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Researchers in France detail neurologic observations of a cohort of 58 consecutive patients admitted to two intensive care units for management of SARS-CoV-2 infection. All were positive for SARS-CoV-2 by RT-PCR assay of nasopharyngeal samples. Median age was 63 years; seven patients had a history of a neurologic disorder.
Neurologic findings were recorded on admission or when sedation and neuromuscular blockade were discontinued. Agitation was observed in 69% of patients, and 26 (65%) of 40 patients assessed met criteria for confusion. Diffuse corticospinal tract signs were present in 67% of patients. At discharge, 33% of 45 patients displayed a dysexecutive syndrome characterized by inattention, disorganization, or poorly organized movements to command.
Thirteen patients underwent brain MRI (11 with perfusion imaging) for evaluation of unexplained encephalopathy. Eight patients had leptomeningeal enhancement. Of the 11 patients with perfusion imaging, all demonstrated bilateral frontotemporal hypoperfusion. One patient had a subacute ischemic stroke. Eight patients underwent electroencephalography, which produced nonspecific findings. Of seven patients who underwent cerebrospinal fluid (CSF) analysis, none demonstrated a CSF pleocytosis and all were negative for SARS-CoV-2 in CSF by RT-PCR.
Helms J et al. Neurologic features in severe SARS-CoV-2 infection. N Engl J Med 2020 Apr 15; [e-pub]. (https://doi.org/10.1056/NEJMc2008597)
Comment
As the authors note, it is unclear to what extent these neurologic observations can be attributed directly to SARS-CoV-2 infection as opposed to encephalopathy due to critical illness, the systemic response to infection, or the effects of medications. The frequent observation of corticospinal tract signs is notable. The lack of virus or other notable findings in CSF assays could result from either absence of central nervous system infection or poor RT-PCR assay sensitivity. The asymptomatic stroke raises concern for increased stroke risk in the setting of systemic inflammation. Dysexecutive syndrome in one third of discharged patients indicates a need for close posthospitalization follow-up. We anticipate that future studies will clarify the pathogenesis of SARS-CoV-2 neurologic syndromes and guide preventive, acute, and longitudinal treatment.