Neurological Complications and Noninvasive Multimodal Neuromonitoring in Critically Ill Mechanically Ventilated COVID-19 Patients

Abstract

Purpose: The incidence and the clinical presentation of neurological manifestations of coronavirus disease-2019 (COVID-19) remain unclear. No data regarding the use of neuromonitoring tools in this group of patients are available. Methods: This is a retrospective study of prospectively collected data. The primary aim was to assess the incidence and the type of neurological complications in critically ill COVID-19 patients and their effect on survival as well as on hospital and intensive care unit (ICU) length of stay. The secondary aim was to describe cerebral hemodynamic changes detected by noninvasive neuromonitoring modalities such as transcranial Doppler, optic nerve sheath diameter (ONSD), and automated pupillometry. Results: Ninety-four patients with COVID-19 admitted to an ICU from February 28 to June 30, 2020, were included in this study. Fifty-three patients underwent noninvasive neuromonitoring. Neurological complications were detected in 50% of patients, with delirium as the most common manifestation. Patients with neurological complications, compared to those without, had longer hospital (36.8 ± 25.1 vs. 19.4 ± 16.9 days, p < 0.001) and ICU (31.5 ± 22.6 vs. 11.5±10.1 days, p < 0.001) stay. The duration of mechanical ventilation was independently associated with the risk of developing neurological complications (odds ratio 1.100, 95% CI 1.046-1.175, p = 0.001). Patients with increased intracranial pressure measured by ONSD (19% of the overall population) had longer ICU stay. Conclusions: Neurological complications are common in critically ill patients with COVID-19 receiving invasive mechanical ventilation and are associated with prolonged ICU length of stay. Multimodal noninvasive neuromonitoring systems are useful tools for the early detection of variations in cerebrovascular parameters in COVID-19.

Keywords: COVID-19; SARS-CoV-2; neurocritical care; neurological complications; neuromonitoring.

Figure 1

Survival cumulative probability after intensive care unit (ICU) admission for the 94 patients included. Survival cumulative probability after ICU admission for the patients (n = 94) who fulfilled the inclusion criteria, stratifying for the absence/presence (no/yes) of neurological complications.

Figure 2

Performance of the multivariate logistic regression model for assessing the factors independently associated with the risk of neurological complications. (A) Overall performance of the multivariate logistic regression model presented in Table 3 (dependent variable: neurological complications; independent variables: days of mechanical ventilation and C-reactive protein). (B) Receiver operating characteristic curve of the same multivariate logistic regression model (area under the curve = 0.818).

Figure 3

Survival cumulative probability after hospital and intensive care unit (ICU) admission for the patients who underwent noninvasive neuromonitoring. Survival cumulative probability after hospital and ICU admission for the patients (n = 49) who underwent noninvasive intracranial pressure, monitoring with both transcranial Doppler (A,B) and optic nerve sheath diameter (C,D).