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The emerging spectrum of COVID-19 neurology: clinical, radiological and laboratory findings

Our take —

Emerging evidence indicates that COVID-19 is associated with challenging neurological dysfunction; however, data have been limited and optimal treatment strategies are unknown. Considerable uncertainty remains about the specific neuropathologic mechanisms involved, which may involve direct viral injury, hyperinflammation, and/or coagulopathy. This study comprehensively characterizes the clinical, laboratory, and neuropathological features of 43 patients with confirmed or probably COVID-19 who presented with neurological complications. Additional research in this area, including longitudinal assessment of clinical and laboratory findings, is warranted to improve understanding of short- and long-term neuropathological complications associated with COVID-19 and inform the use of potential treatment modalities, including the administration of antiplatelet drugs, corticosteroids, and rehabilitation.

Study design

Case Series

Study population and setting

This study characterized the neurological phenotypes (clinical, laboratory, neuropathological, and radiological findings) of laboratory-diagnosed and suspected COVID-19 patients who were referred to a weekly COVID neurology multidisciplinary team meeting at the National Hospital, Queens Square in London, United Kingdom between April 9 and May 15, 2020. COVID-19 diagnosis was categorized as definite (RNA PCR positive), probable (clinical and laboratory symptoms, including lymphopenia, elevated d-dimer and suggestive chest radiology), and possible (suggestive laboratory features but another potential cause was present). COVID-19 disease severity was classified as mild (no or mild pneumonia), severe (dyspnea or hypoxia requiring supplemental oxygen), and critical (respiratory failure, septic shock, or multi-organ failure).

Summary of Main Findings

A total of 43 patients with neurological complications were included (24 males and 19 females; ages 16-85 years). Of these, 29 had a positive RNA PCR test for SARS-CoV-2 infection, while 8 had probable and 6 possible infection. Over the study period, 10 (80% with confirmed SARS-CoV-2 infection) patients developed encephalopathy with features of delirium or psychosis, 12 (67%) had inflammatory central nervous system syndromes, 8 (75%) experienced a large vessel ischemic stroke, and 8 (50%) had peripheral neurological syndromes, including Guillain-Barre syndrome (n=7). Five (60%) patients had uncharacterized or miscellaneous neurological features (seizures, myelitis). An unexpectedly high frequency of cerebral microbleeds among the stroke patients was observed. By end of study follow up, two patients had died and 9 had completely recovered, with the remaining in recovery or partially recovered.

Study Strengths

This case series includes detailed descriptions of five different neurological phenotypes associated with COVID-19 disease, including comprehensive documentation of clinical features, laboratory and radiographic findings, and treatments during and after COVID-19 infection.

Limitations

The study population includes a relatively small number of participants from a single site with fairly short follow-up; follow-up was incomplete for many patients and outcomes may have changed. There was little data presented on pre-infection neurological status or comorbidities, and not all participants had laboratory-confirmed SARS-CoV-2 infection. There are inherent limitations in determining when brain injury occurs given timing of when imaging can occur. Given the descriptive nature of the study, no formal hypotheses were tested.

Value added

This study provides some of the most detailed data, to date, on neurological dysfunction related to confirmed and probable SARS-CoV-2 infection.

This review was posted on: 21 July 2020