Neurological Presentations of COVID-19: Characteristic Features in a Case Series of Hospitalized Patients from Abu Dhabi, UAE

Abstract

Background: COVID-19 patients can present with neurological manifestations in the form of headache, dizziness, hyposmia, myalgia, peripheral neuropathy, acute cerebrovascular disease, and encephalopathy. Neurological involvement could be due to virus-induced brain hypoxia, brain infection, or immune reaction. We aim to describe the neurological presentation of COVID-19 patients and study their neuroimaging findings and disease outcome.

Method: The study is a single-centre, retrospective, observational study in Sheikh Shakhbout Medical City (SSMC), Abu Dhabi, UAE. Patients diagnosed with COVID-19 between March and May 2020 who presented with neuropathological features with or without respiratory manifestations of COVID-19 were enrolled. Electronic records were studied for age, sex, duration of hospitalization, detailed neurological presentation, history or documented concomitant fever and respiratory features of COVID-19, inflammatory markers, neuroimaging, progress, and disease outcome.

Results: Thirty-three patients of 10 nationalities presented with neurological manifestations. Mean (range) age was 51.4 (21-86) years. Twenty-four had comorbidities, and 18 had no prior or concomitant respiratory symptoms. Ten patients presented with encephalopathy and exhibited altered behavior/sensorium: 7 presented with myositis, 8 with stroke, and 4 with seizures, and 4 had peripheral and cranial nerve involvement. The mean (average) duration of hospital stay was 11.4 days (1-38) with the longest observed in stroke patients. Fifteen patients (45%) died and 3 (9%) had residual weakness. Serum ferritin, CRP, and procalcitonin were higher in the severe disease group and correlated with risk of death. Twelve of 22 brain images showed abnormalities including haemorrhage, infarcts, small vessel ischemia, and oedema. Risk of death was higher in older age but did not differ based on the underlying neuropathology.

Conclusion: COVID-19 patients who present with neurological involvement have a higher risk of mortality which is aggravated by older age and higher inflammatory markers. The type of neurological pathology does not seem to influence the risk of mortality.

Figure 1

Outcome of disease of recovery or death based on age (0.00 recovery, 1.00 death).

Figure 2

Median CRP based on the outcome of disease (0.00 recovery, 1.00 death).

Figure 3

Median serum ferritin based on outcome of disease (0.00 recovery, 1.00 death).

Figure 4

Brain imaging showing brain abnormalities in 10 patients (a–j). (a) Noncontrast CT head showing minor periventricular hypodensity suggestive of small vessel-related ischemia. (b) Noncontrast CT head showing multifocal white matter hyperdense foci suggestive of petechial haemorrhages (arrows pointing to areas of haemorrhage). (c) Noncontrast CT head showing old (big arrow) and evolving/new (small arrow) right MCA territory infracts. (d) (A) CT head showing low attenuation in the left internal capsule (B), (C) MRI showing left internal capsule high signal on diffusion weighted and FLAIR sequences, and (D) MRI gradient echo sequences showing blooming artifact suggesting blood break down products. (e) Axial and coronal non contrast CT head showing acute left cerebellar infract. (f) Noncontrast CT head showing a small area of low attenuation in the left internal capsule suggestive of a focal infract. (g) Noncontrast CT head showing (A) dense superior sagittal sinus (SSS) suggestive of venous sinus thrombosis, (B) haemorrhagic venous infract, and (C) CT venogram showing nonopacification of SSS (empty delta sign) due to venous sinus thrombosis. (h) Noncontrast CT head showing (A) lacunar infract left pons and (B) periventricular low attenuation changes in keeping with small vessel ischemia. (i) (A) Axial and sagittal noncontrast head CT showing marked sulcal effacement, extensive oedema, and loss of grey-white matter differentiation. (B) Sagittal section shows herniation of cerebellar tonsils. Appearances in keeping with severe cerebral oedema with coning. (j) Postcontrast CT (A) and MRI (B) of head showing focal enhancing lesion in the right frontal lobe.

Figure 5

Level of procalcitonin based on outcome of disease (0.00 recovery, 1.00 death).