NEJM Correspondence – Neurologic Features in Severe SARS-CoV-2 Infection

Helms J, et. al. Neurologic Features in Severe SARS-CoV-2 Infection: Letter to the Editor, NEJM. Published April 15, 2020: DOI: 10.1056/NEJMc2008597.

Study Background: The authors describe neurologic features identified in two French Hospitals between 3/3-4/3/2020 comprising 64 patients admitted with COVID – 19 acute respiratory distress syndrome (ARDS). The report encompasses the 58 patients who were evaluated in the ICU without neuromuscular blockade at the time of examination by an intensivist and had a neurological evaluation before death. Median age was 63 years and the SAP Score II was 52 (scale ranges form 0-163, with higher values reflecting greater illness severity). Seven patients had prior neurological diagnoses including partial epilepsy, mild cognitive impairment and transient ischemic attack. Surprisingly only 8/49 (16%) patients had fever at the time of examination making this an unlikely cause of the neurological findings and reaffirming the low reliability of this finding for general screening.

Key Points:

  • Analysis was complicated by timing of patient examination: 8(14) on admission before treatment, 39 (67%) after sedation and neuromuscular blockage were withheld.
  • Overall 49/58(85%) of patients exhibited neurological signs
  • Agitation was diagnosed in 40(69%) of patients when sedation and neuro-blockage was withheld.
  • Confusion was diagnosed in 26 of 40 patients (65%).
  • Diffuse cortical tract findings including enhanced tendon reflexes, clonus and bilateral extensor plantar reflexes were noted in 39 patients (67%).
  • A dysexecutive (inattention and/or disorientation) was present in 15 of 45 patients (33%).
  • MRIs were performed in 13 patients. Despite no focal signs of stroke, hypo perfusion was seen in 11/13 patients and 8 patients had leptomeningeal spaces. Two asymptomatic patients had evidence of a small acute ischemic stroke and one patient a subacute stroke.
  • Of 8 patients who underwent an EEG, only nonspecific changes were detected.
  • Spinal fluid analysis was performed in 7 patients showed no cells and all were negative for SARS-CoV-2 virus.
  • In summary, the incidence of incidence of encephalopathy (confusion and nonspecific neurological findings) was frequent and included a small number of patients with focal findings of acute or subacute ischemic stroke on MRI scanning.
  • There is insufficient data to know the contribution of SARS-CoV-2 virus, acute illness, cytokines or medication withdrawal to these findings.

Several other reports have noted stroke and a variety of neurological findings in COVID – 19 patients, emphasizing the need to be vigilant in these patients for neurologic complications.