Neurological presentations of COVID-19: Findings from the Spanish Society of Neurology neuroCOVID-19 registry

Abstract

Objective: We report the findings from the Spanish Society of Neurology's NeuroCOVID-19 Registry.

Methods: We performed a multicentre study of patients with neurological manifestations of COVID-19. Participating physicians reported demographic, clinical, and paraclinical data and judged the involvement of COVID-19 in causing neurological symptoms.

Results: A total of 233 cases were submitted, including 74 different combinations of manifestations. The most frequently reported were stroke (27%), neuromuscular symptoms (23.6%), altered mental status (23.6%), anosmia (17.6%), headache (12.9%), and seizures (11.6%). The mean age of patients was 61.1 years, with 42.1% being women; a higher proportion of women was recorded among patients with altered mental status, anosmia, and headache. The onset of symptoms differed within categories. Onset of anosmia occurred a mean (standard deviation) of 2.9 (2.5) days after the first general symptom, whereas neuromuscular symptoms appeared after 13.9 (10.1) days. Neurological symptoms were persistent in 33% of patients. General symptoms were present in 97.7% of patients, and results from general laboratory studies were abnormal in 99.4% of patients. Cerebrospinal fluid analysis findings were abnormal in 62.7% of the cases in which this test was performed (n = 51), but positive results for SARS-CoV-2 were only found in one case.

Conclusions: The neurological manifestations of COVID-19 are diverse. Anosmia, myalgia, and headache occur earlier in the course of the disease. Altered mental status, neuromuscular symptoms, and stroke are associated with greater severity. COVID-19 must be incorporated into most clinical and radiological differential diagnoses. COVID-19 may cause persistent and disabling neurological symptoms.

Keywords: COVID-19; Cerebrospinal fluid; Delirium; Epilepsy; Headache disorders; Stroke.

Fig. 1

Flow chart of patients who were eligible and included in each analysis.

Fig. 2

One-minus-survival curve of time from onset of the first general COVID-19 symptom to the onset of neurological symptoms in the most frequently represented categories of manifestations in the registry. ‡ Multiple comparisons–adjusted Fisher exact test.

Fig. 3

Severity of COVID-19 in patients with the most frequently represented neurological complications.

Fig. 4

Brain magnetic resonance imaging study of a 59-year-old man (4A: gadolinium-enhanced T1-weighted sequence, 4B: diffusion-weighted imaging sequence, 4C: FLAIR sequence) showing cortico-subcortical hyperintense lesions, in the convexity of both parietal lobes, suggestive of subacute ischaemic lesions in areas of borderline vascularisation between the middle and anterior cerebral arteries (arrows).

Fig. 5

Non-contrast brain CT scan of a 73-year-old woman: decreased generalised cortico-subcortical differentiation with hypodensities in the corpus callosum, and symmetric hyperdensity of the bilateral basal ganglia, suggesting encephalopathy.