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Neurological and neuropsychiatric complications of COVID-19 in 153 patients: a UK-wide surveillance study
Abstract
Background
Concerns regarding potential neurological complications of COVID-19 are being increasingly reported, primarily in small series. Larger studies have been limited by both geography and specialty. Comprehensive characterisation of clinical syndromes is crucial to allow rational selection and evaluation of potential therapies. The aim of this study was to investigate the breadth of complications of COVID-19 across the UK that affected the brain.
Methods
During the exponential phase of the pandemic, we developed an online network of secure rapid-response case report notification portals across the spectrum of major UK neuroscience bodies, comprising the Association of British Neurologists (ABN), the British Association of Stroke Physicians (BASP), and the Royal College of Psychiatrists (RCPsych), and representing neurology, stroke, psychiatry, and intensive care. Broad clinical syndromes associated with COVID-19 were classified as a cerebrovascular event (defined as an acute ischaemic, haemorrhagic, or thrombotic vascular event involving the brain parenchyma or subarachnoid space), altered mental status (defined as an acute alteration in personality, behaviour, cognition, or consciousness), peripheral neurology (defined as involving nerve roots, peripheral nerves, neuromuscular junction, or muscle), or other (with free text boxes for those not meeting these syndromic presentations). Physicians were encouraged to report cases prospectively and we permitted recent cases to be notified retrospectively when assigned a confirmed date of admission or initial clinical assessment, allowing identification of cases that occurred before notification portals were available. Data collected were compared with the geographical, demographic, and temporal presentation of overall cases of COVID-19 as reported by UK Government public health bodies.
Findings
The ABN portal was launched on April 2, 2020, the BASP portal on April 3, 2020, and the RCPsych portal on April 21, 2020. Data lock for this report was on April 26, 2020. During this period, the platforms received notification of 153 unique cases that met the clinical case definitions by clinicians in the UK, with an exponential growth in reported cases that was similar to overall COVID-19 data from UK Government public health bodies. Median patient age was 71 years (range 23–94; IQR 58–79). Complete clinical datasets were available for 125 (82%) of 153 patients. 77 (62%) of 125 patients presented with a cerebrovascular event, of whom 57 (74%) had an ischaemic stroke, nine (12%) an intracerebral haemorrhage, and one (1%) CNS vasculitis. 39 (31%) of 125 patients presented with altered mental status, comprising nine (23%) patients with unspecified encephalopathy and seven (18%) patients with encephalitis. The remaining 23 (59%) patients with altered mental status fulfilled the clinical case definitions for psychiatric diagnoses as classified by the notifying psychiatrist or neuropsychiatrist, and 21 (92%) of these were new diagnoses. Ten (43%) of 23 patients with neuropsychiatric disorders had new-onset psychosis, six (26%) had a neurocognitive (dementia-like) syndrome, and four (17%) had an affective disorder. 18 (49%) of 37 patients with altered mental status were younger than 60 years and 19 (51%) were older than 60 years, whereas 13 (18%) of 74 patients with cerebrovascular events were younger than 60 years versus 61 (82%) patients older than 60 years.
Interpretation
To our knowledge, this is the first nationwide, cross-specialty surveillance study of acute neurological and psychiatric complications of COVID-19. Altered mental status was the second most common presentation, comprising encephalopathy or encephalitis and primary psychiatric diagnoses, often occurring in younger patients. This study provides valuable and timely data that are urgently needed by clinicians, researchers, and funders to inform immediate steps in COVID-19 neuroscience research and health policy.
Funding
None.
... As COVID-19 is a new emerging disease, research continues to reveal different aspects of the disease in children. Previous studies have reported cases of encephalitis in patients with SARS-CoV-2 (1)(2)(3)(4)8). Still, these results cannot be compared with this study because this patient had a different condition due to Chiari malformation type I. Little evidence exists about SARS-CoV-2 infection in children with congenital disease. Severe types of congenital heart disease were reported in a case series of children with COVID-19 (9). ...
... Moreover, encephalitis was evidenced in the patient by the inflammation in the CNS (WBC count in the CSF analysis and MRI scan) as previously reported (8). Numerous other CNS infections were excluded by culture and real-time RT-PCR. ...
... Neurological manifestations and brain MRI findings related to SARS-CoV-2 and viral RNA detection in the CSF suggested that the child with Chiari malformation type I had also viral encephalitis due to SARS-CoV-2 infection. These findings are similar to studies performed by Moriguchi et al., Varatharaj et al., and Huang et al., who reported the detection of SARS-CoV-2 RNA in the CSF (3,8,19). ...
Background/aim:
There is increasing evidence that patients infected with SARS-CoV-2 develop neurological manifestations such as encephalitis. The purpose of this article was to present a case of viral encephalitis associated with SARS-CoV-2 in a 14-year-old child with Chiari malformation type I.
Case report:
The patient manifested frontal headache, nausea, vomiting, skin pallor, right side Babinski sign and was diagnosed with Chiari malformation type I. He was admitted with generalized seizures and suspected encephalitis. Brain inflammation and viral RNA in the cerebrospinal fluid suggested SARS-CoV-2 encephalitis. These findings indicate that the SARS-CoV-2 test in CSF of patients with neurological manifestations, confusion, and fever during the COVID-19 pandemic should be carried out even when there is no evidence of respiratory infection. To our knowledge, this presentation of encephalitis associated with COVID-19 has not yet been reported in a patient with a congenital syndrome such as Chiari malformation type I.
Conclusion:
Further clinical data are needed to determine the complications of encephalitis due to SARS-CoV-2 in patients with Chiari malformation type I to standardize diagnosis and treatment.
... They can also develop a chronic condition, long-COVID or PACS (Post-Acute COVID Syndrome), characterised by fatigue and neuropsychiatric symptoms [5][6][7][8]. More than 40% of COVID-19 patients exhibit neurological, potentially lethal, symptoms during SARS-CoV-2, increasing the need to understand the underlying molecular mechanisms and to develop effective countermeasures [9][10][11]. ...
... Neuroinflammation, which typically accompanies central nervous system (CNS) damage, can be mediated directly by the viral invasion of CNS cells or indirectly by mediators that govern the development of systemic inflammation [3,12]. Briefly, direct action of the SARS-CoV-2 spike protein (S1-protein), which circulates in the blood after being cleaved by the proteases during the viral invasion, and pro-inflammatory cytokines (IL-1β, IL-6, and TNF-α) released by host immunocompetent cells in response to it, impede the bloodbrain barrier (BBB) integrity, resulting in viral entry through the endothelium followed by infection of astrocytes [2,[3][4][5][6][7][8][9][10][11][12][13][14][15]. Symptoms can range from mild headache, nausea, impaired consciousness or reduced cognition to severe, potentially lethal conditions including encephalopathy, delirium, and acute disseminated encephalomyelitis [9][10][11]. ...
... Briefly, direct action of the SARS-CoV-2 spike protein (S1-protein), which circulates in the blood after being cleaved by the proteases during the viral invasion, and pro-inflammatory cytokines (IL-1β, IL-6, and TNF-α) released by host immunocompetent cells in response to it, impede the bloodbrain barrier (BBB) integrity, resulting in viral entry through the endothelium followed by infection of astrocytes [2,[3][4][5][6][7][8][9][10][11][12][13][14][15]. Symptoms can range from mild headache, nausea, impaired consciousness or reduced cognition to severe, potentially lethal conditions including encephalopathy, delirium, and acute disseminated encephalomyelitis [9][10][11]. Multicentre analyses have revealed that stroke (60%+) and encephalopathy (up to 42%) account for most neurological complications associated with SARS-CoV-2 infection. ...
The typical manifestation of coronavirus 2 (CoV-2) infection is a severe acute respiratory syndrome (SARS) accompanied by pneumonia (COVID-19). However, SARS-CoV-2 can also affect t he b rain, c ausing c hronic n eurological s ymptoms, variously known as long, post, post-acute, or persistent COVID-19 condition, and affecting up to 40% of patients. The symptoms (fatigue, dizziness, headache, sleep disorders, malaise, disturbances of memory and mood) usually are mild and resolve spontaneously. However, some patients develop acute and fatal complications, including stroke or encephalopathy. Damage to the brain vessels mediated by the coronavirus spike protein (S-protein) and overactive immune responses have been identified as leading causes of this condition. However, the molecular mechanism by which the virus affects the brain still needs to be fully delineated. In this review article, we focus on interactions between host molecules and S-protein as the mechanism allowing the transit of SARS-CoV-2 through the blood-brain barrier to reach the brain structures. In addition, we discuss the impact of S-protein mutations and the involvement of other cellular factors conditioning the pathophysiology of SARS-CoV-2 infection. Finally, we review current and future COVID-19 treatment options.
... A severe course and fatal outcomes of the disease are commonly associated with the severe acute respiratory syndrome (ARDS) and multi-organ failure [2][3][4][5]. The end-organ failure in COVID-19 patients is generally represented by hepatic lesions in 14-29% of cases, renal injury in 19-29%, heart failure in 33% [6,7], cerebral lesions in 13-69% [8,9], and spleen infarctions in rare cases [10,11]. ...
... As shown in Table 2, a comparison of the serum CPK and SARS-CoV-2 VL in the heart of COVID-19 patients showed no relationship between them. On the contrary, in patients with zero SARS-CoV-2 VL in the heart (No. [5][6][7][8]19), the CPK level exceeded the expected value by 3-5 times (641-1007 IU/L), and in patients with high SARS-CoV-2 VL (No. 9, 23), the CPK level did not exceed the normal range. Furthermore, a significant increase in ALT and AST levels was characteristic for patients with uninfected liver tissue (No. 1,7,8,11,16) and patients with high SARS-CoV-2 VL in the liver (No. 4, 12, 1). ...
... On the contrary, in patients with zero SARS-CoV-2 VL in the heart (No. [5][6][7][8]19), the CPK level exceeded the expected value by 3-5 times (641-1007 IU/L), and in patients with high SARS-CoV-2 VL (No. 9, 23), the CPK level did not exceed the normal range. Furthermore, a significant increase in ALT and AST levels was characteristic for patients with uninfected liver tissue (No. 1,7,8,11,16) and patients with high SARS-CoV-2 VL in the liver (No. 4, 12, 1). The absence of any relationship was also found between the serum LDH, ALP, and Cr levels and SARS-CoV-2 VL in the examined organs of our patients. ...
The main cause of death in COVID-19 patients is acute respiratory distress syndrome (ARDS) and multi-organ failure, which is often caused by extrapulmonary dissemination and the direct damaging effect of SARS-COV-2 on the vital organs tissues. However, the nature of histopathological changes in vital organs and their significance in the thanatogenesis of COVID-19 remain insufficiently studied. Purpose of the research. To study the nature of histopathological changes in organs in COVID-19 patients, and to conduct a comparative analysis of the data obtained with the results of foreign countries’ studies with high mortality rates. Materials and methods. A pathologic study of 179 deceased COVID-19 patients was conducted. The median age of patients was 71 years. In 83.8% (150/179) of cases, COVID-19 was the main disease, and in 16.2% (29/179) of cases, it was concomitant. Results and discussion. Histopathological changes in COVID-19 were multi-organ in nature, which caused ARDS in 91.62%, cardiovascular insufficiency in 27.4%, brain edema – in 20.1%, pulmonary edema – in 3.9%, and pulmonary embolism – in 3.9% of cases. The morphological signs of ARDS in COVID-19 were: lung mass increase in 78.2% of cases, foci of pulmonary parenchyma compaction – 74.8%, discoloration of lung tissue – 60.3%, signs of congestion – 58.1%, the histological basis of which was diffuse alveolar damage. Conclusion. Old age and concomitant chronic diseases of vital organs are the main risk factors for death in COVID-19. Histological changes in organs can be the result of both direct exposure to the virus and hypoxic, metabolic, and ischemic damage.
... The combination of acute ischemic stroke due to the SARS-CoV-2 viral illness alone may not be clinically unexpected, especially in those with severe COVID-19 [4,5]. In a study of 125 COVID-19 patients in the UK, 77 (62%) presented with a cerebrovascular event; 57 (74%) of these 77 patients developed a concurrent ischemic stroke [5]. ...
... The combination of acute ischemic stroke due to the SARS-CoV-2 viral illness alone may not be clinically unexpected, especially in those with severe COVID-19 [4,5]. In a study of 125 COVID-19 patients in the UK, 77 (62%) presented with a cerebrovascular event; 57 (74%) of these 77 patients developed a concurrent ischemic stroke [5]. ...
... Etio-pathogenesis Final Pathological Event common in more severe cases than in milder cases. 5,6,12,15 Neurological involvement in COVID-19 has been evidenced by not only clinical studies but also by neuroimaging and autopsy studies. ...
... Another study showed 125 patients had neurological involvement associated with COVID-19. 15 Of 125 cases 23 (18%) had a neuropsychiatric diagnosis, including 10 (8%) psychosis, 6 (5%) neurocognitive (dementia-like) syndrome, 4 (3%) an affective disorder and the rest others. ...
Corona Virus Disease 2019 (COVID-19) pandemic has been currently going on around the world. The causative virus, Severe Acute Respiratory Syndrome Corona Virus type 2 (SARS-Cov-2), has been detected in various human body fluids including cerebrospinal fluid.
Neurological involvement is one of the important aspects of COVID-19. Though many things in this regard have been published earlier, all the information are scattered and no article has tried to include all the information. Therefore, the main purpose of this article is to summarize all the relevant information about neurological involvement of COVID-19 in a single article.
More than one hundred recently published or pre-print articles have been collected and analyzed in this review. While searching the literatures, keywords such as COVID-19, SARS-CoV-2, encephalitis, stroke, intracranial hemorrhage, neurological manifestations, complications etc. were entered. Pubmed, Medscape etc. were used as a source of information.
Neurological involvement in COVID-19 has been emerging as a matter of interest and further investigation for many who are involved in its management. Though many literatures and reports have explained various neurological aspects of COVID-19, many queries are still unanswered and needs further investigation. Spectrum of neurological involvement, exact mode and basic pathophysiology of central nervous system involvement, possibility of detection of virus in cerebrospinal fluid etc. are yet to be answered which are discussed and addressed in this review.
Based on our analysis, we have discussed on various aspects of neurological involvement in COVID-19 in this review.
... These symptoms are even more prominent in intensive care patients [121]. A UKwide surveillance study to assess psychiatric manifestation in 153 COVID-19 patients concluded that 31% of patients had altered mental status, including anxiety and depression encephalopathy, in younger patients [122]. A retrospective cohort study evaluated neurological and psychotic outcomes in 236,379 survivors of COVID-19 at 6 months. ...
... A UK-wide surveillance study to assess acute neurological manifestation in 153 COVID-19 patients concluded that 62% of patients suffered from cerebrovascular events [122]. An observational study of 58 COVID-19 patients in France reported encephalopathy and acute ischemic strokes [124]. ...
COVID-19 is caused by severe acute respiratory syndrome coronavirus-2, SARS-CoV-2. COVID-19 has changed the world scenario and caused mortality around the globe. Patients who recovered from COVID-19 have shown neurological, psychological, renal, cardiovascular, pulmonary, and hematological complications. In some patients, complications lasted more than 6 months. However, significantly less attention has been given to post-COVID complications. Currently available drugs are used to tackle the complications, but new interventions must address the problem. Phytochemicals from natural sources have been evaluated in recent times to cure or alleviate COVID-19 symptoms. An edible plant, Solanum nigrum, could be therapeutic in treating COVID-19 as the AYUSH ministry of India prescribes it during the pandemic. S. nigrum demonstrates anti-inflammatory, immunomodulatory, and antiviral action to treat the SARS-CoV-2 infection and its post-complications. Different parts of the plant represent a reduction in proinflammatory cytokines and prevent multi-organ failure by protecting various organs (liver, kidney, heart, neuro, and lung). The review proposes the possible role of the plant S. nigrum in managing the symptoms of COVID-19 and its post-COVID complications based on in silico docking and pharmacological studies. Further systematic and experimental studies are required to validate our hypothesis.
... (6) En el Reino Unido mostró que 39 casos de cohorte de 125 pacientes hospitalizados por COVID-19 con manifestaciones neurológicas presentaban alteración del estado mental, con encefalopatía y síndromes neuropsiquiátricos, en la mayor parte de casos existía una nueva aparición u otros trastornos psiquiátricos relacionados. (7) Según datos de investigaciones en España los síntomas neurológicos estaban presentes en el 54,7 % de los casos, tasa que incrementaba hasta el 64,7 % en aquellos con una infección grave. Los niveles alterados de conciencia fueron la manifestación neurológica más común en este grupo. ...
... Varatharaj et al. (7) / Reino Unido/2020 ...
Introducción: el COVID-19 se manifiesta principalmente como una enfermedad respiratoria, posteriormente con el transcurso de la pandemia se describieron síntomas neurológicos, pero principalmente los pacientes desarrollaron complicaciones neurológicas, lo cual se manifestó con síntomas neuropsiquiátricos en alrededor de 35.6 % de los casos con infección por COVID-19. Objetivo: determinar las complicaciones neuropsiquiátricas por covid-19. Metodos: se realizó una revisión narrativa que acotó información sobre las complicaciones neuropsiquiátricas por COVID-19. Para ello se acudió a artículos científicos indexados y publicados desde el 2020 al año 2022, en idioma español e inglés usando buscadores científicos como PubMed y SciELO.Resultados: Los principales síntomas neurológicos, podrían ser consecuencia de una falla multiorgánica, una infección grave o una afectación del tronco encefálico. Se ha reportado que pacientes infectados por SARS-CoV-2, posterior a las 3 semanas los pacientes desarrollaron alteración del estado mental, encefalopatía, psicosis, síndrome neurocognitivo (similiar a demencia) y trastornos afectivos. Se identificó déficits neurocognitivos persistentes en pacientes con delirio incluso después de 18 meses del alta.Conclusiones: el efecto que tiene el SARS-CoV-2 a nivel neuropsiquiátrico se manifiesta como estado mental alterado, psicosis, depresión, ansiedad, síndrome neurocognitivo, trastorno afectivo, deterioro cognitivo, demencia, trastornos de la conciencia. De tal manera, se sugiere que ante la presencia de factores de riesgo como pacientes críticos o con encefalopatías, se debe prevenir el contacto con personas con la infección.
... Some cross-sectional and very short follow-up studies have reported symptoms and disorders like depression, anxiety, posttraumatic stress disorders as common manifestations while some have also reported symptoms of somatization, 9 stress-related adjustment disorders, obsessive-compulsive disorders, acute psychosis, 10 self-injurious thoughts and behaviours. 9,[11][12][13][14][15][16] However, these studies on predictors of mental health issues or psychiatric symptoms in COVID-19 patients, conducted in various parts of the worlds are either limited to specific geographic areas or suffer other limitations. ...
... 9,[11][12][13][14][15][16] However, these studies on predictors of mental health issues or psychiatric symptoms in COVID-19 patients, conducted in various parts of the worlds are either limited to specific geographic areas or suffer other limitations. [10][11][12][13][14][15][16][17][18] A systematic review was conducted to assess implications of Covid-19 on mental health and reported that the vulnerable population comprising of Health care frontline workers, people with preexisting comorbidity, children and elderly population suffered from stress, denial, anger, insomnia, depression, anxiety and suicidal behavior. There was recommendation for the need of Telemedicine services, toll free numbers for psychological help and developing state specific need-based interventions for vulnerable groups. ...
Aim
The study investigate the severity of perceived stress and wide domains of psychiatric symptomsreported on initial screening in hospitalized patients of COVID-19 with a second aim to determine the role of sociodemographic factors and coping styles in the hospitalized patients of COVID-19.
Method
Total 224 patients of COVID-19 infection, hospitalized in various isolation facilities were assessed via web-based self-report questionnaires on perceived stress scale, brief cope inventory, and DSM-5 crosscutting level-1 questionnaire.
Results
Majority of the patients reported moderate level of stress followed by mild and severe. Depression and Anxiety symptoms were most common psychopathology though the patients have reported greater severity in various domains of psychiatric symptoms.Coping styles explains most of variance (64.8%) of the perceived stress. Similarly total PSS scores, coping styles, COVID-19 status and sociodemographic factors contributed significantly to the variance of all psychiatric symptoms.
Conclusion
Factors like female gender, being married, belonging to nuclear families, service class and urban domicile are the significant factors determining higher risk of stress and developing more psychopathologies. Furthermore, coping styles used by the patients have a greater moderating effect on mental health symptoms and their perceived stress which can be a major area for interventions to reduce the mental health morbidities.
... 12 Otro estudio en el Reino Unido que analizó los síntomas neurológicos con los que se presentaban los pacientes con COVID-19, 39 de 125 pacientes (31%) mostraban alteración en el estado de alerta caracterizado por un cambio agudo en la personalidad, comportamiento, cognición o conciencia, lo que coloca a la alteración mental en la segunda forma neurológica de presentación más común en pacientes con CO-VID-19. 13 En Brasil, Garcez y colaboradores realizaron un estudio en pacientes con infección por SARS-CoV-2, en el que incluyeron a 707 pacientes con edad promedio de 66 años, 234 (33%) fueron identificados con delirio, asociándose éste de forma independiente con la mortalidad hospitalaria, así como con la admisión a la unidad de cuidados intensivos, más días de estancia hospitalaria y mayor requerimiento de ventilación mecánica. 14 MATERIAL Y MÉTODOS Tipo de estudio. ...
... Ensefalitis dapat timbul apabila terdapat inflamasi parenkim dan berhubungan dengan prognosis yang lebih buruk.45 Coronavirus telah terdeteksi pada serebrum dan cairan serebrospinal pasien dengan kejang, ensefalitis, dan ensefalomielitis.47 Beberapa gejala neurologis telah dilaporkan pada meningoensefalitis akibat infeksi SARS-CoV-2. ...
Coronavirus disease-19 disebabkan oleh virus SARS-CoV-2 yang menyebabkan pandemi sejak Maret 2020. COVID-19 tidak hanya menyebabkan komplikasi pernapasan dan kardiovaskular, tetapi dapat menyebabkan komplikasi sistem saraf pusat yang juga berkontribusi terhadap mortalitas dan morbiditas. Beberapa komplikasi sistem saraf pusat pada COVID-19 adalah stroke iskemik, stroke hemoragik, meningoensefalitis, acute transverse myelitis, dan ensefalopati. Stroke iskemik pada COVID-19 disebabkan oleh beberapa mekanisme, di antaranya koagulopati, disfungsi endotel, kardioemboli, invasi virus ke sistem saraf pusat, dan terapi imunoglobulin. Stroke hemoragik dapat disebabkan oleh kerusakan endotel akibat inflamasi menyebabkan disregulasi tekanan darah yang meningkatkan risiko stroke hemoragik. Meningoensefalitis pada COVID-19 disebabkan invasi virus langsung melalui cribriform plate atau karena kerusakan endotel yang menjadi pintu masuk SARS-CoV-2 ke otak. Mielitis transversa pada COVID-19 disebabkan hiperinflamasi sistemik, molecular mimicry, dan epitope spreading. Kegagalan organ multipel pada pasien COVID-19 akibat badai sitokin dapat menyebabkan ensefalopati. Coronavirus disease-19 is caused by the SARS-CoV-2 virus that has been causing a pandemic since March 2020. Besides respiratory and cardiovascular complications, COVID-19 can cause complications to central nervous system that also contribute to mortality and morbidity. Some central nervous system complications in COVID-19 are ischemic stroke, hemorrhagic stroke, meningoencephalitis, acute transverse myelitis, and encephalopathy. Ischemic stroke in COVID-19 is caused by several mechanisms, including coagulopathy, endothelial dysfunction, cardioembolism, viral invasion of the central nervous system and immunoglobulin therapy. Hemorrhagic stroke can be associated with blood pressure dysregulation caused by inflammational endothelial damage. Meningoencephalitis in COVID-19 can be caused by direct viral invasion through the cribriform plate or due to endothelial damage that facilitate SARS-CoV-2 entrance to the brain. Transverse myelitis in COVID-19 is caused by systemic hyperinflammation, molecular mimicry and epitope spreading. Multiple organ failure in COVID-19 patients due to a cytokine storm can lead to encephalopathy.
... Emergence of the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in December 2019, responsible for the coronavirus 2019 (COVID-19) pandemic outbreak, has since had a profound impact on health systems globally [1]. While it was initially recognized as the cause of severe pneumonias, COVID-19 has since been found to have a range of extrapulmonary manifestations, including direct effects on the kidney [2][3][4][5][6][7]. The pandemic has also disproportionately affected vulnerable populations, such as elderly people and those affected by chronic medical conditions, in which chronic kidney disease (CKD) has been identified as a significant risk factor for morbidity and mortality following COVID-19 infection [8]. ...
There is an increased incidence of elderly adults diagnosed with kidney failure as our
global aging population continues to expand. Hence, the number of elderly adults indicated for
kidney replacement therapy is also increasing simultaneously. Haemodialysis initiation is more
commonly observed in comparison to kidney transplantation and peritoneal dialysis for the elderly.
The onset of the coronavirus 2019 (COVID-19) pandemic brought new paradigms and insights for
the care of this patient population. Elderly patients receiving haemodialysis have been identified
as high-risk groups for poor COVID-19 outcomes. Age, immunosenescence, impaired response
to COVID-19 vaccination, increased exposure to sources of COVID-19 infection and thrombotic
risks during dialysis are key factors which demonstrated significant associations with COVID-19
incidence, severity and mortality for this patient group. Recent findings suggest that preventative
measures such as regular screening and, if needed, isolation in COVID-19-positive cases, alongside the
fulfillment of COVID-19 vaccination programs is an integral strategy to reduce the number of COVID19 cases and consequential complications from COVID-19, particularly for high-risk groups such as
elderly haemodialysis patients. The COVID-19 pandemic brought about the rapid development and
repurposing of a number of medications to treat patients in the viral and inflammatory stages of their
disease. However, elderly haemodialysis patients were grossly unrepresented in many of these trials.
We review the evidence for contemporary treatments for COVID-19 in this population to provide
clinicians with an up-to-date guide. We hope our article increases awareness on the associations and
impact of COVID-19 for the elderly haemodialysis population, and encourage research efforts to
address knowledge gaps in this topical area.
... The following pathogenetic mechanism of inflammation in the endothelium during COVID-19 has been assumed: endothelial cells produce various bioactive substances in response to damage, in particular cytokines, thrombin, and complement 5a. The NLRP3 inflammasome and the complement are stimulated, which leads to inflammation in the damaged blood vessels [2,18,19]. Based on this knowledge of the pathogenesis, new targets of treatment have been proposed, in particular, immune-mediated therapy with NLRP3-inflammasome antagonists, such as anti-IL-1, anti-IL-6, anti-GM-CSF, and colchicine [3,20,21]. ...
Background: Several cases of skin and central nervous system vasculopathy associated with COVID-19 in children have been published, but the information is rather limited. Our study aimed to describe these cases of vasculitis associated with COVID-19 in children. Methods: In the retrospective-prospective case series study we included information regarding four children with COVID-19-associated vasculitis. In every case, we had a morphological description and the etiology was confirmed via real-time polymerase chain reaction during a tissue biopsy. Results: The most involved systems were skin (4/4), respiratory (3/4), cardiovascular (2/4), nervous (1/4), eye (1/4), kidney (1/4), and inner year (1/4). All patients had increased inflammatory markers and thrombotic parameters (D-dimer). No patient met the criteria for multisystem inflammatory syndrome in children. Two patients met polyarteritis nodosa criteria, one met Henoch–Schonlein purpura criteria, and one met unclassified vasculitis criteria. All patients were treated with systemic glucocorticosteroids (two-pulse therapy). Non-biologic DMARDs were prescribed in all cases; 1/4 patients (25%) was treated with intravenous immunoglobuline, and 3/4 (75%) were treated with biologics (etanercept, tocilizumab, and adalimumab). Conclusions: Vasculitis associated with COVID-19 could be a life-threatening condition; SARS-CoV-2 might be a new trigger or etiological agent for vasculitis and other immune-mediated diseases. Further research and collection of similar cases are required.
... Dear Editor, Patients with Coronavirus Disease (COVID-19) who require hospitalization could be at higher risk of neuropsychiatric sequelae than individuals not requiring inpatient admission [1]. Among different neuropsychiatric manifestations, it has been reported a considerable rate of delirium among inpatients with COVID-19 [2,3]. Indeed, the prevalence of delirium in COVID-19 has been estimated to be up to 80% in intensive care units (ICU) and around 20-30% among non-ICU hospitalized patients [4,5]. ...
... В условиях пандемии COVID-19 установлено, что у 20-30% госпитализированных пациентов с тяжелым течением коронавирусной инфекции независимо от возраста возникает делирий или другие психические расстройства [17,24]. Ранние исследования COVID-19 выявили наличие делирия у 25-33% госпитализированных пациентов [13,15] , у 65% [17], а по некоторым данным -у 80% пациентов отделений интенсивной терапии) [18,24,36]. ...
The aim of the study was to investigate the structure of delirium in elderly patients with different outcomes of coronavirus infection.
Materials and Methods . The study was carried out on the basis of Hospital for War Veterans, St. Petersburg. The study involved 30 patients: 13 male and 17 female (median age (Med) 70.5, interquartile range (IQR) 62-83) with clinical diagnosis: "New coronavirus infection COVID-19 (PCR+), F05.86 other delirium in association with other viral and bacterial neuroinfections. Peculiarities of delirium manifestations were studied using Delirium Rating Scale-Revised-98 (DRS-R-98). Current physical condition was monitored using The National Early Warning Score (NEWS2) for COVID-19.
Results : All patients had moderate to severe disorders of the wake-sleep cycle on the DRS-R-98 scale. In addition, perceptual and long-term memory impairments were common. A significant correlation (p<0.05) was found between the severity of the physical condition and disorders of the sleep-wake cycle, lability of affect, formal thought disorders, motor agitation, and disorientation. In addition, there were significant correlations (p<0.05) between delirium symptoms and physical status scores on the NEWS2 scale. In lethal patients, more pronounced disturbances were recorded on sleep-wake indicators (Med.3.0, IQR 2.0-3.0 vs Med.2.0, IQR 2.0-3.0, p=0.0327) and motor agitation (Med.2.0, IQR 1.0-2.5 vs Med.1.0, IQR 0.0-2.0, p=0.441). A logit regression model showed that the variables "respiratory rate," "heart rate," and the final NEWS2 score could be considered predictors of disease outcome.
Conclusion . Delirium, one of the most frequent manifestations of acute brain dysfunction, is a serious complication of COID-19 in hospitalized patients and a strong predictor of adverse outcome of coronavirus infection in older patients.
... Patients who present with post-COVID persistent chest pain should be thoroughly investigated for pulmonary emboli. It has also been proposed as a potential mechanism for post-COVID chest pain, particularly when accompanied by shortness of breath [102]. Mechanisms of micro-vascular disease in COVID-19 include endothelial injury with endothelial dysfunction and micro-vascular inflammation, and thrombosis [103,104]. ...
An extensive computer search (from January 2020 to January 2023) was conducted including literature from the PubMed, Scopus, MEDLINE, Web of Science, and EMBASE databases. According to preset criteria, a total of 58 articles were included in this review article. Generally, any patient who becomes infected with COVID-19 can develop post-COVID-19 conditions. The course of COVID-19 is divided into three main stages: acute COVID-19 (up to 4 weeks), post-acute COVID-19 (from 4 to 12 weeks), and post-COVID (from 12 weeks to 6 months). If a more protracted course of COVID (over 6 months) is demonstrated, the term "long-COVID" is used. Although the acute stage of COVID-19 infection most commonly manifests with acute respiratory symptoms, one very common symptom of the disease is pain, while the most common symptoms of post-COVID syndrome are shortness of breath, dry cough, fatigue, loss of olfactory and gustatory function, tightness and chest pain, sleep and mood disturbances, body aches, muscle and joint pain, sore throat, fever, and persistent headaches. All observations demonstrated a high incidence of chronic pain syndromes of various localization in the post- and long-COVID period. Post-COVID chronic pain might include a newly developed chronic pain as a part of post-viral syndrome; worsening of preexisting chronic pain due to the associated changes in the medical services, or a de novo chronic pain in healthy individuals who are not infected with COVID. Chronic pain during and post-COVID-19 pandemic is an important health issue due to the significant impacts of pain on the patients, health care systems, and society as well. Therefore, it is important that patients with chronic pain receive effective treatment according to their specific needs. Accordingly, the main goal of this review article is to provide a broad description about the post-COVID pain and to explore the impact of long COVID-19 on chronic pain patients, and also to give brief reports about the prevalence, risk factors, possible mechanisms, different presentations, and the management tools through a systematic approach.
... Више фактора повезаних са болешћу и њеним лечењем може допринети когнитивним последицама. Ти фактори укључују хипоксију, вентилацију, седацију, делиријум, цереброваскуларне поремећаје и упалне процесе (Beach et al., 2020;Romero-Sánchez et al., 2020;Varatharaj et al., 2020). До данас, међутим, подаци о когнитивном функционисању углавном су ограничени на студије случаја и серије случајева. ...
Although the primary focus is still on curbing COVID-19 transmission and saving lives, there is growing evidence that survivors can have significant consequences in terms of communication difficulties. Studies have shown that the process of treating acute respiratory distress syndrome can lead to speech apparatus damage. In addition, there is a body of evidence indicating the possible neurological consequences of COVID-19 infection, with motor speech disorders among other symptoms. Also, there is growing evidence of significant cognitive dysfunction in survivors from severe forms of COVID-19 infection. Documented difficulties include impairment of attention, memory, processing speed, and executive functions, which can negatively affect one’s communication and quality of life after hospital discharge.
The role of speech and language therapists in minimizing the negative consequences of severe forms of COVID-19 is two-way directed. The first emphasise early assessment of the severity and extent of motor speech disorders, as well as early screening of cognitive- communication deficit, already at intensive care units. The second one is focused on the early application of speech and language interventions, as well as giving professional instructions, both to the patients and family members.
... Neuropsychiatric sequelae have been reported after SARS-CoV-2 infection, establishing an association between severe illness from COVID-19 and the manifestation of psychiatric symptoms 14,15 . However, in post-COVID-19 follow-up studies, it has also been observed that people with mild or asymptomatic disease may present delirium, cognitive impairment, fatigue, and mood disturbances 3,11,16 . The incidence of various disorders, such as insomnia, anxiety, suicidal ideation, confusion, and altered consciousness has also been reported 2,7,13,17 . ...
Objective: To describe the sociodemographic and clinical characteristics of acute psychiatric disorders in COVID-19 patients in an emergency department at a national reference psychiatry and mental health hospital.
Methods: A descriptive observational study was performed. Data were collected from medical records of patients admitted by emergency according to the International Classification of Diseases (ICD-11). The group of patients with a first acute psychiatric episode vs. patients with more than one acute psychiatric episode were compared.
Results: 110 patients were included; 61.8% corresponded to the female sex and the mean age was 36 years. 49.1% corresponded to schizophrenia, followed by acute polymorphic psychotic disorder (13.6%), bipolar disorder (10%), and depressive episodes (7.3%). Psychotic disorders and depressive episodes occurred in a higher percentage in the group with a first episode, 42.4% (p< 0.001), and 15.2% (p< 0.001), respectively. The episodes of schizophrenia were higher in the group of patients with previous episodes (63.6%).
Conclusions: A higher frequency of cases of acute psychotic disorder and depressive disorders was found as the first episode in patients with COVID-19 infection; however, within the group with previous episodes, greater predominance of patients with acute disorders due to schizophrenia was found.
... The diagnoses presented in our study appear in several studies found in literature. To investigate the complications of COVID-19 affecting the brain in the UK, an online case-sharing network involving leading UK neuroscience bodies was created, and 153 cases were reported, of which 62% were related to cerebrovascular events, 31% altered mental status (23% with nonspecific encephalopathies and 18% with encephalitis) and 5% had peripheral disorders (in which 67% were diagnosed with GBS) 13 . ...
O SARS-CoV-2 é o agente etiológico da pandemia iniciada em dezembro de 2019 e vem atingindo números alarmantes em todo o mundo. Manifestações neurológicas foram relatadas e devem ser destacadas. Este trabalho relata casos de manifestações neurológicas graves associadas à COVID-19 em pacientes internados em um hospital terciário. O primeiro paciente foi encaminhado com história de convulsões generalizadas após o diagnóstico de COVID-19; exame de imagem indicou trombose venosa cerebral. O segundo paciente, já tratado para COVID-19, desenvolveu dor na região dorsal, evoluindo para parestesia ascendente, e teve diagnóstico de Síndrome de Guillain-Barré, com desfecho fatal. O terceiro paciente, também com desfecho fatal, apresentou cefaléia e hemiparesia à esquerda. Após exames de imagem, recebeu alta, mas dias depois, retornou com quadro de confusão mental e foi confirmada a hipótese de encefalite. A infecção por SARS-CoV-2 foi confirmada após a morte. O principal objetivo deste estudo é relatar manifestações neurológicas graves relacionadas à COVID-19.
... Individuals at a higher genetic risk of developing AD-related dementia (ADRD) are xperiencing a higher risk of severe COVID-19; the risk of severe COVID-19 for people carrying two ApoE ε4 alleles is doubled (OR = 2.31) compared with the more common ApoE ε3ε3 genotype [15,20] as in patient 3. Though Patient 3 carried no ε 4 alleles, his pre-COVID-19 diagnosis placed him within an at-risk category along the ADRD continuum [20]. Although available studies have described memory loss, confusion, and dementia-like manifestations as a component of acute infection [22,23], our cases illustrate progression along the Alzheimer's continuum early in the COVID-19 convalescent period. The immediacy of this threat further underscores the importance of closely following older adult convalescent COVID-19 patients given the broad clinical phenotype of PASC that is now evident from extended follow-up in neurology-based and psychiatry-based clinics. ...
In this case report,we describe the clinical characteristics of three older adults aged >65years with cognitive difficulties prior to theirCOVID-19 infection who reported worsening of neurocognitive symptoms in the convalescent COVID-19 phase. Formal neuropsychological testingalong with neuroimaging were included with each patient. These patients described an initial worseningin cognitive functionafter recovering from the acute phase of COVID19. This case reportdescribes variable recoveryof cognitive abilities in the convalescent stage. The direct effectof the viral infection itselfon cognitive function are well documented. We hypothesize that the persistent inflammatory or immune response in the convalescent COVID-19 stage, more commonly referred to as the indirect mechanism, contributes to the clinical syndromeknown as the Post-Acute Sequelae of SARS-CoV-2 (PASC).
... 24 A study by Varatharaj et al. reported that 10 (43%) out of 23 patients with neuropsychiatric disorders following COVID-19 had new-onset psychosis, 6 (26%) had a neurocognitive (dementia-like) syndrome, and 4 (17%) had an affective disorder. 25 There is dearth of Indian studies that systematically investigated the prevalence of neuropsychiatric manifestations in persons who recovered from COVID-19 illness. Therefore, the index study aimed at finding the prevalence of neuropsychiatric symptoms among patients who recovered from COVID-19 illness. ...
... 31 Se ha notificado vasculitis o fenotipo similar a la vasculitis (incluida la arteriopatía cerebral focal pediátrica) en dos pacientes pediátricos y tres adultos con accidente cerebrovascular isquémico agudo. [32][33][34][35][36] Curiosamente, dos de estos casos mostraron realce de la pared de los vasos arteriales en imágenes de resonancia magnética (IRM) compatibles con inflamación. En el paciente adulto, el proceso vasculítico fue extenso e involucró la ACA bilateralmente, la ACM, las arterias vertebrales y la arteria basilar. ...
La enfermedad cerebrovascular aguda, particularmente el accidente cerebrovascular isquémico, ha surgido como una complicación grave de la infección por el síndrome respiratorio agudo severo coronavirus 2 (SARS-CoV-2). La acumulación de datos sobre pacientes con accidente cerebrovascular asociado con COVID-19 ha arrojado luz sobre las especificidades relacionadas con la presentación clínica, los hallazgos de neuroimagen y sus resultados. Dichas especificidades incluyen una propensión a la oclusión de vasos grandes, accidente cerebrovascular multiterritorial y compromiso de vasos afectados de otra manera poco común. Por el contrario, la enfermedad cerebral de vasos pequeños, la trombosis venosa cerebral y la hemorragia intracerebral parecen ser menos frecuentes. Los casos que presen-taban encefalopatía o encefalitis con crisis epilépticas sintomáticas que presagiaban un accidente cerebrovascular fueron particularmente desafiantes. La patogénesis y el manejo óptimo del accidente cerebrovascular isquémico asociado con COVID-19 aún son inciertos, pero la evidencia emergente sugiere que la coagulopatía y la endoteliopatía desencadenadas por tormentas de citoquinas representan posibles mecanismos a los que se puede apuntar. Algunos problemas de manejo específicos en esta población incluyen la dificultad para identifi-car signos clínicos de accidente cerebrovascular en pacientes críticos en la unidad de cuidados intensivos, así como la necesidad de una vía protegida para imágenes cerebrales, trombólisis intravenosa y trombectomía mecánica, teniendo en cuenta que "el tiempo es cerebro" también para pacientes con COVID-19. ICTUS 2023;4(1):e31012304001 Palabras clave-SARS-CoV-2, Coronavirus, Enfermedad cerebrovascular, Coagulopatía, Evento cerebrovascular hemorrágico, Compli-caciones neurológicas
Abstract-Cerebrovascular disease in COVID-19, Review of its Pathological Mechanisms, Diagnostic Imaging and Therapeutic Implications Acute cerebrovascular disease, particularly ischemic stroke, has emerged as a serious complication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The accumulation of data on stroke patients associated with COVID-19 has shed light on speci-ficities related to clinical presentation, neuroimaging findings, and their outcomes. Such specificities include a propensity for large-vessel occlusion, multiterritorial stroke, and involvement of otherwise uncommonly affected vessels. In contrast, cerebral small vessel disease, cerebral venous thrombosis, and intracerebral hemorrhage appear to be less common. Cases presenting with encephalopathy or encephalitis with seizures presaging stroke were particularly challenging. The pathogenesis and optimal management of ischemic stroke associated with COVID-19 remain uncertain, but emerging evidence suggests that cytokine storm-triggered coagulopathy and endotheliopathy represent possible target mechanisms. Some specific management issues in this population include the difficulty in identifying clinical signs of stroke in critically ill patients in the intensive care unit, as well as the need for a protected pathway for brain imaging, intravenous thrombolysis, and mechanical thrombectomy, considering that "time is brain. a lso for patients with COVID-19. ICTUS 2023;4(1):e31012304001
... After an initial period in which health care was concentrated on the most evident aspects of the acute syndrome (i.e., life-threatening and respiratory symptoms), it was noted early on that SARS-CoV-2 infection also had more wide-ranging effects (e.g., Ashraf et al., 2020). Similarly, it became early evident that infection due to SARS-CoV-2 may significantly affect the CNS, sometimes resulting in serious consequences (e.g., Boldrini et al., 2021;Pilotto, Cristillo, et al., 2021, Pilotto, Masciocchi, et al., 2021Varatharaj et al., 2020;Wu et al., 2020). SARS-CoV-2 infection may also give rise to neuropsychiatric impairment, resulting in cognitive symptoms likely accompanied by anxiety and/or fatigue (e.g., Bertuccelli et al., 2022;Boldrini et al., 2021;Pilotto, Cristillo, et al., 2021;Taquet et al., 2021;Wu et al., 2020). ...
Purpose:
We present two patients who developed neurogenic stuttering after long COVID-19 related to SARS-CoV-2 infection.
Methods and results:
Both patients experienced both physical (e.g., fatigue) and cognitive difficulties, which led to impaired function of attention, lexical retrieval, and memory consolidation. Both patients had new-onset stuttering-like speech dysfluencies: Blocks and repetitions were especially evident at the initial part of words and sentences, sometimes accompanied by effortful and associated movements (e.g., facial grimaces and oro-facial movements). Neuropsychological evaluations confirmed the presence of difficulties in cognitive tasks, while neurophysiological evaluations (i.e., electroencephalography) suggested the presence of "slowed" patterns of brain activity. Neurogenic stuttering and cognitive difficulties were evident for 4-5 months after negativization of SARS-CoV-2 nasopharyngeal swab, with gradual improvement and near-to-complete recovery.
Conclusions:
It is now evident that SARS-CoV-2 infection may significantly involve the central nervous system, also resulting in severe and long-term consequences, even if the precise mechanisms are still unknown. In the present report, long COVID-19 resulted in neurogenic stuttering, as the likely consequence of a "slowed" metabolism of (pre)frontal and sensorimotor brain regions (as suggested by the present and previous clinical evidence). As a consequence, the pathophysiological mechanisms related to the appearance of neurogenic stuttering have been hypothesized, which help to better understand the broader and possible neurological consequences of COVID-19.
... The high affinity of the virus to the Angiotensin-Converting Enzyme-2 (ACE2), also expressed in the Central Nervous System (CNS), implies an acute inflammatory response, with interleukin and interferon activity due to an adaptive immune response [12][13][14] ; by hematogenous dissemination, retrograde neuronal transport and passage through the cribriform plate, this phenomenon explains the presence of neuropsychiatric symptoms, in which between 40-88% of patients with severe COVID-19 present neurological symptoms, neurodegeneration, neuroinflammation and demyelination 11,12 . Among the post-COVID psychiatric manifestations, there are depressive, anxious, traumatic symptoms, insomnia and psychosis, including dissociative manifestations [15][16][17][18] . ...
Background: Complex trauma is a variant of post-traumatic stress disorder (PTSD), adding symptoms of affect dysregulation, difficulty in relationships, and negative self-perception. Its neurobiology is closely linked to the pro-inflammatory alterations by the disruption of the hypothalamic-pituitary-adrenal axis, which are also described in psychosis, and neuropsychiatric symptoms of the SARS-CoV-2 virus infection. Aim: To present a case that illustrates the clinical and neurobiological overlap between COVID-19, psychosis, and complex trauma. Case presentation: A 24-year-old female who initially presented dissociative symptoms evolving into a psychotic episode, after suffering from COVID-19 disease, in whom a history of abuse was later clarified. The clinical case is reviewed, performing a free search of articles for the discussion of clinical and pathophysiological challenges. Conclusion: Trauma is one of the greatest determinants in mental health, and is associated with several clinical spectra, being necessary to open the phenomenological and physiological debate to understand the sum of effects in patients who present with severe mental illness.
... При цьому дослідження A. Varatharaj та співавт. [29] показало, що виникнення психічних розладів унаслідок загострення вже наявної психіатричної патології спостерігалося лише в 9 % випадків, тоді як інші були вперше виявленими. ...
Objective — to find the mainCOVID-19-associated psychiatric disorders and mechanisms of their development basing on the literature analysis. Materials and methods. 112 literature sources from the PubMed database for the queries «Covid AND mental health», «Covid AND mental disorders» were analyzed and 36 of them were selected for detailed study. Results and discussion. It were found that patients with COVID-19 often have multiple neurological and mental disorders, such as agitation (69 %), signs of damage to the corticospinal tract (67 %), confusion (65 %) and neuropsychological disorders (33 %). Among the mental disorders that are observed after a coronavirus disease, the most common are insomnia (42 %), decreased concentration and attention (38 %), anxiety (36 %), memory disorders (34 %), depression (33 %), confusion (28 %) and other disorders of consciousness (21 %). The most vulnerable contingents of the population are children, adolescents and the elderly, who suffer not only from the disease itself, but also from the consequences of isolation. Special attention should be paid to healthcare professionals, who often have anxiety (12—20 %), depression (15—25 %), insomnia (8 %) and post-traumatic stress disorder (35—49 %). Conclusions. The COVID-19 pandemic has already profoundly strongly influenced the mental health of the population. This was especially reflected in such groups of the population as patients with psychiatric pathology, medical workers, the elderly and people in difficult financial situations. Given the potential for new waves of COVID-19 disease and increased quarantine restrictions, as well as the possibility of new epidemics in the future, it is important to make clear guidelines that will help mitigate the impact of the pandemic crisis and restrictive measures and prevent massive mental health deterioration.
... Psychological disruptions, including dizziness, confusion, delirium, and psychosis have also been reported. For instance, when an online network of researchers in the UK composed of neuroscientists, stroke physicians, psychiatrists, and intensive care doctors examined over 100 patient cases identified in April 2020, altered mental states were noted as the second most common presentation (Varatharaj et al., 2020). The majority (59%) of these patients displayed altered mental states that met criteria for diagnosis as determined by a psychiatrist or neuropsychiatrist. ...
Since the first confirmed case in Wuhan, China on December 31, 2019, the novel coronavirus (SARS-CoV-2) has spread quickly, infecting 165 million people as of May 2021. Since this first detection, research has indicated that people contracting the virus may suffer neurological and mental disorders and deficits, in addition to the respiratory and other organ challenges caused by COVID-19. Specifically, early evidence suggests that COVID-19 has both mild (e.g., loss of smell (anosmia), loss of taste (ageusia), latent blinks (heterophila), headaches, dizziness, confusion) and more severe outcomes (e.g., cognitive impairments, seizures, delirium, psychosis, strokes). Longer-term neurological challenges or damage may also occur. This knowledge should inform clinical guidelines, assessment, and public health planning while more systematic research using biological, clinical, and longitudinal methods provides further insights.
... illnesses, cognitive disorders and depression are frequent in this subacute phase of the disease, as well as in the long term, and are often present concurrently (9,14,(29)(30)(31). These clinical signs of early depression can worsen in the following weeks, leading to the appearance of post-traumatic stress disorder, especially in patients who underwent orotracheal intubation and who have been recovered in ICU in the acute phase (14,32,33). ...
Objective:
We aimed to investigate the clinical symptoms and specific care requirements of SARS-CoV-2 patients who were admitted to a COVID-19 Rehabilitation Unit while still infectious for SARS-CoV-2 and in the subacute phase of the disease.
Methods:
Patients admitted to our COVID-19 Rehabilitation Unit from March 2020 to December 2020 were evaluated for sarcopenia, and they also completed the following assessments: functional independence measure, short physical performance battery and Hamilton Rating Scale for Depression. Age and body mass index and symptoms of dysosmia or dysgeusia were also recorded.
Results:
A total of 126 patients were enrolled (50 women, median age 72 years, 18.7 years), of whom 82% of patients presented with low grip strength. Sarcopenia was diagnosed in 52 patients. Sarcopenic patients were older than non-sarcopenic ones (median age 73.4 years, IQR 13.2 vs 63.9 years, IQR 14.5, respectively, p = 0.014). Sarcopenia was associated with the presence of depression (p = 0.008), was more common in women (p = 0.023) and was associated with greater functional deficits (functional independence measure and short physical performance battery analyses, p < 0.05). Sarcopenic patients also had a lower body mass index than other patients (p < 0.01).
Conclusion:
More than 40% of our patients suffered from sarcopenia, which was associated with ageing, depression, low body mass index, reduction in functional autonomy and being a woman. Such data provide evidence for the need to assist hospitalized COVID-19 patients by means of a multidisciplinary specialist team.
... There are multiple reports of abnormal findings on common head MRI/A sequences in COVID-19 patients who required hospitalization [13][14][15]. In a cross-sectional study of head MRI/A findings of 125 COVID-19 in patients with neuropsychiatric symptoms across the UK, 77 (62%) had a cerebrovascular disorder, 57 (74%) had cerebral infarction, nine (12%) had a cerebral hemorrhage, and one (1%) patient had central nervous system vasculitis [27]. A total of 39 patients (31%) had psychiatric symptoms, of whom nine patients (23%) had nonspecific encephalopathy and seven patients (18%) had encephalitis. ...
Purpose:
There have been several reports of central nervous system impairments associated with severe coronavirus disease 2019 (COVID-19) infection on head magnetic resonance imaging and angiography (MRI/A). However, head MRI/A is rarely performed in mild cases, and there have been few reports on intracranial changes after COVID-19 infection in these cases. Here, we report a comparative examination of the findings seen in common head MRI/A sequences in mild cases of COVID-19.
Methods:
Of the 15,376 patients who underwent head MRI/A examination called "Brain Dock" between June 2020 and June 2021, 746 patients who received a COVID-19 antibody test were evaluated. Positive and negative patients were comparatively examined for head MRI/A findings such as cerebral white matter lesions, ischemic changes, cerebral microbleeds, cerebral aneurysms, arterial stenosis, sinusitis, and other abnormal findings.
Results:
Overall, 31 (4.2%) patients were COVID-19 positive, and all of them had mild infections not requiring hospitalization. There was no significant difference in patient characteristics and head MRI/A findings between positive and negative patients. All positive patients showed no particular abnormalities in the nasal findings such as olfactory bulb atrophy or thickening of the olfactory mucosa.
Conclusion:
Intracranial lesions in mild patients do not show a clear difference from those in negative patients. This indicates that findings seen in common MRI/A sequences of severe patients are not likely in mild patients, supporting that there is relatively no damage to the central nervous system in mild patients.
... In agreement with preclinical studies suggesting that respiratory infections can lead to inflammation in the central nervous system or have access to it via the olfactory route, recent large cohort studies have shown complications such as psychosis and cognitive alterations in COVID-19 patients [108]. All these observations suggest that, although the mechanism of the association between nasal viral infections and schizophrenia remains unknown, nasal inflammation caused by infections may contribute to olfactory disturbances in psychopathology of schizophrenia. ...
Purpose of Review
Olfactory dysfunction contributes to the psychopathology of mental illness. In this review, we describe the neurobiology of olfaction, and the most common olfactory alterations in several mental illnesses. We also highlight the role, hitherto underestimated, that the olfactory pathways play in the regulation of higher brain functions and its involvement in the pathophysiology of psychiatric disorders, as well as the effect of inflammation on neurogenesis as a possible mechanism involved in olfactory dysfunction in psychiatric conditions.
Recent Findings
The olfactory deficits present in anxiety, depression, schizophrenia or bipolar disorder consist of specific alterations of different components of the sense of smell, mainly the identification of odours, as well as the qualifications of their hedonic valence (pleasant or unpleasant). Epidemiological findings have shown that both environmental factors, such as air pollutants, and inflammatory disease of the upper respiratory tract, can contribute to an increased risk of mental illness, at least in part, due to peripheral inflammatory mechanisms of the olfactory system.
Summary
In this review, we describe the neurobiology of olfaction, and the most common olfactory function alterations in several psychiatric conditions and its role as a useful symptom for the differential diagnosis. We also highlight the effect of inflammation on neurogenesis as a possible mechanism involved in olfactory dysfunction in these psychiatric conditions.
... The typical symptoms of COVID-19 include anosmia and ageusia along with fever, dry cough, and shortness of breath [6,7]. COVID-19 is a neurotropic virus associated with neurological manifestations in up to 36% of patients [8], and the most commonly reported manifestations are cerebrovascular events, followed by altered mental status [9]. Neurological manifestations can range from a mild headache or "brain fog" [10] to more serious complications, such as Guillain-Barre syndrome [11], cells) [37]. ...
Infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is associated with the onset of neurological and psychiatric symptoms during and after the acute phase of illness. Inflammation and hypoxia induced by SARS-CoV-2 affect brain regions essential for fine motor function, learning, memory, and emotional responses. The mechanisms of these central nervous system symptoms remain largely unknown. While looking for the causes of neurological deficits, we conducted a study on how SARS-CoV-2 affects neurogenesis. In this study, we compared a control group with a group of patients diagnosed with COVID-19. Analysis of the expression of neurogenesis markers showed a decrease in the density of neuronal progenitor cells and newborn neurons in the SARS-CoV-2 group. Analysis of COVID-19 patients revealed increased microglial activation compared with the control group. The unfavorable effect of the inflammatory process in the brain associated with COVID-19 disease increases the concentration of cytokines that negatively affect adult human neurogenesis.
... In brain, apart from strokes, seizures and Guillain-Barre syndrome, there is increased risk of developing Parkinson's and Alzheimer's disease which have been related to vasculopathy and endothelial injury, and thrombosis [14]. The elderly people are more prone to long-term effects, but younger persons who had milder form of the disease may also suffer with persistent symptoms [15]. Covid-19 may trigger the onset of diabetes in healthy people. ...
Human Settlements and Ecological Footprints: As such, the ecosystems are the planet's life-support systems for the human species and all other forms of life. The ecological alterations in turn may lead to irreparable climate change, and have repercussions on human health, which are complex. The ecological alterations affect the distribution of patterns of human settlement, nutritional and health status, and disease patterns including pandemics. COVID-19 Pandemic and the Clinical Fallouts: There have been turbulent times with the novel pandemic COVID-19, engulfing, imprisoning, and debilitating the humanity all over the Globe. The unabated transmission of the virus led to immense human suffering and overwhelmed healthcare facilities. The disease has high infectivity and fatality, and the survivors have propensity to suffer with organopathies and exacerbation of other pre-existing diseases. Changing Healthcare Scenario and Options: The fallouts of COVID-19 pandemic have been striking. The pandemic has been a reality check for various provisions of available healthcare. As the existing healthcare facilities were unable to cope with the sudden surge leading to an intense pressure on the system, the pandemic has acted as a transformation catalyst and accelerated transformation in healthcare including remote and Hospital-at-Home care. Planning Healthcare for Post-Covid illness: The COVID-19 now persists as endemic in most places with the infection affecting those with a high-risk. Presently, a heightened awareness is required for diagnosing post-Covid symptoms and complications. There are needed specialized OPD services for diagnostic workup, treatment, and regular follow up, along with a dedicated indoor facility for profiling the post-Covid illness, treatment, and intensive care.
... In a study conducted in France, it was stated that 69% of 58 hospitalized patients had CNS involvement, and 33% of 43 patients discharged from the hospital had dysexecutive syndrome including inattention, disorientation, or poorly organized response to the command [4]. A recent study carried out in England found that mental status changes including psychosis and neurocognitive changes were observed in 31% of 125 patients [1,5]. Although the neurovirulence of the COVID-19 has not been completely proven yet, some studies showed that it affects the CNS in different ways, and causes neurological problems such as ischemia and encephalitis in two-thirds of hospitalized patients [1]. ...
Background and PurposeCognitive deficits that are associated with coronavirus disease 2019 (COVID-19) and occur in the acute period are gaining importance. While most studies have focused on the elderly severely affected during acute infection, it remains unclear whether mild to moderate COVID-19 results in cognitive deficits in young patients. This study aims to evaluate the post-infection cognitive functions of young adults with mild to moderate symptoms of COVID-19.MethodsA total of 100 adults with similar age and educational background were included in the study. Half of those had been infected with COVID-19 in the last 60 days (N = 50), and the other half had not (N = 50). Global cognitive skills of the participants were evaluated through Montreal Cognitive Assessment Scale (MoCA) and Clock-Drawing Test; memory functions with Öktem Verbal Memory Processes Test (Ö-VMPT); attention span with Digit Span Test; executive functions with Fluency Tests, Stroop Test, and Trail Making Test; visual perceptual skills with Rey Osterrieth Complex Figure Test (ROCF); and neuropsychiatric status with Neuropsychiatric Inventory (NPI). Evaluations were performed in the experimental group for 21 to 60 days from the onset of the disease, and throughout the study, in the control group.ResultsIt was found that global cognitive skills, verbal memory, visual memory, executive function, and neuropsychiatric status were affected during COVID-19 (p < 0.05).Conclusion
When the cases were analyzed according to disease severity, no relationship was found between cognitive deficits and disease severity.
... Neurological involvement seen during COVID-19 active infection has frequently been evaluated in studies. 3,21,22 However, there is only limited knowledge and experience concerning the clinical profile of prolonged neurological symptoms associated with COVID-19. 19,20,[23][24][25][26][27][28][29][30][31][32] In this prospective multicenter study, we documented the neurologic symptoms of our patients that persisted for at least one month using a structured face-to-face standardized questioning. ...
Background: COVID-19 was declared as a pandemic by World Health Organization on March 11, 2020, and still constitutes a serious health problem affecting millions of people across the world. The evaluation and follow-up of ongoing and/or newly developing neurological involvement after recovery from COVID-19 are important. This study aims to reveal post-COVID-19 neurological symptoms and risk factors for their development. Methods: Patients over the age of 18 years who applied to centers, at least 4 weeks after COVID-19 infection and agreed to participate in the study were included in this cross-sectional study between January 20 and March 15, 2021. The patients were evaluated face to face, and their sociodemographic data, medical history, post-COVID-19 neurological symptoms, treatments, and Beck Depression Inventory scores were recorded. All statistical analyses were performed using SPSS 23 for Windows software package (SPSS Inc., Chicago, IL). Results: Four hundred patients were included in this study, an average of 108+5.12 days had passed after the onset of COVID-19. The rate of post-COVID-19 neurological involvement was 73.3%, and the top 3 most common symptoms were headache (47%), myalgia (43%), and sleep disturbance (39%). Having depression (OR: 4.54, 95% Cl :1.88-10.96), female gender (OR:2.18, 95% Cl :1.36-3.49), hospitalization (OR: 2.01, 95% Cl :103-3.64), and usage of favipiravir (OR:2.07 95 Cl :1.15-3.72) were determined as independent predictors of developing prolonged neurological symptoms. Conclusion: The long-term consequences of COVID-19 remain uncertain. It should be remembered that neurological symptoms are very common in post-infectious patients and long-term follow-up may be required in the management of this condition.
COVID-19-inflicted psychiatric and psychopathological sequelae are reported in some survivors of the acute form of the disease. However, few studies have investigated psychopathology of COVID-19 infection in patients who contracted mild or moderate forms of this disease. Current study aimed to investigate this issue further. 305 university students with a history of falling ill with either mild or moderate COVID-19 infection answered the items in the SCL-90-R. Point biserial and Kendall's tau-b correlation tests, feature selection machine learning, and robust regression were employed to analyse the collected data. The results showed that there was a significant relationship between the Length of Time Passed since Recovery and an increase in the participants' depression scores. Further, a significant two-way Severity of Disease × Age interaction was found in the dimension of somatisation. Finally, a significant three-way Severity of Disease × Length of Time Passed since Recovery × Sex interaction was found in the dimension of hostility. Our results suggest that there are complicated relations between Sex, Age, Length of Time Passed since Recovery, and Severity of Disease, probably mediated by stress, which result in different patterns of psychopathology in patients.
COVID-19 can cause psychological problems including loss of smell and taste, long-lasting memory, speech, and language impairments, and psychosis. Here, we provide the first report of prosopagnosia following symptoms consistent with COVID-19. Annie is a 28-year-old woman who had normal face recognition prior to contracting COVID-19 in March 2020. Two months later, she noticed face recognition difficulties while experiencing symptom relapses and her deficits with faces have persisted. On two tests of familiar face recognition and two tests of unfamiliar face recognition, Annie showed clear impairments. In contrast, she scored normally on tests assessing face detection, face identity perception, object recognition, scene recognition, and non-visual memory. Navigational deficits frequently co-occur with prosopagnosia, and Annie reports that her navigational abilities are substantially worse than before she became ill. Self-report survey data from 54 respondents with long COVID showed that a majority reported reductions in visual recognition and navigation abilities. In summary, Annie's results indicate that COVID-19 can produce severe and selective neuropsychological impairments similar to deficits seen following brain damage, and it appears that high-level visual impairments are not uncommon in people with long COVID.
Understanding the transmission pathways of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) will aid in developing effective therapies directed at the virus's life cycle or its side effects. While severe respiratory distress is the most common symptom of a coronavirus 2019 (COVID-19) infection, the virus is also known to cause damage to almost every major organ and system in the body. However, it is not obvious whether pathological changes in extra-respiratory organs are caused by direct infection, indirect, or combination of these effects. In this narrative review, we first elaborate on the characteristics of SARS-CoV-2, followed by the mechanisms of this virus on various organs such as brain, eye, and olfactory nerve and different systems such as the endocrine and gastrointestinal systems.
In recent years, the interplay between the development and function of the central nervous system and the immune system in the homeostatic and pathological state has become evident. Thus, understanding the crosstalk between the immune system and cerebellar development and functions has noticeable implications for managing neurodevelopmental, neurodegenerative, and neuroinflammatory disorders. In this chapter, we highlight the current progress of knowledge in the field of neuroimmunology and psychoneuroimmunology. Specifically, we discuss the contribution of the various immune responses in cerebellar development and its associated pathologies and highlight the current understanding of mechanisms involved in these processes. Immune pathways that play a crucial role in cerebellar development and functions are likely to become therapeutic targets for several neurodevelopmental, neurodegenerative, and neuroinflammatory disorders, thus suppression or activation of these selected immune pathways may propose new therapeutic approaches.
The COVID-19 pandemic led ADHD services to modify the clinical practice to reduce in-person contact as much as possible to minimise viral spread. This had far-reaching effects on day-to-day clinical practice as remote assessments were widely adopted. Despite the attenuation of the acute threat from COVID, many clinical services are retaining some remote practices. The lack of clear evidence-based guidance about the most appropriate way to conduct remote assessments meant that these changes were typically implemented in a localised, ad hoc, and un-coordinated way. Here, the European ADHD Guidelines Group (EAGG) discusses the strengths and weaknesses of remote assessment methods of children and adolescents with ADHD in a narrative review based on available data and expert opinions to highlight key recommendations for future studies and clinical practice. We conclude that going forward, despite remote working in clinical services functioning adequately during the pandemic, all required components of ADHD assessment should still be completed following national/international guidelines; however, the process may need adaptation. Social restrictions, including changes in education provision, can either mask or exacerbate features associated with ADHD and therefore assessment should carefully chart symptom profile and impairment prior to, as well as during an ongoing pandemic. While remote assessments are valuable in allowing clinical services to continue despite restrictions and may have benefits for routine care in the post-pandemic world, particular attention must be paid to those who may be at high risk but not be able to use/access remote technologies and prioritize these groups for conventional face-to-face assessments.
The Coronavirus has infected up to 900 million people as of 11 Jan 2023 in China Mainland, which is more than 60% of the population. The sudden and unprecedented nature of pandemic has resulted in a range of psychosomatic issues among the population. These issues can manifest in a variety of ways and it is important to address these issues as they can have serious consequences for individuals' mental and physical health. The lifting of lockdown measures in China presents an opportunity to address these issues and provide support to those who have been affected.
A novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was first identified in December 2019 in Wuhan, China. The new coronavirus disease (COVID-19) was declared a global pandemic by the World Health Organization (WHO) in March 2020. SARS-CoV-2 can invade the nervous system aside from infecting the respiratory system as its primary target. The most common nervous system symptoms of COVID-19 are stated as headache, myalgia, fatigue, nausea, vomiting, sudden and unexplained anosmia, and ageusia. More severe conditions such as encephalomyelitis, acute myelitis, thromboembolic events, ischemic stroke, intracerebral hemorrhage, Guillain-Barré-syndrome, Bell's palsy, rhabdomyolysis, and even coma have also been reported. Cohort studies revealed that neurological findings are associated with higher morbidity and mortality. The neurological symptoms and manifestations caused by SARS-CoV-2 and COVID-19 are examined and summarized in this article.
Background:
Hesitancy surrounding the coronavirus disease 2019 (COVID-19) vaccine is high in those with mental illnesses owing to intrapersonal barriers and barriers relating to social determinants of health.
Objectives:
This study describes the implementation of a pharmacy-driven, culturally sensitive education program focused on COVID-19 vaccine hesitancy.
Methods:
This was an institutional review board-exempt, descriptive, quality improvement study held at a behavioral health facility. An education program dedicated to reduce COVID-19 vaccine hesitancy was developed. Each educator completed training on providing culturally sensitive care to behavioral health patients. Patients voluntarily attended pharmacist-led patient medication education groups (PMEGs) and were offered an anonymous survey. Participation was documented in the electronic health record (EHR). Vaccination status and perception of the education were collected through retrospective analysis of the EHR, survey results, and state COVID-19 vaccine registry.
Results:
Twenty PMEGs were provided and reached 90 individuals, with 47% identifying as black, indigenous, or person of color. Sixty of 90 patients received at least 1 vaccine. For participants who were eligible for a second dose of a 2-dose series, 62% completed their second vaccination after PMEGs. Vaccination rates were highest in white participants (73.9%) followed by 64.7% of black participants, both higher than state specific rates. Participants self-reported an increase in their likelihood to become vaccinated after PMEG attendance on surveys and rated the quality of education as high.
Conclusion:
Patients who experience vaccine hesitancy had the opportunity to address their concerns on the COVID-19 vaccine. Overall, the program was well received and positively affected the patient's likelihood of obtaining and completing vaccination against COVID-19.
This meta-analysis was conducted to quantify the risk of patients exhibiting cognitive deficits in the acute phase of COVID-19 at the time of the first variants (i.e., before the vaccine) and quantify the potential vulnerability of older patients and those who experienced more severe respiratory symptoms. To this end, we searched the LitCovid and EMBASE platforms for articles, including preprints, and included all studies (n = 48) that featured a measurement of cognition, which encompassed 2233 cases of COVID-19. Of these, 28 studies reported scores on global cognitive efficiency scales administered in the acute phase of COVID-19 (up to 3 months after infection). We were able to perform a meta-analysis of proportions on 24 articles (Npatients = 943), and a logistic regression on 18 articles (Npatients = 518). The meta-analysis for proportion indicated that 52.31% of patients with COVID-19 exhibited cognitive deficits in the acute phase. This high percentage, however, has to be interpreted taking in consideration the fact that the majority of patients were hospitalized, and some presented neurological complications, such as encephalopathy. A bootstrap procedure with random resampling revealed that an age of 59 was the threshold at which one would be more prone to present cognitive deficits. However, the severity of respiratory symptoms did not influence the scores on a global cognitive efficiency scale. Overall, our results indicated that neuropsychological deficits were a major consequence of the acute phase of the first forms of COVID-19.
The paper discusses a new clinical psychology service developed during the first Covid-19 pandemic to offer psychological assessment and intervention to patients diagnosed with Covid-19. Information about the type of referrals and interventions offered were collected. Reflections of the service were captured from a patient and therapist perspective.
Effective public-health measures against SARS-CoV-2 require granular knowledge of population-level immune responses. We developed a Tripartite Automated Blood Immunoassay (TRABI) to assess the IgG response against three SARS-CoV-2 proteins. We used TRABI for continuous seromonitoring of hospital patients and blood donors (n=72’250) in the canton of Zurich from December 2019 to December 2020 (pre-vaccine period). We found that antibodies waned with a half-life of 75 days, whereas the cumulative incidence rose from 2.3% in June 2020 to 12.2% in mid-December 2020. A follow-up health survey indicated that about 10% of patients infected with wildtype SARS-CoV-2 sustained some symptoms at least twelve months post COVID-19. Crucially, we found no evidence for a difference in long-term complications between those whose infection was symptomatic and those with asymptomatic acute infection. The cohort of asymptomatic SARS-CoV-2-infected subjects represents a resource for the study of chronic and possibly unexpected sequelae.
COVID-19 continues to strain healthcare systems around the globe. Research has shown a relationship between COVID-19 and an inflammatory response, including neuropathological outcomes. Additionally, studies have shown positive effects of engagement with music on inflammatory responses; music may have potential, as a method, to reduce inflammation triggered by COVID-19. This review compiles exhaustive research from multiple disciplines to account for this possibility. The authors utilized a meta-narrative approach to complete this review. The search was conducted using PubMed, Embase, OneSearch, Primo, Google Scholar, Clinicaltrials.gov, and the bibliographies of relevant articles. In total, 84 articles were included for full-text review, discussion, and analysis. Articles pertaining to music and acoustics encompassed a date range from 1964–2020. Articles referencing COVID-19 spanned the years 2019–2021. This work focused on associations between engagement with music, stress response, blood-brain barrier integrity, inflammation, COVID-19, and neuropathology in preclinical and clinical models. Detailed analysis revealed that engagement with music has the potential to reduce the harmful effects of COVID-19, particularly in the inflammation and blood clotting pathways associated with a range of pathophysiological and neuropathological issues. Further work is warranted to standardize and validate existing methods associating positive effects of engagement with music on the negative effects of COVID-19.
Background and Objectives
Neurological involvement associated with SARS-CoV-2 infection is increasingly recognized. However, the specific characteristics and prevalence in pediatric patients remain unclear. The objective of this study was to describe the neurological involvement in a multinational cohort of hospitalized pediatric patients with SARS-CoV-2.
Methods
This was a multicenter observational study of children <18 years of age with confirmed SARS-CoV-2 infection or multisystemic inflammatory syndrome (MIS-C) and laboratory evidence of SARS-CoV-2 infection in children, admitted to 15 tertiary hospitals/healthcare centers in Canada, Costa Rica, and Iran February 2020–May 2021. Descriptive statistical analyses were performed and logistic regression was used to identify factors associated with neurological involvement.
Results
One-hundred forty-seven (21%) of 697 hospitalized children with SARS-CoV-2 infection had neurological signs/symptoms. Headache ( n = 103), encephalopathy ( n = 28), and seizures ( n = 30) were the most reported. Neurological signs/symptoms were significantly associated with ICU admission (OR: 1.71, 95% CI: 1.15–2.55; p = 0.008), satisfaction of MIS-C criteria (OR: 3.71, 95% CI: 2.46–5.59; p < 0.001), fever during hospitalization (OR: 2.15, 95% CI: 1.46–3.15; p < 0.001), and gastrointestinal involvement (OR: 2.31, 95% CI: 1.58–3.40; p < 0.001). Non-headache neurological manifestations were significantly associated with ICU admission (OR: 1.92, 95% CI: 1.08–3.42; p = 0.026), underlying neurological disorders (OR: 2.98, 95% CI: 1.49–5.97, p = 0.002), and a history of fever prior to hospital admission (OR: 2.76, 95% CI: 1.58–4.82; p < 0.001).
Discussion
In this study, approximately 21% of hospitalized children with SARS-CoV-2 infection had neurological signs/symptoms. Future studies should focus on pathogenesis and long-term outcomes in these children.
Objective:
To analyse the overall effectiveness and cost-efficiency of a mobile application (APP) as a community health asset (HA) with recommendations and recovery exercises created bearing in mind the main symptoms presented by patients in order to improve their quality of life, as well as other secondary variables, such as the number and severity of ongoing symptoms, physical and cognitive functions, affective state, and sleep quality.
Methods:
The first step was to design and develop the technologic community resource, the APP, following the steps involved in the process of recommending health assets (RHA). After this, a protocol of a randomised clinical trial for analysing its effectiveness and cost-efficiency as a HA was developed. The participants will be assigned to: (1st) usual treatment by the primary care practitioner (TAU), as a control group; and (2nd) TAU + use of the APP as a HA and adjuvant treatment in their recovery + three motivational interviews (MI), as an interventional group. An evaluation will be carried out at baseline with further assessments three and six months following the end of the intervention.
Discussion:
Although research and care for these patients are still in their initial stages, it is necessary to equip patients and health care practitioners with tools to assist in their recovery. Furthermore, enhanced motivation can be achieved through telerehabilitation (TR).
Some time has already passed since the COVID-19 pandemic began in 2019, but little is known about the long-term effects of SARS-CoV-2 infection on heart and blood vessel function. SARS-CoV-2 infection was initially thought to be associated with acute respiratory distress syndrome, it has been observed over time that the COVID-19, is actually a multi-organ disease that can also induce cardiovascular symptoms, including myocardial infarction, myocarditis, stress cardiomyopathy, heart failure, arrhythmias, and secondary heart injury. Several possible mechanisms underlying the heart muscle injury related to COVID-19 have been proposed, i.e., direct cytotoxic damage, dysregulation of the renin-angiotensin-aldosterone system, endothelial inflammation, and dysregulation of the immune response. The management of long COVID-19 effects is largely based on conservative treatment, consisting in the elimination of risk factors related to the development of cardiovascular diseases. In this chapter, we discuss the cardiovascular complications of long COVID-19, with an emphasis on prevalence, diagnosis, and risk factors.
La Neurología es una especialidad medica encargada del estudio de la estructura, desarrollo y función del sistema nervioso. Las enfermedades neurológicas afectan a personas de todos los grupos etarios, desde jóvenes y de forma predominante a aquellos de edad avanzada, puede afectar las capacidades y la funcionalidad de los afectados hasta llegar a limitar la realización de actividades básicas de la vida diaria y con frecuencia ocasionar discapacidad y dependencia; por lo tanto, es esencial para los médicos estar capacitados y actualizados en esta área, para abordar de forma integral las patología neurológica.
El presente trabajo analiza siete temas selectos en neurología, inicialmente desde un enfoque sindromático que incluye el temblor como manifestación motora de múltiples enfermedades, enfermedades degenerativas y neuromusculares, el enfoque de anticoagulación posterior a eventos neurológicos (cardioembólico y hemorrágico), enfermedad cerebrovascular en COVID-19 y criptogenica hasta la temida epilepsia en el embarazo. El objetivo principal del presente texto es presentar una revisión de las controversias actuales y perspectivas futuras para cada uno de los temas seleccionados, de esta manera ofrecer un panorama y una guía en su abordaje.
Se concluye que es fundamental el conocimiento del componente genético en algunas patologías, la comprensión de los mecanismos fisiopatológicos, la actualización en las herramientas de diagnóstico precoz y tratamiento oportuno, con el fin de brindar una mejor calidad de vida de cada uno de los pacientes con estas patologías.
Background
Before the COVID-19 pandemic, coronaviruses caused two noteworthy outbreaks: severe acute respiratory syndrome (SARS), starting in 2002, and Middle East respiratory syndrome (MERS), starting in 2012. We aimed to assess the psychiatric and neuropsychiatric presentations of SARS, MERS, and COVID-19.
Methods
In this systematic review and meta-analysis, MEDLINE, Embase, PsycINFO, and the Cumulative Index to Nursing and Allied Health Literature databases (from their inception until March 18, 2020), and medRxiv, bioRxiv, and PsyArXiv (between Jan 1, 2020, and April 10, 2020) were searched by two independent researchers for all English-language studies or preprints reporting data on the psychiatric and neuropsychiatric presentations of individuals with suspected or laboratory-confirmed coronavirus infection (SARS coronavirus, MERS coronavirus, or SARS coronavirus 2). We excluded studies limited to neurological complications without specified neuropsychiatric presentations and those investigating the indirect effects of coronavirus infections on the mental health of people who are not infected, such as those mediated through physical distancing measures such as self-isolation or quarantine. Outcomes were psychiatric signs or symptoms; symptom severity; diagnoses based on ICD-10, DSM-IV, or the Chinese Classification of Mental Disorders (third edition) or psychometric scales; quality of life; and employment. Both the systematic review and the meta-analysis stratified outcomes across illness stages (acute vs post-illness) for SARS and MERS. We used a random-effects model for the meta-analysis, and the meta-analytical effect size was prevalence for relevant outcomes, I² statistics, and assessment of study quality.
Findings
1963 studies and 87 preprints were identified by the systematic search, of which 65 peer-reviewed studies and seven preprints met inclusion criteria. The number of coronavirus cases of the included studies was 3559, ranging from 1 to 997, and the mean age of participants in studies ranged from 12·2 years (SD 4·1) to 68·0 years (single case report). Studies were from China, Hong Kong, South Korea, Canada, Saudi Arabia, France, Japan, Singapore, the UK, and the USA. Follow-up time for the post-illness studies varied between 60 days and 12 years. The systematic review revealed that during the acute illness, common symptoms among patients admitted to hospital for SARS or MERS included confusion (36 [27·9%; 95% CI 20·5–36·0] of 129 patients), depressed mood (42 [32·6%; 24·7–40·9] of 129), anxiety (46 [35·7%; 27·6–44·2] of 129), impaired memory (44 [34·1%; 26·2–42·5] of 129), and insomnia (54 [41·9%; 22·5–50·5] of 129). Steroid-induced mania and psychosis were reported in 13 (0·7%) of 1744 patients with SARS in the acute stage in one study. In the post-illness stage, depressed mood (35 [10·5%; 95% CI 7·5–14·1] of 332 patients), insomnia (34 [12·1%; 8·6–16·3] of 280), anxiety (21 [12·3%; 7·7–17·7] of 171), irritability (28 [12·8%; 8·7–17·6] of 218), memory impairment (44 [18·9%; 14·1–24·2] of 233), fatigue (61 [19·3%; 15·1–23·9] of 316), and in one study traumatic memories (55 [30·4%; 23·9–37·3] of 181) and sleep disorder (14 [100·0%; 88·0–100·0] of 14) were frequently reported. The meta-analysis indicated that in the post-illness stage the point prevalence of post-traumatic stress disorder was 32·2% (95% CI 23·7–42·0; 121 of 402 cases from four studies), that of depression was 14·9% (12·1–18·2; 77 of 517 cases from five studies), and that of anxiety disorders was 14·8% (11·1–19·4; 42 of 284 cases from three studies). 446 (76·9%; 95% CI 68·1–84·6) of 580 patients from six studies had returned to work at a mean follow-up time of 35·3 months (SD 40·1). When data for patients with COVID-19 were examined (including preprint data), there was evidence for delirium (confusion in 26 [65%] of 40 intensive care unit patients and agitation in 40 [69%] of 58 intensive care unit patients in one study, and altered consciousness in 17 [21%] of 82 patients who subsequently died in another study). At discharge, 15 (33%) of 45 patients with COVID-19 who were assessed had a dysexecutive syndrome in one study. At the time of writing, there were two reports of hypoxic encephalopathy and one report of encephalitis. 68 (94%) of the 72 studies were of either low or medium quality.
Interpretation
If infection with SARS-CoV-2 follows a similar course to that with SARS-CoV or MERS-CoV, most patients should recover without experiencing mental illness. SARS-CoV-2 might cause delirium in a significant proportion of patients in the acute stage. Clinicians should be aware of the possibility of depression, anxiety, fatigue, post-traumatic stress disorder, and rarer neuropsychiatric syndromes in the longer term.
Funding
Wellcome Trust, UK National Institute for Health Research (NIHR), UK Medical Research Council, NIHR Biomedical Research Centre at University College London Hospitals NHS Foundation Trust and University College London.
Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, is associated with coagulopathy causing venous and arterial thrombosis.1 2 Recent data from the pandemic epicentre in Wuhan, China, reported neurological complications in 36% of 214 patients with COVID-19; acute cerebrovascular disease (mainly ischaemic stroke) was more common among 88 patients with severe COVID-19 than those with non-severe disease (5.7% vs 0.8%).3 However, the mechanisms, phenotype and optimal management of ischaemic stroke associated with COVID-19 remain uncertain. We describe the demographic, clinical, radiological and laboratory characteristics of six consecutive patients assessed between 1st and 16th April 2020 at the National Hospital for Neurology and Neurosurgery, Queen Square, London, UK, with acute ischaemic stroke and COVID-19 (confirmed by reverse-transcriptase PCR (RT-PCR)) (table 1). All six patients had large vessel occlusion with markedly elevated D-dimer levels (≥1000μg/L). Three patients had multiterritory infarcts, two had concurrent venous thrombosis, and, in two, ischaemic strokes occurred despite therapeutic anticoagulation.
Importance
The outbreak of coronavirus disease 2019 (COVID-19) in Wuhan, China, is serious and has the potential to become an epidemic worldwide. Several studies have described typical clinical manifestations including fever, cough, diarrhea, and fatigue. However, to our knowledge, it has not been reported that patients with COVID-19 had any neurologic manifestations.
Objective
To study the neurologic manifestations of patients with COVID-19.
Design, Setting, and Participants
This is a retrospective, observational case series. Data were collected from January 16, 2020, to February 19, 2020, at 3 designated special care centers for COVID-19 (Main District, West Branch, and Tumor Center) of the Union Hospital of Huazhong University of Science and Technology in Wuhan, China. The study included 214 consecutive hospitalized patients with laboratory-confirmed diagnosis of severe acute respiratory syndrome coronavirus 2 infection.
Main Outcomes and Measures
Clinical data were extracted from electronic medical records, and data of all neurologic symptoms were checked by 2 trained neurologists. Neurologic manifestations fell into 3 categories: central nervous system manifestations (dizziness, headache, impaired consciousness, acute cerebrovascular disease, ataxia, and seizure), peripheral nervous system manifestations (taste impairment, smell impairment, vision impairment, and nerve pain), and skeletal muscular injury manifestations.
Results
Of 214 patients (mean [SD] age, 52.7 [15.5] years; 87 men [40.7%]) with COVID-19, 126 patients (58.9%) had nonsevere infection and 88 patients (41.1%) had severe infection according to their respiratory status. Overall, 78 patients (36.4%) had neurologic manifestations. Compared with patients with nonsevere infection, patients with severe infection were older, had more underlying disorders, especially hypertension, and showed fewer typical symptoms of COVID-19, such as fever and cough. Patients with more severe infection had neurologic manifestations, such as acute cerebrovascular diseases (5 [5.7%] vs 1 [0.8%]), impaired consciousness (13 [14.8%] vs 3 [2.4%]), and skeletal muscle injury (17 [19.3%] vs 6 [4.8%]).
Conclusions and Relevance
Patients with COVID-19 commonly have neurologic manifestations. During the epidemic period of COVID-19, when seeing patients with neurologic manifestations, clinicians should suspect severe acute respiratory syndrome coronavirus 2 infection as a differential diagnosis to avoid delayed diagnosis or misdiagnosis and lose the chance to treat and prevent further transmission.
Coronavirus disease 2019 (COVID-19) or severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a novel coronavirus strain disease, has recently emerged in China and rapidly spread worldwide. This novel strain is highly transmittable and severe disease has been reported in up to 16% of hospitalized cases. More than 600,000 cases have been confirmed and the number of deaths is constantly increasing. COVID-19 hospitalized patients, especially those suffering from severe respiratory or systemic manifestations, fall under the spectrum of the acutely ill medical population, which is at increased venous thromboembolism risk. Thrombotic complications seem to emerge as an important issue in patients infected with COVID-19. Preliminary reports on COVID-19 patients’ clinical and laboratory findings include thrombocytopenia, elevated d-dimers, prolonged prothrombin time, and disseminated intravascular coagulation. As the pandemic is spreading and the whole picture is yet unknown, we highlight the importance of coagulation disorders in COVID-19 infected patients and review relevant data of previous coronavirus epidemics caused by the severe acute respiratory syndrome coronavirus 1 (SARS-CoV-1) and the Middle East Respiratory Syndrome coronavirus (MERS-CoV).
Objective
To investigate the occurrence of olfactory and gustatory dysfunctions in patients with laboratory-confirmed COVID-19 infection.Methods
Patients with laboratory-confirmed COVID-19 infection were recruited from 12 European hospitals. The following epidemiological and clinical outcomes have been studied: age, sex, ethnicity, comorbidities, and general and otolaryngological symptoms. Patients completed olfactory and gustatory questionnaires based on the smell and taste component of the National Health and Nutrition Examination Survey, and the short version of the Questionnaire of Olfactory Disorders-Negative Statements (sQOD-NS).ResultsA total of 417 mild-to-moderate COVID-19 patients completed the study (263 females). The most prevalent general symptoms consisted of cough, myalgia, and loss of appetite. Face pain and nasal obstruction were the most disease-related otolaryngological symptoms. 85.6% and 88.0% of patients reported olfactory and gustatory dysfunctions, respectively. There was a significant association between both disorders (p < 0.001). Olfactory dysfunction (OD) appeared before the other symptoms in 11.8% of cases. The sQO-NS scores were significantly lower in patients with anosmia compared with normosmic or hyposmic individuals (p = 0.001). Among the 18.2% of patients without nasal obstruction or rhinorrhea, 79.7% were hyposmic or anosmic. The early olfactory recovery rate was 44.0%. Females were significantly more affected by olfactory and gustatory dysfunctions than males (p = 0.001).Conclusion
Olfactory and gustatory disorders are prevalent symptoms in European COVID-19 patients, who may not have nasal symptoms. The sudden anosmia or ageusia need to be recognized by the international scientific community as important symptoms of the COVID-19 infection.
Novel coronavirus (SARS-Coronavirus-2:SARS-CoV-2) which emerged in Wuhan, China, has spread to multiple countries rapidly. We report the first case of meningitis associated with SARS-CoV-2 who was brought in by ambulance due to a convulsion accompanied by unconsciousness. He had never been to any foreign countries. He felt generalized fatigue and fever (day 1). He saw doctors nearby twice (day2 and 5) and was prescribed Laninamivir and antipyretic agents, His family visited his home and found that he was unconsciousness and lying on the floor in his vomit. He was immediately transported to this hospital by ambulance (day 9). Under emergency transport, he had transient generalized seizures that lasted about a minute. He had obvious neck stiffness. The specific SARS-CoV-2 RNA was not detected in the nasopharyngeal swab but was detected in a CSF. Anti- HSV 1 and varicella-zoster IgM antibodies were not detected in serum samples. A brain MRI showed hyperintensity along the wall of right lateral ventricle and hyperintense signal changes in the right mesial temporal lobe and hippocampus, suggesting the possibility of SARS-CoV-2 meningitis. This case warns the physicians of patients who have CNS symptoms.
Background and purpose:
Middle East respiratory syndrome (MERS) has a high mortality rate and pandemic potential. However, the neurological manifestations of MERS have rarely been reported since it first emerged in 2012.
Methods:
We evaluated four patients with laboratory-confirmed MERS coronavirus (CoV) infections who showed neurological complications during MERS treatment. These 4 patients were from a cohort of 23 patients who were treated at a single designated hospital during the 2015 outbreak in the Republic of Korea. The clinical presentations, laboratory findings, and prognoses are described.
Results:
Four of the 23 admitted MERS patients reported neurological symptoms during or after MERS-CoV treatment. The potential diagnoses in these four cases included Bickerstaff's encephalitis overlapping with Guillain-Barré syndrome, intensive-care-unit-acquired weakness, or other toxic or infectious neuropathies. Neurological complications did not appear concomitantly with respiratory symptoms, instead being delayed by 2-3 weeks.
Conclusions:
Neuromuscular complications are not rare during MERS treatment, and they may have previously been underdiagnosed. Understanding the neurological manifestations is important in an infectious disease such as MERS, because these symptoms are rarely evaluated thoroughly during treatment, and they may interfere with the prognosis or require treatment modification.
Background:
The emergence of influenza A(H1N1) 2009 was met with increased reports of associated neurological manifestations. We aimed to describe neurological manifestations of influenza in adults and children in the United Kingdom that presented at this time.
Methods:
A 2-year surveillance study was undertaken through the British adult and pediatric neurological surveillance units from February 2011. Patients were included if they met clinical case definitions within 1 month of proven influenza infection.
Results:
Twenty-five cases were identified: 21 (84%) in children and 4 (16%) in adults. Six (29%) children had preexisting neurological disorders. Polymerase chain reaction of respiratory secretions identified influenza A in 21 (81%; 20 of which [95%] were H1N1) and influenza B in 4 (15%). Twelve children had encephalopathy (1 with movement disorder), 8 had encephalitis, and 1 had meningoencephalitis. Two adults had encephalopathy with movement disorder, 1 had encephalitis, and 1 had Guillain-Barré syndrome. Seven individuals (6 children) had specific acute encephalopathy syndromes (4 acute necrotizing encephalopathy, 1 acute infantile encephalopathy predominantly affecting the frontal lobes, 1 hemorrhagic shock and encephalopathy, 1 acute hemorrhagic leukoencephalopathy). Twenty (80%) required intensive care, 17 (68%) had poor outcome, and 4 (16%) died.
Conclusions:
This surveillance study described a cohort of adults and children with neurological manifestations of influenza. The majority were due to H1N1. More children than adults were identified; many children had specific encephalopathy syndromes with poor outcomes. None had been vaccinated, although 8 (32%) had indications for this. A modified classification system is proposed based on our data and the increasing spectrum of recognized acute encephalopathy syndromes.
Background
The COVID-19 pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is of a scale not seen since the 1918 influenza pandemic. Although the predominant clinical presentation is with respiratory disease, neurological manifestations are being recognised increasingly. On the basis of knowledge of other coronaviruses, especially those that caused the severe acute respiratory syndrome and Middle East respiratory syndrome epidemics, cases of CNS and peripheral nervous system disease caused by SARS-CoV-2 might be expected to be rare.
Recent developments
A growing number of case reports and series describe a wide array of neurological manifestations in 901 patients, but many have insufficient detail, reflecting the challenge of studying such patients. Encephalopathy has been reported for 93 patients in total, including 16 (7%) of 214 hospitalised patients with COVID-19 in Wuhan, China, and 40 (69%) of 58 patients in intensive care with COVID-19 in France. Encephalitis has been described in eight patients to date, and Guillain-Barré syndrome in 19 patients. SARS-CoV-2 has been detected in the CSF of some patients. Anosmia and ageusia are common, and can occur in the absence of other clinical features. Unexpectedly, acute cerebrovascular disease is also emerging as an important complication, with cohort studies reporting stroke in 2–6% of patients hospitalised with COVID-19. So far, 96 patients with stroke have been described, who frequently had vascular events in the context of a pro-inflammatory hypercoagulable state with elevated C-reactive protein, D-dimer, and ferritin.
Where next?
Careful clinical, diagnostic, and epidemiological studies are needed to help define the manifestations and burden of neurological disease caused by SARS-CoV-2. Precise case definitions must be used to distinguish non-specific complications of severe disease (eg, hypoxic encephalopathy and critical care neuropathy) from those caused directly or indirectly by the virus, including infectious, para-infectious, and post-infectious encephalitis, hypercoagulable states leading to stroke, and acute neuropathies such as Guillain-Barré syndrome. Recognition of neurological disease associated with SARS-CoV-2 in patients whose respiratory infection is mild or asymptomatic might prove challenging, especially if the primary COVID-19 illness occurred weeks earlier. The proportion of infections leading to neurological disease will probably remain small. However, these patients might be left with severe neurological sequelae. With so many people infected, the overall number of neurological patients, and their associated health burden and social and economic costs might be large. Health-care planners and policy makers must prepare for this eventuality, while the many ongoing studies investigating neurological associations increase our knowledge base.
We report the case of a 36‐year‐old health care worker who suffered a subacute infarct with a mild deviation of the midline, and a large vessel occlusion with a free‐floating thrombus in the ascending aorta in the context of a SARS‐CoV‐2 infection. With this case we want to increase the awareness about severe forms of systemic ischemia and stroke in patients with signs of COVID infection.
Endothelial cell infection and endotheliitis in COVID-19
The coronavirus disease 2019 (COVID-19) pandemic is having a profound effect on all aspects of society, including mental health and physical health. We explore the psychological, social, and neuroscientific effects of COVID-19 and set out the immediate priorities and longer-term strategies for mental health science research. These priorities were informed by surveys of the public and an expert panel convened by the UK Academy of Medical Sciences and the mental health research charity, MQ: Transforming Mental Health, in the first weeks of the pandemic in the UK in March, 2020. We urge UK research funding agencies to work with researchers, people with lived experience, and others to establish a high level coordination group to ensure that these research priorities are addressed, and to allow new ones to be identified over time. The need to maintain high-quality research standards is imperative. International collaboration and a global perspective will be beneficial. An immediate priority is collecting high-quality data on the mental health effects of the COVID-19 pandemic across the whole population and vulnerable groups, and on brain function, cognition, and mental health of patients with COVID-19. There is an urgent need for research to address how mental health consequences for vulnerable groups can be mitigated under pandemic conditions, and on the impact of repeated media consumption and health messaging around COVID-19. Discovery, evaluation, and refinement of mechanistically driven interventions to address the psychological, social, and neuroscientific aspects of the pandemic are required. Rising to this challenge will require integration across disciplines and sectors, and should be done together with people with lived experience. New funding will be required to meet these priorities, and it can be efficiently leveraged by the UK's world-leading infrastructure. This Position Paper provides a strategy that may be both adapted for, and integrated with, research efforts in other countries.
Background and purpose:
Infections have been found to increase the risk of stroke over the short term. We hypothesized that stroke risk would be highest shortly after a sepsis hospitalization, but that the risk would decrease, yet remain up to 1 year after sepsis.
Methods:
This case-crossover analysis utilized data obtained from the California State Inpatient Database of the Healthcare Cost and Utilization Project. All stroke admissions were included. Exposure was defined as hospitalization for sepsis or septicemia 180, 90, 30, or 15 days before stroke (risk period) or similar time intervals exactly 1 or 2 years before stroke (control period). Conditional logistic regression was used to calculate the odds ratio (OR) and 95% confidence interval (95% CI) for the association between sepsis/septicemia and ischemic or hemorrhagic stroke.
Results:
Ischemic (n=37 377) and hemorrhagic (n=12 817) strokes that occurred in 2009 were extracted where 3188 (8.5%) ischemic and 1101 (8.6%) hemorrhagic stroke patients had sepsis. Sepsis within 15 days before the stroke placed patients at the highest risk of ischemic (OR, 28.36; 95% CI, 20.02-40.10) and hemorrhagic stroke (OR, 12.10; 95% CI, 7.54-19.42); however, although the risk decreased, it remained elevated 181 to 365 days after sepsis for ischemic (OR, 2.59; 95% CI, 2.20-3.06) and hemorrhagic (OR, 3.92; 95% CI 3.29-4.69) strokes. There was an interaction with age (P=0.0006); risk of developing an ischemic stroke within 180 days of hospitalization for sepsis increased 18% with each 10-year decrease in age.
Conclusions:
Risk of stroke is high after sepsis, and this risk persists for up to a year. Younger sepsis patients have a particularly increased risk of stroke after sepsis.
In the 1980s the outcome of patients with herpes simplex encephalitis was shown to be dramatically improved with aciclovir treatment. Delays in starting treatment, particularly beyond 48 h after hospital admission, are associated with a worse prognosis. Several comprehensive reviews of the investigation and management of encephalitis have been published. However, their impact on day-to day clinical practice appears to be limited. The emergency management of meningitis in children and adults was revolutionised by the introduction of a simple algorithm as part of management guidelines. In February 2008 a group of clinicians met in Liverpool to begin the development process for clinical care guidelines based around a similar simple algorithm, supported by an evidence base, whose implementation is hoped would improve the management of patients with suspected encephalitis.
Olfactory and gustatory dysfunctions as a clinical presentation of mildto moderate forms of the coronavirus disease (COVID19): a multicenter European study
- J R Lechien
- C M Chiesaestomba
- De Siati
Lechien JR, ChiesaEstomba CM, De Siati DR, et al. Olfactory and
gustatory dysfunctions as a clinical presentation of mildto
moderate forms of the coronavirus disease (COVID19):
a multicenter European study. Eur Arch Otorhinolaryngol 2020;
published online April 6. DOI:10.1007/s00405020059651.
Largevessel stroke as a presenting feature of COVID19 in the young
- T J Oxley
- J Mocco
- S Majidi
Oxley TJ, Mocco J, Majidi S, et al. Largevessel stroke as a
presenting feature of COVID19 in the young. N Engl J Med 2020;
382: e60.
Characteristics of ischaemic stroke associated with COVID19
- R Beyrouti
- M E Adams
- L Benjamin
Beyrouti R, Adams ME, Benjamin L, et al. Characteristics of
ischaemic stroke associated with COVID19.
J Neurol Neurosurg Psychiatry 2020; published online April 30.
DOI:10.1136/jnnp2020323586.