By Melinda Young

EXECUTIVE SUMMARY

One major health problem related to COVID-19 involves neurological symptoms and signs of brain injury.

  • Patients with COVID-19 can experience acute periods of confusion, post-traumatic amnesia, and delirium.
  • Physicians and researchers do not know what will happen to patients with COVID-19 over the long term and whether they will fully regain their prior cognitive status.
  • Case managers and nurses could ask patients to report personality changes, memory changes, and other signs of neurological problems, and suggest referrals to a neuropsychologist or speech pathologist.

Neurological symptoms and signs of brain injury have cropped up as one of the major health problems that people experience with COVID-19.

“We’re seeing a lot of patients with delirium,” says Katharine Seagly, PhD, director of the traumatic brain injury rehabilitation program, clinical neuropsychologist, and assistant professor at Michigan Medicine at the University of Michigan.

Patients with traumatic brain injury (TBI) often present with post-traumatic amnesia or confusion. Some patients with COVID-19 experience similar symptoms, Seagly says.

“Patients might not know where they are, what they’re doing, and their attention is waxing and waning,” Seagly says. “They can pay attention for a minute at a time, but are easily distractible.”

Ventilators or sedating medication could have caused confusion, delirium, or memory issues. “There can be significant cognitive consequences of those types of procedures — decreased oxygen to the brain,” she explains. “We call that acute period of confusion post-traumatic amnesia, which is due to prolonged ventilation, multiple infections, or sedating medications,” she explains.1

Some patients with COVID-19 will be cleared of delirium by the time they are transitioned to rehabilitation care, but others experience lingering cognitive issues, Seagly says. The most frequent cognitive problems involve processing information. Patients might show improvement in maintaining attention, but could struggle with complex attention, such as multitasking. Shifting attention from one item to the next can be challenging for these patients, and they might not be able to process information as quickly as they did before their illness.

“We’re seeing that visual-spatial processing seems to be more impacted than verbal processing, but this is all anecdotal,” Seagly says.

Many COVID-19 survivors are behaving like brain-injured patients, says Gerard Francisco, MD, chair of physical medicine and rehabilitation at The University of Texas Health Science Center at Houston (UTHealth), and chief medical officer of The Institute for Rehabilitation and Research (TIRR) Memorial Hermann. “They might be people who have permanent or long-lasting injury,” he says.

Long-Term Effects Unknown

The problem is no one knows what happens over the long term because COVID-19 cases have only been around since late 2019. As scientists and physicians learn more about the disease, their information can help case managers, rehabilitation professionals, and physicians prepare better treatment plans.

“Like with any other virus, there’s a good chance we’ll have another surge,” Francisco says. “Should it happen again, we’ll be better prepared and know better how to handle the needs for people with COVID-19.”

For example, clinicians in Texas learned methods for treating patients with COVID-19 from their colleagues in New York, since the surge in Texas started after New York’s surge was winding down.

Many COVID-19 patients are professionals, and there is a risk that neurological complications could impair their ability to return to work. “I’m concerned there are cognitive issues not addressed, and that they may fail when they return to work,” Francisco says.

One way to address this is for patients to report personality changes and memory changes. These are sent to a neuropsychologist and speech pathologist for evaluation, Francisco says.

“Older age puts you at greater risk — as is the case with many health complications, in general — but younger people are not excluded,” Seagly adds. “This notion that if you are young and you get the virus, you’ll be OK is a misconception.” Seagly has seen patients in their 20s with lingering cognitive impairment after they are transitioned from the intensive care unit to inpatient rehabilitation to home.

All Ages at Risk for Stroke

Younger people, as well as older populations, are at risk of strokes caused by COVID-19 — even if they lack other risk factors.2,3

People who have strokes typically also have underlying conditions, such as high blood pressure, high cholesterol, smoking habits, sleep apnea, and other things that affect their vascular system. “We’re seeing patients who don’t have these types of risk factors and are still having cerebral vascular incidents in the course of their COVID recovery trajectory,” Seagly says.

One recent study revealed neurological complications from COVID-19 are becoming more common and present in the form of encephalitis, meningitis, Guillain-Barré syndrome, and seizures.4 In another study, autopsies of COVID-19 patients revealed signs of mild-to-moderate hypoxia-associated changes, severe ischemic injury, and abundant microhemorrhages.5

Chinese researchers, studying 86 COVID-19 patients, reported 65% presented with at least one neurological symptom. Nearly one-quarter of patients had symptoms that included delirium, cerebrovascular diseases, or hypoxic-ischemic brain injury. Seven patients had a new stroke.6

“What people call the ‘COVID brain’ can manifest as overt neurological problems, similar to a stroke,” Francisco says. “One report I heard was they had patients who had COVID, but the symptoms were so mild they didn’t require hospitalization,” he says. “But, after a few weeks, they ended up in the emergency room with a stroke.”

These patients often were in their 30s or 40s and not at high risk of experiencing a stroke, so their condition was attributed to an inflammatory response from COVID-19, he adds.

Other people might not have a stroke, but they experience changes in their memories and report they do not feel like the same person as pre-COVID-19.

“‘It’s like having a veil over my head,’ one patient said,” Francisco recalls.

“I’m hoping through our rehab interventions, we can facilitate recovery so loss from work will be minimized,” he adds. “Imagine the psychological impact of a high performer who develops COVID and is not able to resume his or her prior activities. Imagine how devastating it is for that person.”

REFERENCES

  1. Emery G. Brain problems can linger months after ICU stay. Reuters, Oct. 3, 2013. https://www.reuters.com/article/us-health-brain-icu/brain-problems-can-linger-months-after-icu-stay-idUSBRE9920UR20131003
  2. Kolikonda MK, Jandrasupalli KK, Lippmann S. Association of coronavirus disease 2019 and stroke: A rising concern. Neuroepidemiology 2020:Aug 13;1-5. doi: 10.1159/000510134. [Online ahead of print].
  3. Ntaios G, Michel P, Georgiopoulos G, et al. Characteristics and outcomes in patients with COVID-19 and acute ischemic stroke: The Global COVID-19 Stroke Registry. Stroke 2020;51:e254-e258.
  4. Janjua T, Moscote-Salazar LR. Acute cerebellar strokes with anoxic brain injury after a cardiopulmonary arrest in SARS-CoV-2 patient. Act Med Indones 2020;52:177-178.
  5. Kantonen J, Mahzabin S, Mayranpaa MI, et al. Neuropathologic features of four autopsied COVID-19 patients. Brain Pathol 2020; doi.org/10.1111/bpa.12889. [Online ahead of print].
  6. Fan S, Xiao M, Han F, et al. Neurological manifestations in critically ill patients with COVID-19: A retrospective study. Front Neurol 2020;11:806.