. 23.
    Yamada N, Imakita S, Sakuma T, Takamiya M (1996) Intracranial calcification on gradient-echo phase image: depiction of diamagnetic susceptibility. Radiology 198:172–178CrossRefGoogle Scholar
  24. 24.
    Gupta RK, Rao SB, Rajan J et al (2001) Differentiation of calcification from chronic hemorrhage with corrected gradient echo phase imaging. J Comput Assist Tomogr 25:698–704CrossRefPubMedGoogle Scholar
  25. 25.
    Cummins D, Bennett D, Fisher-Hoch SP, Farrar B, Machin SJ, McCormick JB (1992) Lassa fever encephalopathy: clinical and laboratory findings. J Trop Med Hyg 95:197–201PubMedGoogle Scholar
  26. 26.
    Wilson MR, Peters CJ (2014) Diseases of the central nervous system caused by lymphocytic choriomeningitis virus and other arenaviruses. Handb Clin Neurol 123:671–681CrossRefPubMedGoogle Scholar
  27. 27.
    Çelikbaş AK, Dokuzoğuz B, Baykam N et al (2014) Crimean-Congo hemorrhagic fever among health care workers, Turkey. Emerg Infect Dis 20:477–479PubMedPubMedCentralCrossRefGoogle Scholar
  28. 28.
    Ftika L, Maltezou HC (2013) Viral haemorrhagic fevers in healthcare settings. J Hosp Infect 83:185–192CrossRefPubMedGoogle Scholar
  29. 29.
    Ceylan B, Calıca A, Ak O, Akkoyunlu Y, Turhan V (2013) Ribavirin is not effective against Crimean-Congo hemorrhagic fever: observations from the Turkish experience. Int J Infect Dis 17:e799–e801CrossRefPubMedGoogle Scholar
  30. 30.
    Ergönül Ö (2014) Evidence supports ribavirin use in Crimean-Congo hemorrhagic fever. Int J Infect Dis 29:296CrossRefPubMedGoogle Scholar
  31. 31.
    Özbey SB, Kader Ç, Erbay A, Ergönül Ö (2014) Early use of ribavirin is beneficial in Crimean-Congo hemorrhagic fever. Vector Borne Zoonotic Dis 14:300–302CrossRefPubMedGoogle Scholar
  32. 32.
    Dokuzoğuz B, Çelikbaş AK, Gök ŞE, Baykam N, Eroğlu MN, Ergönül Ö (2013) Severity scoring index for Crimean-Congo hemorrhagic fever and the impact of ribavirin and corticosteroids on fatality. Clin Infect Dis 57:1270–1274CrossRefPubMedGoogle Scholar

Copyright information

© European Society of Radiology 2018

Authors and Affiliations

  1. 1.Department of RadiologyCumhuriyet University School of MedicineSivasTurkey
  2. 2.Department of Infectious Diseases and Clinical MicrobiologyCumhuriyet University School of MedicineSivasTurkey

Personalised recommendations