Friday, June 26, 2020

The Lancet: Yet Another Study On Neurological Manifestations In Severe COVID-19 Patients


Although many people still regard COVID-19 as primarily a respiratory disease, the evidence suggests - at least among those severely ill - that neurological, cardiovascular, and hematological complications are not uncommon.  

Some of the non-neurological complications we've explored include:

WHO Scientific Brief: Multisystem Inflammatory Syndrome in Children & Adolescents with COVID-19

EID Journal: Two Reports On Thrombotic Events In COVID-19 Patients

EID Journal: Pulmonary Embolism and Increased Levels of d-Dimer in COVID-19 Patients

Large-Vessel Stroke as a Presenting Feature of Covid-19 in the Young

Increasingly, however, we are seeing reports of neurological manifestations, and even permanent damage, among COVID-19 patients. 

Last April, in JAMA: Neurologic Manifestations Of Patients With Severe Coronavirus Disease, we examined a report from China that more than 1/3rd of a study group of 214 patients hospitalized with COVID-19 in Wuhan City showed signs of neurological involvement.
Neurological manifestations ranged from relatively mild (headaches, dizziness, anosmia, mild confusion, etc.) to more profound (seizures, stupor, loss of consciousness, etc.) to potentially fatal (ischemic stroke, cerebral hemorrhage, muscle injury (rhabdomyolysis), etc.). 
Not quite 3 weeks ago, in PrePrint: Cytokine Release Syndrome-Associated Encephalopathy in Patients with COVID-19we saw a preprint (not-yet-peer-reviewed) article describing 5 COVID-19 patients admitted to a renal unit at the Strasbourg University Hospital, all presenting with neurological symptoms and blood markers suggestive of a Cytokine Release Syndrome (CRS),

And earlier this week, in The Lancet: COVID-19: Can We Learn From Encephalitis Lethargica?, we looked at growing concerns over long-lasting neurological sequelae among recovered COVID cases. 

Although I haven't covered them all, more studies have recently emerged that document a neurological component to severe COVID-19 disease, including:

First published:07 June 2020

Neurologic manifestations in hospitalized patients with COVID-19: The ALBACOVID registry
Carlos Manuel Romero-Sanchez, MD et al.
First published June 1, 2020,

Brain MRI Findings in Severe COVID-19: A Retrospective Observational Study
Published Online:Jun 16 2020

To this growing list we can add a new study, published yesterday in The Lancet Psychiatry, that describes 153 COVID-19 cases treated in UK hospitals which found a wide range of neurological and psychiatric complications affecting both younger and elderly patients. 

First a link and a small snippet: 
Aravinthan Varatharaj, MRCP, Naomi Thomas, MRCPCH, Mark A Ellul, MRCP, Nicholas W S Davies, PhD, Thomas A Pollak, MRCP, Elizabeth L Tenorio, PhD et al.
Published: June 25, 2020

Complete clinical datasets were available for 125 (82%) of 153 patients. 77 (62%) of 125 patients presented with a cerebrovascular event, of whom 57 (74%) had an ischaemic stroke, nine (12%) an intracerebral haemorrhage, and one (1%) CNS vasculitis. 39 (31%) of 125 patients presented with altered mental status, comprising nine (23%) patients with unspecified encephalopathy and seven (18%) patients with encephalitis.
The remaining 23 (59%) patients with altered mental status fulfilled the clinical case definitions for psychiatric diagnoses as classified by the notifying psychiatrist or neuropsychiatrist, and 21 (92%) of these were new diagnoses. Ten (43%) of 23 patients with neuropsychiatric disorders had new-onset psychosis, six (26%) had a neurocognitive (dementia-like) syndrome, and four (17%) had an affective disorder. 18 (49%) of 37 patients with altered mental status were younger than 60 years and 19 (51%) were older than 60 years, whereas 13 (18%) of 74 patients with cerebrovascular events were younger than 60 years versus 61 (82%) patients older than 60 years.
          (Continue . . . )

While dramatic, these findings need to be interpreted cautiously. 

It is unknown what proportion of these neurological problems can be directly attributed to the SARS-CoV-2 virus, what portion were caused by the body's immune response to infection, and how many may have been caused by the stress of being hospitalized, by treatments (isolation, ventilators, drugs, etc.) received, or by previous diagnosed psychiatric conditions.

A 2013 NEJM study by researchers at Vanderbilt University - called Long-Term Cognitive Impairment after Critical Illness - famously found that a large percentage of ICU patients experience some form of dementia or psychosis - both during their hospital stay - and often lingering after their release (see STAT News Hospitals struggle to address terrifying and long-lasting ‘ICU delirium’).

A number of experts have weighed in on yesterday's Lancet study, and their comments can be found on the Science Media Center (SMC).

JUNE 25, 2020

Research, published in The Lancet Psychiatry, looked at brain complications in hospitalised patients with severe COVID-19.

While the vast majority of people who contract COVID-19 will recover without serious illness or sequelae, for an unlucky subset, this disease can produce profound, lasting, and sometimes fatal complications.