Neurologic Manifestations of Long COVID Differ Based on Acute COVID-19 Severity

OBJECTIVE

To characterize neurologic manifestations in post-hospitalization Neuro-PASC (PNP) and non-hospitalized Neuro-PASC (NNP) patients.

METHODS

Prospective study of the first 100 consecutive PNP and 500 NNP patients evaluated at a Neuro-COVID-19 clinic between 5/2020 and 8/2021.

RESULTS

PNP were older than NNP patients (mean 53.9 vs 44.9 y; p < 0.0001) with a higher prevalence of pre-existing comorbidities. An average 6.8 months from onset, the main neurologic symptoms were "brain fog" (81.2%), headache (70.3%), and dizziness (49.5%) with only anosmia, dysgeusia and myalgias being more frequent in the NNP compared to the PNP group (59 vs 39%, 57.6 vs 39% and 50.4 vs 33%, all p < 0.003). Moreover, 85.8% of patients experienced fatigue. PNP more frequently had an abnormal neurologic exam than NNP patients (62.2 vs 37%, p < 0.0001). Both groups had impaired quality of life in cognitive, fatigue, sleep, anxiety, and depression domains. PNP patients performed worse on processing speed, attention, and working memory tasks than NNP patients (T-score 41.5 vs 55, 42.5 vs 47 and 45.5 vs 49, all p < 0.001) and a US normative population. NNP patients had lower results in attention task only. Subjective impression of cognitive ability correlated with cognitive test results in NNP but not in PNP patients.

INTERPRETATION

PNP and NNP patients both experience persistent neurologic symptoms affecting their quality of life. However, they harbor significant differences in demographics, comorbidities, neurologic symptoms and findings, as well as pattern of cognitive dysfunction. Such differences suggest distinct etiologies of Neuro-PASC in these populations warranting targeted interventions. ANN NEUROL 2023;94:146-159.

Persistent neurologic symptoms and cognitive dysfunction in non-hospitalized Covid-19 "long haulers"

OBJECTIVE

Most SARS-CoV-2-infected individuals never require hospitalization. However, some develop prolonged symptoms. We sought to characterize the spectrum of neurologic manifestations in non-hospitalized Covid-19 "long haulers".

METHODS

This is a prospective study of the first 100 consecutive patients (50 SARS-CoV-2 laboratory-positive (SARS-CoV-2+ ) and 50 laboratory-negative (SARS-CoV-2- ) individuals) presenting to our Neuro-Covid-19 clinic between May and November 2020. Due to early pandemic testing limitations, patients were included if they met Infectious Diseases Society of America symptoms of Covid-19, were never hospitalized for pneumonia or hypoxemia, and had neurologic symptoms lasting over 6 weeks. We recorded the frequency of neurologic symptoms and analyzed patient-reported quality of life measures and standardized cognitive assessments.

RESULTS

Mean age was 43.2 ± 11.3 years, 70% were female, and 48% were evaluated in televisits. The most frequent comorbidities were depression/anxiety (42%) and autoimmune disease (16%). The main neurologic manifestations were: "brain fog" (81%), headache (68%), numbness/tingling (60%), dysgeusia (59%), anosmia (55%), and myalgias (55%), with only anosmia being more frequent in SARS-CoV-2+ than SARS-CoV-2- patients (37/50 [74%] vs. 18/50 [36%]; p < 0.001). Moreover, 85% also experienced fatigue. There was no correlation between time from disease onset and subjective impression of recovery. Both groups exhibited impaired quality of life in cognitive and fatigue domains. SARS-CoV-2+ patients performed worse in attention and working memory cognitive tasks compared to a demographic-matched US population (T-score 41.5 [37, 48.25] and 43 [37.5, 48.75], respectively; both p < 0.01).

INTERPRETATION

Non-hospitalized Covid-19 "long haulers" experience prominent and persistent "brain fog" and fatigue that affect their cognition and quality of life.

Bilateral carotid artery occlusion resulting from giant cell arteritis

A 65-year-old woman with subacute global deterioration of neurological function had bilateral occlusion of the internal carotid arteries demonstrated by angiography. Postmortem examination showed isolated giant cell arteritis involving the carotid siphon bilaterally.

Multifocal central nervous system damage caused by toluene abuse

Four toluene abusers had evidence of severe multifocal central nervous system damage. Impairment of cognitive, cerebellar, brainstem, auditory, and pyramidal tract function, as well as CT evidence of cerebral cortical, cerebellar, and brainstem atrophy, have been noted. In addition, we found opsoclonus, ocular flutter, and ocular dysmetria. All three patients tested had abnormal brainstem auditory evoked potentials, indicative of brainstem dysfunction. The patient with opsoclonus had CT evidence of brainstem, cerebellar, and cerebral cortical atrophy.

Spinal leptomeningeal infiltration by systemic cancer: myelographic features

Five cases of spinal leptomeningeal infiltration by systemic cancer are presented and myelographic features are discussed with a review of the literature. Common characteristic features are parallel longitudinal striations due to thickened nerve roots in the cauda equina and bizarre irregular filling defects with varying degrees of blocks, resembling arachnoiditis. Another pattern described in the literature consists of multiple nodular filling defects along the nerve roots of the cause equina.

Multiple brain abscesses

A young woman with 12 separate brain abscesses was treated medically after aspiration of one abscess for diagnostic bacteriological examination. She made an excellent recovery with only minimal residual neurological dysfunction. Surgical aspiration for detailed bacteriological studies followed by appropriate antimicrobial therapy is an effective way of treating multiple brain abscesses in the neurologically stable patient.

Cerebellar infarction: a clinical and CT study

Seven patients with computed tomographic (CT) evidence of cerebellar infarction were found during review of all CT records over a 5-year period. CT demonstrated decreased density in 2 distinct anatomic areas, corresponding to the distribution of the posterior inferior cerebellar artery and the superior cerebellar artery. Some patients also had hydrocephalus and fourth ventricular effacement and displacement. The location and extent of infarction do not relate directly to the clinical outcome. Rapid deterioration of the patient's sensorium is the best indication for surgical decompression.

Hereditary multiple exostoses with myelopathy

A 58-year-old woman with hereditary multiple exostoses had slowly progressive myelopathy due to a vertebral exostosis that compressed the spinal cord at T1-2. She did not show skeletal deformities, but had numerous palpable long-bone exostoses. While CNS complications are rare in hereditary multiple exostosis, 17 other cases have been reported.

Sarcoid encephalopathy with diffuse inflammation and focal hydrocephalus shown by sequential CT

Sequential computerized tomography (CT) was performed on a patient with seizures and an organic mental syndrome. Cerebral sarcoidosis was subsequently diagnosed on the basis of noncaseating granulomas in three organ systems. Cranial nerve palsies, hypothalamic dysfunction, and widespread disease were absent. An unusual neuroradiologic sequence of events indicated focal and asymmetric hydrocephalus, mass effect, ependymitis, diffuse breakdown of the blood-brain barrier, and periventricular white matter destruction. These findings have not been previously described together in a patient with sarcoid. With the advent of noninvasive CT, it is possible to perform serial investigations of encephalopathies of obscure origin. Findings similar to those in the present case should prompt a thorough search for subclinical systemic involvement by sarcoid.

Visual evoked potentials and postmortem findings in a case of cortical blindness

A patient with cortical blindness due to extensive bilateral posterior cerebral infarcts showed occipital visual evoked potentials to flash stimulation on repeated testing. These responses were probably mediated by extrageniculocalcarine connections between the optic nerve and the secondary visual cortex of the occipital convexity.

CT scan in inter hemispheric subdural hematoma. Clinical and pathological correlation

In a patient with a large interhemispheric subdural hematoma, the CT scan showed a radiodensity with a straight sagittal and a convex lateral border. This image correlated with the autopsy findings. It differs from CT scan images of intracerebral hematomas.