Neurological Manifestation of COVID-19 and the Enhanced Role of Physiatrists.

Background

SARS-CoV-2 is a novel and highly contagious coronavirus that has infected millions of people worldwide. COVID-19 is the viral illness that manifests as a result of SARS-CoV-2 infection. While the primary presentation is a respiratory infection contributing to pulmonary disease including acute respiratory distress syndrome, COVID-19 influences other body systems. The pervasive nature of the disease is likely a function of its mechanism of infectivity. To enter host cells, SARS-CoV-2 binds the angiotensin converting enzyme-2 (ACE-2) receptor. ACE-2 receptors are present throughout the body, with abundant expression in lung, intestinal, and endothelial cells, contributing to variable disease manifestation. Reports of neurological symptoms and stroke in those with COVID-19 raises concerns that the neurological system is also impacted by this virus. A recent retrospective case study by Mao et al details the neurological signs and symptoms associated with COVID-19 infection in a hospitalized population in Wuhan, China, the initial epicenter of the disease[1].

Clinical Question

What neurological symptoms are associated with COVID-19 in hospitalized patients? Can neurological symptoms be the primary presenting symptom of COVID-19?

Summary Answer

Approximately one-third of hospitalized patients with COVID-19 displayed neurological signs or symptoms, including a small subset of patients for which stroke-like symptoms were the primary presentation of infection.

Why is this relevant to physiatry?

The practice of physiatry has always transcended body system or disease state with a goal of improving function and quality of life and reducing physical disability. Physiatrists play a pivotal role in managing the functional sequelae of critical illness including long term ventilator weaning, pulmonary rehabilitation, recovery from critical illness neuropathies and myopathies, and physical deconditioning. In response to the COVID-19 pandemic, many physiatrists have seen or are preparing for a substantial increase in patients with critical illness and respiratory related functional impairments. As such, this study highlights that the presentation and path to recovery of COVID-19 patients often includes neurologic impairments.

Research Findings

The study included 214 patients with polymerase chain reaction positive test for SARS-CoV-2. Approximately one-third (36.4%) of patients had neurological manifestation of the disease. Of those with neurological manifestations, 67.9% had central nervous system symptoms, most commonly dizziness (46.2%) and headache (35.8%), and 24.4% had peripheral nervous system manifestations including impaired taste (15.4%) and smell (14.1%). Other notable manifestations included stroke (n=6) and altered mental status (n=16). When assessed by severity of illness, stroke and altered mental status were significantly more common in those with severe illness. Notably, 2 of 6 patients with stroke had new onset hemiplegia as the only presenting symptom at time of hospitalization, developing pulmonary symptoms later in the hospital course [1]. Limitations of the study include retrospective study design, small sample size, and generalizability of the results outside of hospitalized patients and to other countries.

Impact of these Findings on Physiatric Clinical Practice

This is an important study that highlights the neurological manifestations of COVID-19 and that this virus may directly impact the central and peripheral nervous systems. Recognition of the neurological features of COVID-19 will be important for diagnosis of the illness. Persistence of symptoms that affect the nervous system, such as headache and dizziness, can have a profound impact on function and may contribute to disability. Moreover, reports of stroke associated with or as the presenting feature of COVID-19 generates a role for physiatrists in stroke rehabilitation. Despite only a small overall number of strokes in this study, another case series of similar symptoms in critically ill patients with COVID-19, found 3 of 13 patients with evidence of stroke on neuroimaging. Leptomeningeal enhancement, agitation, brain perfusion abnormalities, and corticospinal tract signs were also reported suggesting a variety of neurological insults may occur. While the chronicity of these neurological symptoms is not yet fully realized, one third of discharged patients in this study complained of persistent inattention, disorientation, and incoordination [2].

What questions remain outstanding?

The mechanisms and manifestations of illness in people infected with this virus are complex. Neurological disease is now recognized as a grave concern in a subset of patients with COVID-19. Further studies should explore the pathophysiology of these neurological symptoms to understand disease mechanisms and optimize treatment. Are these symptoms that results of a systemic inflammatory response and critical illness or does SARS-CoV-2 directly affect the central and peripheral nervous systems? In the case of stroke, coagulopathy and vascular dysfunction may represent a potential etiology and have been referenced in other studies of COVID-19. While not certain, it is likely that neurological signs and symptoms will persist for some patients, particularly those that have been critically ill [2]. Physiatrists have already begun to care for patients with neurological sequela of COVID-19. Our training makes us well positioned to care for the subacute and chronic manifestations as well as any disability that may ensue. Future considerations for physiatry should include early rehabilitation intervention in the acute care setting for those with devastating neurological involvement and development of post-COVID-19 clinical programs for those with prolonged recoveries. These patients will benefit from setting functional goals and having a multidisciplinary approach to care, which are the cornerstones of physiatry practice.