Neurologic Findings Among Inpatients With COVID-19 at a Safety-net US Hospital

Abstract

Objective: To characterize the breadth of neurologic findings associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in a diverse group of inpatients at an urban, safety-net US medical center.

Methods: Patients were identified through an electronic medical record review from April 15, 2020, until July 1, 2020, at a large safety-net hospital in Boston, MA, caring primarily for underserved, low-income, and elderly patients. All hospitalized adult patients with positive nasopharyngeal swab or respiratory PCR testing for SARS-CoV-2 during their hospitalization or in the 30 days before admission who received an inpatient neurologic or neurocritical care consultation or admission during the study period were enrolled.

Results: Seventy-four patients were identified (42/57% male, median age 64 years). The majority of patients self-identified as Black or African American (38, 51%). The most common neurologic symptoms at presentation to the hospital included altered mental status (39, 53%), fatigue (18, 24%), and headache (18, 18%). Fifteen patients had ischemic strokes (20%). There were 10 in-hospital mortalities, with moderately severe disability among survivors at discharge (14%, median modified Rankin Scale score of 4).

Conclusions: Neurologic findings spanned inflammatory, vascular pathologies, sequelae of critical illness and metabolic derangements, possible direct involvement of the nervous system by SARS-CoV-2, and exacerbation of underlying neurologic conditions, highlighting a broad range of possible etiologies of neurologic complications in patients with coronavirus disease 2019 (COVID-19). Further studies are needed to characterize the infectious and postinfectious neurologic complications of COVID-19 in diverse patient populations.

Figure 1. Range of Inflammatory Imaging Findings in Patients With Coronavirus Disease 2019

(A) Postgadolinium T1-weighted MRI sequences demonstrate diffuse smooth pachymeningeal thickening and enhancement most prominent in the frontal and temporal lobes. (B) Postgadolinium T1-weighted MRI sequences reveal asymmetric enhancement of the labyrinthine segment and genu of the right facial nerve. (C) T2-weighted fluid-attenuated inversion recovery MRI sequences demonstrate hyperintensity of the bilateral frontal lobes that (D) resolved 3 weeks later following the administration of corticosteroids.

Figure 2. Range of Vascular Imaging Findings in Patients With Coronavirus Disease 2019

(A) CT venogram showing extensive thrombosis of cerebral venous sinuses (arrows: right transverse sinus clot extending into the torcula herophiles). (B) T2-weighted fluid-attenuated inversion recovery (FLAIR) MRI sequences demonstrate symmetric, confluent white matter abnormalities in the parieto-occipital lobes consistent with posterior reversible encephalopathy syndrome. (C) T2-weighted FLAIR MRI sequences with patchy infarcts within the left middle cerebral artery (MCA) territory. (D) Digital subtraction angiography showing diffuse vasculopathy of the M2 and M3 divisions of MCA and left pericallosal artery.