Despite the devastating global impact of coronavirus disease 2019 (COVID-19), there remains knowledge gaps on the range of complications the virus may have on various organs and body systems, particularly the nervous system. While COVID-19 is known to primarily target the respiratory system, research has revealed that it is also neuroinvasive and may have neurological manifestations.1 In this article, we review some common questions regarding the occurrence, identification, and treatment of neurological symptoms related to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.
What is the occurrence of neurological symptoms in those affected by COVID-19?
Early research from Wuhan, China, indicated that around 37% of those infected by COVID-19 displayed neurological symptoms. There were reports of central nervous system (CNS) and peripheral nervous system (PNS) symptoms in those with COVID-19. Individuals with severe SARS-CoV-2 infection including those >58 years old or with underlying conditions like hypertension were found to have a greater incidence of neurological manifestations.2
What neurological symptoms have been observed in those diagnosed with COVID-19?
Some examples of reported CNS symptoms include dizziness, headache, impaired consciousness, ataxia, and epilepsy. PNS symptoms that have been observed include ageusia, anosmia, vision impairment, and neuralgia.3 Major neurological events such as ischemic stroke and cerebral hemorrhage are also reported in those with severe infection. According to Ramaswami P. Sundar, MD, attending neurologist at Brookdale University Hospital Medical Center, in Brooklyn, New York, “loss of smell and taste are commonly reported in those with COVID-19.” “In addition, new onset headaches, dizziness, weakness and unsteady gait, fatigue, muscle spasms, confusion and disorientation to time and place, altered level of consciousness, seizures, and stroke have all been observed.”
How long after first COVID-19 symptoms do neurological symptoms appear?
The timeline of onset of neurological symptoms in COVID-19 is not entirely clear. In those with severe infection, serious consequential neurological manifestations like stroke and cerebral hemorrhage may occur during admission or even weeks after infection.1 There have been limited studies on when neurological symptoms start appearing and the wide variations in patient symptom presentation makes these estimates complex.
Neurological symptoms are often the earliest, and sometimes the only symptoms, of COVID-19. How has this knowledge changed assessment routines?
Some research has suggested that while new cases of COVID-19 are still surfacing every day, practitioners should evaluate all patients with neurological manifestations with a differential diagnosis of COVID-19 infection.2 The aim here is to reduce the chances of virus spread, prevent misdiagnosis, and avoid delays in diagnosis.2
Laboratory blood tests and computerized tomography (CT) scans have been used to evaluate the extent of the impact of COVID-19 in those suspected to have the viral infection. This is because symptom severity in COVID-19 is not an accurate predictor of organ damage. For example, even in those with low to moderate fever, respiratory system damage could be extensive. CT scans and other laboratory tests are important to determine progression of infection.3
Dr Sundar acknowledges that his assessment techniques have changed. “I’ve started to check for COVID-19 indicators such as elevated sedimentation rate, C-reactive protein, and D-Dimer in patients with new neurological symptoms, especially stroke with no known risk factors,” he said. “I am strongly recommending nasopharyngeal swab if these are abnormal.”
Revathi Vijayaraghaven, a physician’s assistant in neurology at Brookdale Medical Center, also shared that “all patients presenting to [the emergency department] have a routine head CT scan [ordered] to rule out strokes.”
Do neurological symptoms require a specific treatment in addition to the COVID-19 treatment protocol?
Artem Sunik, MD, attending neurologist in Brooklyn, NY, further stated that “treatment largely depends on symptoms.” “People with seizures will get anti-seizure medications. Patients with strokes will be treated with medications for future stroke prevention. Other treatment is supportive, such as adequate hydration, rehab therapy, and correction of electrolytes, he said.
Other practitioners agree that treatment for neurological symptoms is largely symptomatic. However, other practitioners in neurology have stated that their patients are now routinely placed on anticoagulants to prevent clots and strokes in the face of emerging research that COVID-19 causes a hypercoagulable state.
Some symptoms such as ageusia and anosmia are self-limiting and usually resolve on their own, particularly if the infection is mild to moderate in intensity. It is recommended that other symptoms like pain, delirium and stroke are treated according to existing protocols.4
How has the impact of COVID-19 on the nervous system changed treatment protocols for patients with chronic neurological conditions such as multiple sclerosis (MS)?
One study investigating the risk for infection in those with MS reported that people with MS are just as likely as those in the general population to be infected, but noted that immunosuppressive therapies may introduce the element of increased risk of infection.5
All practitioners we contacted agreed that there isn’t enough evidence on how COVID-19 affects those with long-term neurological conditions for them to alter MS treatment plans. However, it is recommended that those with long-term conditions practice social distancing and strict hygiene protocols.
What direction should research take regarding the neurological impact of COVID-19?
Despite the large number of published and ongoing studies focused on COVID-19, very few explore the subject of neurology and COVID-19. Larger, more concentrated studies are necessary to provide a solid evidence base for neurologists and other neurology practitioners. Ultimately, more clarity is needed on the neurological impact of COVID-19, its diagnosis, and its treatment to further establish evidence-based protocols.
1. Asadi-pooya AA, Simani L. Central nervous system manifestations of COVID-19: A systematic review. J Neurol Sci. 2020;413:116832.
2. Mao L, Jin H, Wang M, et al. Neurologic manifestations of hospitalized patients with Coronavirus Disease 2019 in Wuhan, China. JAMA Neurol. 2020;77(6):683–690.
3. Jin H, Hong C, Chen S, et al. Consensus for prevention and management of coronavirus disease 2019 (COVID-19) for neurologists. Stroke Vasc Neurol. 2020;5(2):146-151.
4. Orsucci D, Ienco EC, Nocita G, Napolitano A, Vista M. Neurological features of COVID-19 and their treatment: a review. Drugs Context. 2020;9
5. Brownlee W, Bourdette D, Broadley S, Killestein J, Ciccarelli O. Treating multiple sclerosis and neuromyelitis optica spectrum disorder during the COVID-19 pandemic. Neurology. 2020;94(22):949-952.