July 8, 2020

expert reaction to study looking at neurological complications of Covid-19

Research, published in the journal Brain, looked at the neurological complications of Covid-19.

Dr Ben Turner, Consultant Neurologist and Honorary Senior Lecturer, Barts Health NHS Trust, said:

“This important study confirms the invidious nature of this Coronavirus, not only having potentially devastating effects on the respiratory system, also the ability to impact the nervous system on rare occasions. It is likely the harm to the nervous system in a small number of patients is both from direct neurotropic mechanism and indirect immunological response to the virus but further studies are required to understand the mechanism. One further question is will there more subtle but long term effects on the brain in those infected, such as fatigue or cognitive impairment.”

Dr Thomas Jenkins, Consultant Neurologist, Sheffield Teaching Hospitals NHS Foundation Trust & Senior Lecturer in Neurology, University of Sheffield, said:

“The press release generally accurately reflects the content of the paper. This is a retrospective descriptive study of the emerging neurological features seen in COVID-19 infection from a very good UK research group. It is increasingly recognised that COVID-19 can be associated with neurological problems, and this has been researched by groups across Europe and the world. The findings appear consistent with other case reports, survey and emerging registry data and the large cohort of ADEM patients is interesting. The authors report numbers higher than expected in their usual practice, but this is always a difficult aspect to prove in retrospective studies in which assessment of prevalence and incidence is not the primary goal. Other limitations of retrospective studies include case selection bias. Neurological symptoms were not only seen in patients with severe COVID-19 by respiratory criteria in this study. The focus is the acute complications of COVID-19 and further work is required to understand whether there are long-term neurological complications of COVID-19. This study did not investigate the frequency of severe neurological complications at population level, rather it reports on a series of people in whom these complications occurred. Other studies and clinical observations suggest that neurological complications of this severity are not common in COVID-19, but when they do occur, the consequences can be severe. However, the authors also report that many patients made a degree of recovery.”

Dr David Strain, Senior Clinical Lecturer, University of Exeter Medical School, said:

“This is a very good observational report describing some of the atypical complications from COVID-19. These findings are not surprising at all. It’s already been established that this virus can get into the nervous system, so it follows that it could cause delirium, and we’re seeing a small number of patients presenting to hospital for whom delirium is the main presenting feature of COVID-19.

“The main limitation is that we don’t know what the denominator so we don’t know how frequently these complications arise. More work will be required to determine what the true prevalence of these complications is, and whether these represent the extremes of a complication that is far more common. This is very important as we start to prepare post COVID-19 rehabilitation programs. 

“We’ve already seen that some people with COVID-19 may need a long rehabilitation period – both physical rehabilitation such as exercise, and brain rehabilitation. We need to understand more about the impact of this infection on the brain.” 

Dr Timothy Nicholson, Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King’s College London, said:

“This paper adds to the emerging evidence for a wide range of potentially severe neurological complications of COVID-19 beyond its effects on the respiratory system. It describes the details of 43 complex cases brought to a multi-disciplinary expert clinic, some of which had prominent psychiatric symptoms such as psychosis. This study highlights the importance of future research to assess how common these neurological and psychiatric complications are, what mechanisms are causing them and therefore how we might treat them better and improve longer term outcomes.”

Prof Anthony David, Director, UCL Institute of Mental Health, said:

“This paper represents the initial fruits of a multidisciplinary clinic – virtual of course – set up as a response to an emerging clinical need: to pool expertise to deal with – in real time – patients presenting with complex neurological problems in the context of the coronavirus pandemic. As an occasional member of the extended multidisciplinary team (MDT) I can say that the clinic is exemplary and embodies the best of neuropsychiatry in the NHS today.

“As a piece of research it is best described as a case series. It maps the territory that needs to be explored with more rigorous and systematic methods. There is (rightly) no attempt to estimate the incidence of the disorders described in the paper since the cases were identified by interested clinicians willing to share their knowledge (and more likely ignorance) in exchange for that of the group. Hence the incidence and medium and long term outcome of the syndromes described is yet to be determined. There is also no comparison group – eg. of neurological complications of other serious viral infections.

“While we (in the UK) have only 5 months of real experience of Covid-19, the rest of the world has had 11,000,000 cases – and it has been the high income countries with their full armamentarium of diagnostics that, up until recently, has borne the brunt of them. This plus the scrutiny that the pandemic attracts, means it would be very unlikely that there is a large parallel pandemic of unusual brain damage linked to COVID-19.

“On the other hand, the spectrum of disorder described by Patterson and colleagues is very likely to be replicated elsewhere. Para- and post infection neurological syndromes comprise a chapter found in all textbooks of neurology and this topic has been boosted by the recent description of novel autoimmune encephalitides. Covid-19 can now be added to the list of possible causes. Will that chapter remain a relatively slim esoteric one? In my opinion, probably yes, as I think these complex neuropsychiatric conditions associated with COVID-19 are likely to be rare.

“Delirium as a presenting condition in those with moderate to severe Covid-19 noted in the current article, is already recognised by clinicians as rather common and indeed, probably a feature shared with other coronavirus infections¹.

“The allusion to encephalitis lethargica made by Dr Zandi in the press release is tantalising. The brains of victims of that disorder from the 1920s and 1930s have subsequently been found not to contain any trace of the H1N1 virus known to have caused Spanish Flu although that still leaves open the possibility of a delayed post-infections (immune mediated) pathogenesis. Again, despite the scrutiny on the current pandemic and the near instantaneous speed of information sharing in the internet age we have yet to hear of the first case of post Covid-19 encephalitis lethargica and so it seems unlikely these neurological complications will be common symptoms but time will tell.”

1. See Rogers et al’s systematic review: Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemic. Lancet Psychiatry. doi: https://doi.org/10.1016/ S2215-0366(20)30203-0.

‘The emerging spectrum of COVID-19 neurology: clinical, radiological and laboratory findings’ by  Paterson et al was published in Brain at 00:01 UK Time Wednesday 8 July 2020.

All our previous output on this subject can be seen at this weblink: www.sciencemediacentre.org/tag/covid-19

Declared interests

Dr Thomas Jenkins: Conflict of interest: In my role as editor of the European Academy of Neurologists EAN Pages website, I am a member of the EAN COVID-19 Task Force, contribute to  the EAN COVID-19 Core website resource, and through this work am involved in pan-European surveys and registries to investigate neurological complications of COVID-19.

Prof Anthony David: An occasional member of the extended multidisciplinary team involved in this study. No other declarations.

None others received.