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Lannon M, Duda T, Greer A, Hewitt M, Sharma A, Martyniuk A, Owen J, Amin F, Sharma S. Intracranial hemorrhage in patients treated for SARS-CoV-2 with extracorporeal membrane oxygenation: A systematic review and meta-analysis. J Crit Care 2023; 77:154319. [PMID: 37178492 PMCID: PMC10173703 DOI: 10.1016/j.jcrc.2023.154319] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 12/21/2022] [Accepted: 04/24/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is routinely used in patients with severe respiratory failure and has been increasingly needed during the COVID-19 pandemic. In patients treated with ECMO, significant intracranial hemorrhage (ICH) risk exists due to circuit characteristics, anticoagulation, and disease characteristics. ICH risk may be substantially higher in COVID-19 patients than patients treated with ECMO for other indications. METHODS We systematically reviewed current literature regarding ICH during ECMO treatment of COVID-19. We utilized Embase, MEDLINE, and Cochrane Library databases. Meta-analysis was performed for included comparative studies. Quality assessment was performed using MINORS criteria. RESULTS A total of 54 studies with 4000 ECMO patients were included, all retrospective. Risk of bias was increased via MINORS score primarily due to retrospective designs. ICH was more likely in COVID-19 patients (RR 1.72, 95% CI 1.23, 2.42). Mortality among COVID patients on ECMO with ICH was 64.0%, compared with 41% in patients without ICH (RR1.9, 95% 1.44, 2.51). CONCLUSION This study suggests increased hemorrhage rates in COVID-19 patients on ECMO compared to similar controls. Hemorrhage reduction strategies may include atypical anticoagulants, conservative anticoagulation strategies, or biotechnology advances in circuit design and surface coatings.
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Affiliation(s)
- Melissa Lannon
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada.
| | - Taylor Duda
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada.
| | - Alisha Greer
- Division of Emergency Medicine, Department of Medicine, Division of Critical Care, McMaster University, Hamilton, Ontario, Canada.
| | - Mark Hewitt
- Division of Emergency Medicine, Department of Medicine, Division of Critical Care, McMaster University, Hamilton, Ontario, Canada.
| | - Arjun Sharma
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, Ontario, Canada.
| | - Amanda Martyniuk
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada.
| | - Julian Owen
- Division of Emergency Medicine, Department of Medicine, Division of Critical Care, McMaster University, Hamilton, Ontario, Canada.
| | - Faizan Amin
- Department of Medicine, Divisions of Critical Care and Cardiology, McMaster University, Hamilton, Ontario, Canada.
| | - Sunjay Sharma
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada.
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The Use of ECMO for COVID-19: Lessons Learned. Clin Chest Med 2022; 44:335-346. [PMID: 37085223 PMCID: PMC9705197 DOI: 10.1016/j.ccm.2022.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has seen an increase in global cases of severe acute respiratory distress syndrome (ARDS), with a concomitant increased demand for extracorporeal membrane oxygenation (ECMO). Outcomes of patients with severe ARDS due to COVID-19 infection receiving ECMO support are evolving. The need for surge capacity, practical and ethical limitations on implementing ECMO, and the prolonged duration of ECMO support in patients with COVID-19-related ARDS has revealed limitations in organization and resource utilization. Coordination of efforts at multiple levels, from research to implementation, resulted in numerous innovations in the delivery of ECMO.
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Short B, Abrams D, Brodie D. Extracorporeal membrane oxygenation for coronavirus disease 2019-related acute respiratory distress syndrome. Curr Opin Crit Care 2022; 28:90-97. [PMID: 34670997 PMCID: PMC8711309 DOI: 10.1097/mcc.0000000000000901] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW To understand the potential role of extracorporeal membrane oxygenation (ECMO) in coronavirus disease 2019 (COVID-19)-related acute respiratory distress syndrome (ARDS), highlighting evolving practices and outcomes. RECENT FINDINGS The role for ECMO in COVID-19-related ARDS has evolved throughout the pandemic. Early reports of high mortality led to some to advocate for withholding ECMO in this setting. Subsequent data suggested mortality rates were on par with those from studies conducted prior to the pandemic. However, outcomes are evolving and mortality in these patients may be worsening with time. SUMMARY ECMO has an established role in the treatment of severe forms of ARDS. Current data suggest adherence to the currently accepted algorithm for management of ARDS, including the use of ECMO. However, planning related to resource utilization and strain on healthcare systems are necessary to determine the feasibility of ECMO in specific regions at any given time. Utilization of national and local networks, pooling of resources and ECMO mobilization units are important to optimize access to ECMO as appropriate. Reported complications of ECMO in the setting of COVID-19-related ARDS have been predominantly similar to those reported in studies of non-COVID-19-related ARDS. Further high-quality research is needed.
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Affiliation(s)
- Briana Short
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians & Surgeons
- Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, New York, USA
| | - Darryl Abrams
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians & Surgeons
- Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, New York, USA
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians & Surgeons
- Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, New York, USA
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4
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The relationship between COVID-19 infection and intracranial hemorrhage: A systematic review. BRAIN HEMORRHAGES 2021; 2:141-150. [PMID: 34786548 PMCID: PMC8582085 DOI: 10.1016/j.hest.2021.11.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 11/04/2021] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION In addition to the deleterious effects Covid-19 has on the pulmonary and cardiovascular systems, COVID-19 can also result in damage to the nervous system. This review aims to explore current literature on the association between COVID-19 and intracranial hemorrhage (ICH). METHODS We conducted a systematic review of PubMed for literature published on COVID-19 and ICH. Ninety-four of 295 screened papers met inclusion criteria. RESULTS The literature addressed incidence and mortality of ICH associated with Covid-19. It also revealed cases of COVID-19 patients with subarachnoid hemorrhage, intraparenchymal hemorrhage, subdural hematomas, and hemorrhage secondary to cerebral venous thrombosis and ischemic stroke. ICH during COVID-19 infections was associated with increased morbidity and mortality. Risk factors for ICH appeared to be therapeutic anticoagulation, ECMO, and mechanical ventilation. Outcomes varied widely, depending on the severity of COVID-19 infection and neurologic injury. CONCLUSION Although treatment for severe Covid-19 infections is often aimed at addressing acute respiratory distress syndrome, vasculopathy, and coagulopathy, neurologic injury can also occur. Evidence-based treatments that improve COVID-19 mortality may also increase risk for developing ICH. Providers should be aware of potential neurologic sequelae of COVID-19, diagnostic methods to rule out other causes of ICH, and treatment regimens.
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Migdady I, Shoskes A, Hasan LZ, Hassett C, George P, Newey C, Cho SM, Rae-Grant A, Uchino K. Timing of Acute Stroke in COVID-19-A Health System Registry Study. Neurohospitalist 2021; 11:285-294. [PMID: 34567388 DOI: 10.1177/1941874420985983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background and Purpose The association between SARS-CoV-2 infection and stroke remains unknown. We aimed to compare the characteristics of stroke patients who were hospitalized with Coronavirus Disease 2019 (COVID-19) based on the timing of stroke diagnosis. Methods We performed a retrospective analysis of adult patients in a health system registry of COVID-19 who were hospitalized and had imaging-confirmed acute stroke during hospitalization. Baseline characteristics and hospital outcomes were collected and analyzed. Results Out of 882 COVID-19 patients who were hospitalized between March 9 to May 17, 2020, 14 patients (2% of all COVID-19 patients and 21% of those who underwent imaging) presented with stroke or developed stroke during hospitalization. Eleven had acute ischemic stroke (AIS) and 3 had acute hemorrhagic stroke. Six patients (43%) presented to the hospital with acute stroke symptoms and were found to have SARS-CoV-2. Compared to patients who presented with AIS, more patients with AIS during hospitalization were male, of older age, had pneumonia and acute respiratory distress syndrome, were severely ill, and had high inflammatory and thrombotic markers (including C reactive protein, D dimer, ferritin, and fibrinogen). Among all patients, hospital mortality was high (50%) and the majority of patients who were discharged had poor neurological outcome. Conclusions A distinction should be made between patients who present with acute stroke with concurrent SARS-CoV-2 infection and those who develop stroke as a complication of severe COVID-19. It is likely that a subset of stroke patients will incidentally test positive for the virus given the widespread pandemic.
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Affiliation(s)
- Ibrahim Migdady
- Department of Neurology, Cleveland Clinic, Cleveland, OH, USA.,Division of Neurocritical Care, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Aaron Shoskes
- Department of Neurology, Cleveland Clinic, Cleveland, OH, USA
| | - Leen Z Hasan
- Department of Medicine, University of Connecticut, Farmington, CT, USA.,Department of Infectious Diseases, Cleveland Clinic, Cleveland, OH, USA
| | - Catherine Hassett
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Pravin George
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Christopher Newey
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sung-Min Cho
- Departments of Neurology, Neurological Intensive Care, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alexander Rae-Grant
- Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ken Uchino
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
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Lashkari A, Ranjbar R. A case-based systematic review on the SARS-COVID-2-associated cerebrovascular diseases and the possible virus routes of entry. J Neurovirol 2021; 27:691-701. [PMID: 34546547 PMCID: PMC8454012 DOI: 10.1007/s13365-021-01013-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 08/13/2021] [Accepted: 08/20/2021] [Indexed: 12/12/2022]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) sparked a global pandemic that continues to affect various facets of human existence. Many sources reported virus-induced acute cerebrovascular disorders. Systematically, this paper reviews the case studies of COVID-19-related acute cerebrovascular diseases such as ischaemic stroke, intracerebral hemorrhage, and cerebral sinus thrombosis. We also spoke about how SARS-CoV-2 can infect the brain and trigger the aforementioned disorders. We stated that SARS-CoV-2 neuroinvasion and BBB dysfunction could cause the observed disorders; however, further research is required to specify the mechanisms and pathogenesis of the virus.
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Affiliation(s)
- Ali Lashkari
- Institute of Biochemistry and Biophysics (IBB), University of Tehran, Tehran, Iran
| | - Reza Ranjbar
- Molecular Biology Research Center, Systems Biology and Poisonings Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran.
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Kazemi S, Pourgholaminejad A, Saberi A. Stroke Associated with SARS-CoV-2 Infection and its Pathogenesis: A Systematic Review. Basic Clin Neurosci 2021; 12:569-586. [PMID: 35173912 PMCID: PMC8818122 DOI: 10.32598/bcn.2021.3277.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 07/24/2021] [Accepted: 08/02/2021] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION The change of stroke incidence during the COVID-19 pandemic period and the proposed mechanisms of the relationship between SARS-CoV-2 and stroke is reviewed. METHODS Web of Science, PMC/Medline, and Scopus databases were searched until July 2020 without time and language limitations. After quality assessment, 22 articles were included in this study. RESULTS Based on the results, it is impossible to conclude any definite relationship between the rising or decreasing stroke frequency or the shift in the ischemic and hemorrhagic ratio and SARS-CoV-2 infection. However, it appears that SARS-CoV-2 infection has some correlation with stroke. The supposed mechanisms for the SARS-CoV-2-related hemorrhagic stroke include 1) SARS-CoV-2-related vasculopathy with the endothelial damage of small vessels, 2) viral infection-induced platelet dysfunction or thrombocytopenia, and 3) activation of the proinflammatory cascade leading to coagulopathy. The helpful strategies are receiving therapeutic anticoagulation for high D-dimer or a known thrombus due to SARS-CoV-2 infection, as well as using extracorporeal membrane oxygenation (ECMO) in some patients. Furthermore, the possible mechanisms for the SARS-CoV-2-related ischemic stroke include 1) dysregulation of angiotensin-converting enzyme 2 (a key host cellular receptor for SARSCoV-2)-related physiologic functions, 2) endothelial cell damages, 3) thrombo-inflammation, and 4) coagulopathy and coagulation abnormalities related to SARS-CoV-2 infection. CONCLUSION A better understanding of the SARS-CoV-2 pathogenesis and its relation to neurologic abnormalities such as stroke can help to design new therapeutic approaches.
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Affiliation(s)
- Samaneh Kazemi
- Deputy of Research and Technology, Guilan University of Medical Sciences, Rasht, Iran
| | - Arash Pourgholaminejad
- Department of Immunology, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - Alia Saberi
- Department of Neurology, Poursina Hospital, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
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8
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Huth SF, Cho SM, Robba C, Highton D, Battaglini D, Bellapart J, Suen JY, Li Bassi G, Taccone FS, Arora RC, Whitman G, Fraser JF, Fanning JP. Neurological Manifestations of Coronavirus Disease 2019: A Comprehensive Review and Meta-Analysis of the First 6 Months of Pandemic Reporting. Front Neurol 2021; 12:664599. [PMID: 34456840 PMCID: PMC8387564 DOI: 10.3389/fneur.2021.664599] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 06/28/2021] [Indexed: 12/24/2022] Open
Abstract
Background: There is growing evidence that SARS-Cov-2 infection is associated with severe neurological complications. Understanding the nature and prevalence of these neurologic manifestations is essential for identifying higher-risk patients and projecting demand for ongoing resource utilisation. This review and meta-analysis report the neurologic manifestations identified in hospitalised COVID-19 patients and provide a preliminary estimate of disease prevalence. Methods: MEDLINE, Embase and Scopus were searched for studies reporting the occurrence of neurological complications in hospitalised COVID-19 patients. Results: A total of 2,207 unique entries were identified and screened, among which 14 cohort studies and 53 case reports were included, reporting on a total of 8,577 patients. Central nervous system manifestations included ischemic stroke (n = 226), delirium (n = 79), intracranial haemorrhage (ICH, n = 57), meningoencephalitis (n = 13), seizures (n = 3), and acute demyelinating encephalitis (n = 2). Peripheral nervous system manifestations included Guillain-Barrè Syndrome (n = 21) and other peripheral neuropathies (n = 3). The pooled period prevalence of ischemic stroke from identified studies was 1.3% [95%CI: 0.9–1.8%, 102/7,715] in all hospitalised COVID-19 patients, and 2.8% [95%CI: 1.0–4.6%, 9/318] among COVID-19 patients admitted to ICU. The pooled prevalence of ICH was estimated at 0.4% [95%CI: 0–0.8%, 6/1,006]. Conclusions: The COVID-19 pandemic exerts a substantial neurologic burden which may have residual effects on patients and healthcare systems for years. Low quality evidence impedes the ability to accurately predict the magnitude of this burden. Robust studies with standardised screening and case definitions are required to improve understanding of this disease and optimise treatment of individuals at higher risk for neurologic sequelae.
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Affiliation(s)
- Samuel F Huth
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Sung-Min Cho
- Neuroscience Critical Care Division, Departments of Neurology, Neurosurgery, and Anaesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Chiara Robba
- San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, University of Genoa, Genoa, Italy
| | - David Highton
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Princess Alexandra Hospital Southside Clinical Unit, Division of Surgery, Department of Anesthesia, University of Queensland, Brisbane, QLD, Australia
| | - Denise Battaglini
- San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, University of Genoa, Genoa, Italy.,Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Judith Bellapart
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Jacky Y Suen
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Gianluigi Li Bassi
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Biomedical Science, Queensland University of Technology, Brisbane, QLD, Australia.,Department of Pulmonary and Critical Care, Institut d'Investigacions Biomediques August Pi I Sunyer, Barcelona, Spain
| | | | - Rakesh C Arora
- Cardiac Sciences Program, St. Boniface General Hospital Research Center, Winnipeg, MB, Canada.,Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Glenn Whitman
- Neuroscience Critical Care Division, Departments of Neurology, Neurosurgery, and Anaesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Biomedical Science, Queensland University of Technology, Brisbane, QLD, Australia.,Intensive Care Services, St. Andrew's War Memorial Hospital, UnitingCare, Brisbane, QLD, Australia
| | - Jonathon P Fanning
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Intensive Care Services, St. Andrew's War Memorial Hospital, UnitingCare, Brisbane, QLD, Australia.,Department of Neurology, Gold Coast University Hospital, Gold Coast, QLD, Australia
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9
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Kleineberg NN, Knauss S, Gülke E, Pinnschmidt HO, Jakob CEM, Lingor P, Hellwig K, Berthele A, Höglinger G, Fink GR, Endres M, Gerloff C, Klein C, Stecher M, Classen AY, Rieg S, Borgmann S, Hanses F, Rüthrich MM, Hower M, Tometten L, Haselberger M, Piepel C, Merle U, Dolff S, Degenhardt C, Jensen BEO, Vehreschild MJGT, Erber J, Franke C, Warnke C. Neurological symptoms and complications in predominantly hospitalized COVID-19 patients: Results of the European multinational Lean European Open Survey on SARS-Infected Patients (LEOSS). Eur J Neurol 2021; 28:3925-3937. [PMID: 34411383 PMCID: PMC8444823 DOI: 10.1111/ene.15072] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 08/07/2021] [Indexed: 12/30/2022]
Abstract
Background and purpose During acute coronavirus disease 2019 (COVID‐19) infection, neurological signs, symptoms and complications occur. We aimed to assess their clinical relevance by evaluating real‐world data from a multinational registry. Methods We analyzed COVID‐19 patients from 127 centers, diagnosed between January 2020 and February 2021, and registered in the European multinational LEOSS (Lean European Open Survey on SARS‐Infected Patients) registry. The effects of prior neurological diseases and the effect of neurological symptoms on outcome were studied using multivariate logistic regression. Results A total of 6537 COVID‐19 patients (97.7% PCR‐confirmed) were analyzed, of whom 92.1% were hospitalized and 14.7% died. Commonly, excessive tiredness (28.0%), headache (18.5%), nausea/emesis (16.6%), muscular weakness (17.0%), impaired sense of smell (9.0%) and taste (12.8%), and delirium (6.7%) were reported. In patients with a complicated or critical disease course (53%) the most frequent neurological complications were ischemic stroke (1.0%) and intracerebral bleeding (ICB; 2.2%). ICB peaked in the critical disease phase (5%) and was associated with the administration of anticoagulation and extracorporeal membrane oxygenation (ECMO). Excessive tiredness (odds ratio [OR] 1.42, 95% confidence interval [CI] 1.20–1.68) and prior neurodegenerative diseases (OR 1.32, 95% CI 1.07–1.63) were associated with an increased risk of an unfavorable outcome. Prior cerebrovascular and neuroimmunological diseases were not associated with an unfavorable short‐term outcome of COVID‐19. Conclusion Our data on mostly hospitalized COVID‐19 patients show that excessive tiredness or prior neurodegenerative disease at first presentation increase the risk of an unfavorable short‐term outcome. ICB in critical COVID‐19 was associated with therapeutic interventions, such as anticoagulation and ECMO, and thus may be an indirect complication of a life‐threatening systemic viral infection.
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Affiliation(s)
- Nina N Kleineberg
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.,Cognitive Neuroscience, Institute of Neuroscience and Medicine (INM-3), Research Centre Jülich, Jülich, Germany
| | - Samuel Knauss
- Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site, Berlin, Germany
| | - Eileen Gülke
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hans O Pinnschmidt
- Institute of Medical Biometry, Epidemiology University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Carolin E M Jakob
- Department I for Internal Medicine, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany.,German Center for Infection Research (DZIF), Partner-Site Cologne-Bonn, Cologne, Germany
| | - Paul Lingor
- Department of Neurology, Technical University of Munich, School of Medicine, Klinikum Rechts der Isar, Munich, Germany
| | - Kerstin Hellwig
- Department of Neurology, Katholisches Klinikum Bochum, Klinikum der Ruhr Universität, Bochum, Germany
| | - Achim Berthele
- Department of Neurology, Technical University of Munich, School of Medicine, Klinikum Rechts der Isar, Munich, Germany
| | - Günter Höglinger
- Department of Neurology with Clinical Neurophysiology, Hannover Medical School, Hannover, Germany.,German Center for Neurodegenerative Diseases (DZNE), Munich, Germany
| | - Gereon R Fink
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.,Cognitive Neuroscience, Institute of Neuroscience and Medicine (INM-3), Research Centre Jülich, Jülich, Germany
| | - Matthias Endres
- Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Berlin, Germany.,ExcellenceCluster NeuroCure, Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Christian Gerloff
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christine Klein
- Institute of Neurogenetics, University of Luebeck and University Hospital Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - Melanie Stecher
- Department I for Internal Medicine, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany.,German Center for Infection Research (DZIF), Partner-Site Cologne-Bonn, Cologne, Germany
| | - Annika Y Classen
- Department I for Internal Medicine, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany.,German Center for Infection Research (DZIF), Partner-Site Cologne-Bonn, Cologne, Germany
| | - Siegbert Rieg
- Division of Infectious Diseases, Department of Medicine II, Medical Centre, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Stefan Borgmann
- Department of Infectious Diseases and Infection Control, Ingolstadt Hospital, Ingolstadt, Germany
| | - Frank Hanses
- Emergency Department, University Hospital Regensburg, Regensburg, Germany.,Department of Infectious Diseases and Infection Control, University Hospital Regensburg, Regensburg, Germany
| | - Maria M Rüthrich
- Department of Internal Medicine II, Hematology and Medical Oncology, University Hospital Jena, Jena, Germany.,Leibniz Institute for Natural Product Research and Infection Biology, Hans-Knöll Institute, Jena, Germany
| | - Martin Hower
- Department of Internal Medicine, Klinikum Dortmund, Dortmund, Germany
| | - Lukas Tometten
- Department I for Internal Medicine, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | | | - Christiane Piepel
- Department of Internal Medicine I, Hospital Bremen Central, Bremen, Germany
| | - Uta Merle
- Department of Internal Medicine IV, University Hospital Heidelberg, Heidelberg, Germany
| | - Sebastian Dolff
- Department of Infectious Diseases, West German Centre of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | | | - Björn-Erik O Jensen
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Maria J G T Vehreschild
- Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Johanna Erber
- Department of Internal Medicine II, Technical University of Munich, School of Medicine, University Hospital Rechts der Isar, Munich, Germany
| | - Christiana Franke
- Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Clemens Warnke
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
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10
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Bermea RS, Raz Y, Sertic F, Rubin J, Wolf M, Olia S, Richards T, Crowley J, Funamoto M, Shelton K, Bermudez C. Increased Intracranial Hemorrhage Amid Elevated Inflammatory Markers in Those With COVID-19 Supported With Extracorporeal Membrane Oxygenation. Shock 2021; 56:206-214. [PMID: 33587724 PMCID: PMC10763976 DOI: 10.1097/shk.0000000000001730] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
ABSTRACT COVID-19-related coagulopathy is a known complication of SARS-CoV-2 infection and can lead to intracranial hemorrhage (ICH), one of the most feared complications of extracorporeal membrane oxygenation (ECMO). We sought to evaluate the incidence and etiology of ICH in patients with COVID-19 requiring ECMO. Patients at two academic medical centers with COVID-19 who required venovenous-ECMO support for acute respiratory distress syndrome (ARDS) were evaluated retrospectively. During the study period, 33 patients required ECMO support; 16 (48.5%) were discharged alive, 13 died (39.4%), and 4 (12.1%) had ongoing care. Eleven patients had ICH (33.3%). All ICH events occurred in patients who received intravenous anticoagulation. The ICH group had higher C-reactive protein (P = 0.04), procalcitonin levels (P = 0.02), and IL-6 levels (P = 0.05), lower blood pH before and after ECMO (P < 0.01), and higher activated partial thromboplastin times throughout the hospital stay (P < 0.0001). ICH-free survival was lower in COVID-19 patients than in patients on ECMO for ARDS caused by other viruses (49% vs. 79%, P = 0.02). In conclusion, patients with COVID-19 can be successfully bridged to recovery using ECMO but may suffer higher rates of ICH compared to those with other viral respiratory infections.
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Affiliation(s)
- Rene S. Bermea
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Yuval Raz
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Federico Sertic
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jonah Rubin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Molly Wolf
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Salim Olia
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Thomas Richards
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jerome Crowley
- Division of Cardiac Anesthesia, Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Masaki Funamoto
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kenneth Shelton
- Division of Cardiac Anesthesia, Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Christian Bermudez
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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11
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Nath A. Neurologic Manifestations of Severe Acute Respiratory Syndrome Coronavirus 2 Infection. Continuum (Minneap Minn) 2021; 27:1051-1065. [PMID: 34623104 PMCID: PMC9527260 DOI: 10.1212/con.0000000000000992] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW This article describes the spectrum of neurologic complications associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, their underlying pathology and pathogenic mechanisms, gaps in knowledge, and current therapeutic strategies. RECENT FINDINGS COVID-19 is the clinical syndrome caused by the novel coronavirus SARS-CoV-2. It can affect the entire neuraxis, and presentations in the acute phase are variable, although anosmia is a common manifestation. Encephalopathy is common in patients who are hospitalized and is often associated with multiorgan involvement. Immune-mediated encephalitis is probably underrecognized; however, viral encephalitis is rare. Other manifestations include stroke, seizures, myelitis, and peripheral neuropathies, including Guillain-Barré syndrome, which sometimes has atypical manifestations. Treatment is symptomatic, and immunotherapies have been used successfully in some patients. Long-term complications include dysautonomia, exercise intolerance, malaise, sleep disturbances, cognitive impairment, and mood disorders. SUMMARY Neurologic manifestations of COVID-19 may occur in the acute setting and may be independent of respiratory manifestations. Immune-mediated syndromes and cerebrovascular complications are common. Large populations of patients are expected to have long-term neurologic complications of COVID-19, many of which may emerge only after recovery from the acute illness.
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12
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Qi X, Keith KA, Huang JH. COVID-19 and stroke: A review. BRAIN HEMORRHAGES 2021; 2:76-83. [PMID: 33225251 PMCID: PMC7670261 DOI: 10.1016/j.hest.2020.11.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 11/10/2020] [Accepted: 11/11/2020] [Indexed: 12/15/2022] Open
Abstract
COVID-19 patients have presented with a wide range of neurological disorders, among which stroke is the most devastating. We have reviewed current studies, case series, and case reports with a focus on COVID-19 patients complicated with stroke, and presented the current understanding of stroke in this patient population. As evidenced by increased D-dimer, fibrinogen, factor VIII and von Willebrand factor, SARS-CoV-2 infection induces coagulopathy, disrupts endothelial function, and promotes hypercoagulative state. Collectively, it predisposes patients to cerebrovascular events. Additionally, due to the unprecedented strain on the healthcare system, stroke care has been inevitably compromised. The underlying mechanism between COVID-19 and stroke warrants further study, so does the development of an effective therapeutic or preventive intervention.
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Key Words
- ACE2, Angiotensin-converting enzyme 2
- COVID-19
- COVID-19, Coronavirus disease 2019
- CPR, C-reactive protein
- CVD, Cerebrovascular disease
- Cerebrovascular diseases
- DIC, Disseminated intravascular coagulation
- ECMO, Extracorporeal membrane oxygenation
- ICH, Intracranial hemorrhage
- IL-6, Interleukin-6
- MERS, Middle East Respiratory Syndrome
- NIHSS, National Institutes of Health Stroke Scale
- PT, Prothrombin time
- SARS-CoV-1, Severe acute respiratory syndrome coronavirus 1
- SARS-CoV-2
- SARS-CoV-2, Severe acute respiratory syndrome coronavirus 2
- Stroke
- TNF-alpha, Tumor necrosis factor-alpha
- aPL, Antiphospholipid
- aPTT, Activated partial thromboplastin time
- rt-PCR, Reverse transcription polymerase chain reaction
- vWF, Von Willebrand Factor
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Affiliation(s)
- Xiaoming Qi
- Department of Neurosurgery, Baylor Scott & White Health, Temple, TX, USA
| | - Kristin A Keith
- Department of Neurosurgery, Baylor Scott & White Health, Temple, TX, USA
- College of Medicine, Texas A&M Health Science Center, Temple, TX, USA
| | - Jason H Huang
- Department of Neurosurgery, Baylor Scott & White Health, Temple, TX, USA
- College of Medicine, Texas A&M Health Science Center, Temple, TX, USA
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13
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Badulak J, Antonini MV, Stead CM, Shekerdemian L, Raman L, Paden ML, Agerstrand C, Bartlett RH, Barrett N, Combes A, Lorusso R, Mueller T, Ogino MT, Peek G, Pellegrino V, Rabie AA, Salazar L, Schmidt M, Shekar K, MacLaren G, Brodie D. Extracorporeal Membrane Oxygenation for COVID-19: Updated 2021 Guidelines from the Extracorporeal Life Support Organization. ASAIO J 2021; 67:485-495. [PMID: 33657573 PMCID: PMC8078022 DOI: 10.1097/mat.0000000000001422] [Citation(s) in RCA: 229] [Impact Index Per Article: 76.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
DISCLAIMER This is an updated guideline from the Extracorporeal Life Support Organization (ELSO) for the role of extracorporeal membrane oxygenation (ECMO) for patients with severe cardiopulmonary failure due to coronavirus disease 2019 (COVID-19). The great majority of COVID-19 patients (>90%) requiring ECMO have been supported using venovenous (V-V) ECMO for acute respiratory distress syndrome (ARDS). While COVID-19 ECMO run duration may be longer than in non-COVID-19 ECMO patients, published mortality appears to be similar between the two groups. However, data collection is ongoing, and there is a signal that overall mortality may be increasing. Conventional selection criteria for COVID-19-related ECMO should be used; however, when resources become more constrained during a pandemic, more stringent contraindications should be implemented. Formation of regional ECMO referral networks may facilitate communication, resource sharing, expedited patient referral, and mobile ECMO retrieval. There are no data to suggest deviation from conventional ECMO device or patient management when applying ECMO for COVID-19 patients. Rarely, children may require ECMO support for COVID-19-related ARDS, myocarditis, or multisystem inflammatory syndrome in children (MIS-C); conventional selection criteria and management practices should be the standard. We strongly encourage participation in data submission to investigate the optimal use of ECMO for COVID-19.
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Affiliation(s)
- Jenelle Badulak
- From the Department of Emergency Medicine, University of Washington, Seattle, Washington
- Division of Pulmonary Critical Care and Sleep Medicine, University of Washington, Seattle, Washington
| | - M. Velia Antonini
- General ICU, University Hospital of Parma, Parma, Italy
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena & Reggio Emilia, Modena, Italy
| | | | - Lara Shekerdemian
- Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas
| | - Lakshmi Raman
- Children’s Medical Center of Dallas, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Matthew L. Paden
- Emory University, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Cara Agerstrand
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
- Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, New York
| | | | - Nicholas Barrett
- Department of Critical Care, Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom
- Centre for Human and Applied Physiological Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Alain Combes
- Institute of Cardiometabolism and Nutrition, INSERM, Sorbonne Université, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Thomas Mueller
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Mark T. Ogino
- Nemours Children’s Health System, Wilmington, Delaware
| | - Giles Peek
- Congenital Heart Center, Departments of Surgery and Pediatrics, University of Florida, Gainesville, Florida
| | | | - Ahmed A. Rabie
- Critical Care ECMO Service, King Saud Medical City, Ministry Of Health (MOH), Riyadh, Saudi Arabia
| | - Leonardo Salazar
- Fundación Cardiovascular de Colombia, Floridablanca, Santander, Colombia
| | - Matthieu Schmidt
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, AP-HP, Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France
- Sorbonne Université, GRC n°30, GRC RESPIRE, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | | | - Daniel Brodie
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
- Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, New York
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14
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Vellieux G, Sonneville R, Vledouts S, Jaquet P, Rouvel-Tallec A, d’Ortho MP. COVID-19-Associated Neurological Manifestations: An Emerging Electroencephalographic Literature. Front Physiol 2021; 11:622466. [PMID: 33679425 PMCID: PMC7933549 DOI: 10.3389/fphys.2020.622466] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 12/29/2020] [Indexed: 02/02/2023] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread worldwide since the end of year 2019 and is currently responsive for coronavirus infectious disease 2019 (COVID-19). The first reports considered COVID-19 as a respiratory tract disease responsible for pneumonia, but numerous studies rapidly emerged to warn the medical community of COVID-19-associated neurological manifestations, including encephalopathy at the acute phase and other postinfectious manifestations. Using standard visual analysis or spectral analysis, recent studies reported electroencephalographic (EEG) findings of COVID-19 patients with various neurological symptoms. Most EEG recordings were normal or revealed non-specific abnormalities, such as focal or generalized slowing, interictal epileptic figures, seizures, or status epilepticus. Interestingly, novel EEG abnormalities over frontal areas were also described at the acute phase. Underlying mechanisms leading to brain injury in COVID-19 are still unknown and matters of debate. These frontal EEG abnormalities could emphasize the hypothesis whereby SARS-CoV-2 enters the central nervous system (CNS) through olfactory structures and then spreads in CNS via frontal lobes. This hypothesis is reinforced by the presence of anosmia in a significant proportion of COVID-19 patients and by neuroimaging studies confirming orbitofrontal abnormalities. COVID-19 represents a new viral disease characterized by not only respiratory symptoms but also a systemic invasion associated with extra-respiratory signs. Neurological symptoms must be the focus of our attention, and functional brain evaluation with EEG is crucial, in combination with anatomical and functional brain imaging, to better understand its pathophysiology. Evolution of symptoms together with EEG patterns at the distance of the acute episode should also be scrutinized.
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Affiliation(s)
- Geoffroy Vellieux
- Université de Paris, NeuroDiderot, Inserm, Paris, France
- Neurophysiologie clinique, Service de Physiologie – Explorations Fonctionnelles, AP-HP, Hôpital Bichat-Claude Bernard, Paris, France
| | - Romain Sonneville
- Médecine Intensive-Réanimation, AP-HP, Hôpital Bichat-Claude Bernard, Paris, France
- Université de Paris, UMR 1148, LVTS, Paris, France
| | - Sérafima Vledouts
- Université de Paris, NeuroDiderot, Inserm, Paris, France
- Neurophysiologie clinique, Service de Physiologie – Explorations Fonctionnelles, AP-HP, Hôpital Bichat-Claude Bernard, Paris, France
| | - Pierre Jaquet
- Médecine Intensive-Réanimation, AP-HP, Hôpital Bichat-Claude Bernard, Paris, France
- Université de Paris, UMR 1148, LVTS, Paris, France
| | - Anny Rouvel-Tallec
- Université de Paris, NeuroDiderot, Inserm, Paris, France
- Neurophysiologie clinique, Service de Physiologie – Explorations Fonctionnelles, AP-HP, Hôpital Bichat-Claude Bernard, Paris, France
| | - Marie-Pia d’Ortho
- Université de Paris, NeuroDiderot, Inserm, Paris, France
- Neurophysiologie clinique, Service de Physiologie – Explorations Fonctionnelles, AP-HP, Hôpital Bichat-Claude Bernard, Paris, France
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15
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Abstract
Purpose of Review Coronavirus disease 2019 (COVID-19) has become a global health crisis of our time. The disease arises from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that binds to angiotensin-converting enzyme 2 (ACE2) receptors on host cells for its internalization. COVID-19 has a wide range of respiratory symptoms from mild to severe and affects several other organs, increasing the complexity of the treatment. There is accumulating evidence to suggest that SARS-CoV-2 can target the nervous system. In this review, we provide an account of the COVID-19 central nervous system (CNS) manifestations. Recent Findings A broad spectrum of the CNS manifestations including headache, impaired consciousness, delirium, loss of smell and taste, encephalitis, seizures, strokes, myelitis, acute disseminated encephalomyelitis, neurogenic respiratory failure, encephalopathy, silent hypoxemia, generalized myoclonus, neuroleptic malignant syndrome and Kawasaki syndrome has been reported in patients with COVID-19. Summary CNS manifestations associated with COVID-19 should be considered in clinical practice. There is a need for modification of current protocols and standing orders to provide better care for COVID-19 patients presenting with neurological symptoms.
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