COVID-19 Curbside Consults

Neurologic complications of COVID-19

Catherine E. Hassett, DO, Aron Gedansky, MD, Ibrahim Migdady, MD, Adarsh Bhimraj, MD, Ken Uchino, MD and Sung-Min Cho, DO
Cleveland Clinic Journal of Medicine August 2020, DOI: https://doi.org/10.3949/ccjm.87a.ccc058
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Article Figures & Data

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  • Encephalopathy
    Presentation:Altered mental status
    Supportive testing:MRI: Normal;
    EEG: Abnormal (slowing);
    CSF: Normal;
    CSF: SARS-CoV-2 negative
    Treatment:Supportive; treat underlying COVID-19

    • CSF = cerebrospinal fluid; EEG = electroencephalogram; MRI = magnetic resonance imaging

  • Stroke
    Presentation:Acute presentation with focal motor, sensory or speech disturbance
    Supportive testing:MRI: Abnormal, lesion located in a vascular distribution
    Treatment:No society guidelines for COVID-19–specific stroke treatment
    1. Acute ischemic stroke treatment: thrombolytic and endovascular therapy should be considered. No society guidelines on stroke prevention. Therapeutic anticoagulation should be considered on a case-by-case basis.
    2. Acute hemorrhagic stroke (rare): standard treatment with blood pressure control.
    3. Cerebral venous sinus thrombosis: standard treatment with full-dose therapeutic anticoagulation, evaluate for other thrombosis sites.

    • MRI = magnetic resonance

  • Encephalitis, meningitis
    Presentation:Headache, nuchal rigidity, seizures, focal neurologic deficits; plus altered mental status for encephalitis
    Supportive testing:MRI: Abnormal, WM changes noted; EEG: Abnormal (slow, +/− focal epileptiform discharges);
    CSF: Pleocytosis, elevated protein;
    CSF: SARs-CoV-2, positive
    Treatment:Remains unclear;
    Role for corticosteroids?

    • CSF = cerebrospinal fluid; EEG = electroencephalogram; MRI = magnetic resonance; WM = white matter

  • Acute disseminated encephalomyelitis
    Presentation:Headache, acute neurologic symptoms
    Supportive testing:MRI: Hyperintense FLAIR lesions with variable enhancement
    Treatment:2 case reports showing improvement with the following:
    • 5 days of IVIG (0.4 g/kg/day)19
    • 5 days of IV dexamethasone (20 mg/day) with a 10-day taper20

    • FLAIR = fluid-attenuated inversion recovery; IV = intravenous; IVIG = intravenous immunoglobulin; MRI = magnetic resonance imaging

  • >Muscle injury
    Presentation:Myalgias
    Supportive testing:CPK: elevated;
    Muscle biopsy: necrosis
    Treatment:Supportive: Remains unclear;
    Role for corticosteroids?
    Physical therapy

    • CPK = creatinine phosphate kinase

  • Acute inflammatory demyelinating polyneuropathya
    Presentation:Flaccid paralysis +/ − respiratory compromise, cranial nerve deficits
    Supportive testing:CSF: Increased protein, normal WBC;
    NCS: Abnormal, axonal and demyelinating variants noted
    Treatment:Standard GBS treatment with 5 days of IVIG (0.4 g/kg/day)
    Case series noted only minimal improvement in 2 of 5 patients post-treatment28

    • CSF = cerebrospinal fluid; GBS = Guillain-Barre syndrome; IVIG = intravenous immunoglobulin; NCS = nerve conduction study; WBC = white blood cells

    • ↵a Also known as Guillain-Barre syndrome.

  • Anosmia/dysgeusia
    Presentation:Olfactory or taste dysfunction
    Supportive testing:Abnormal smell and taste evaluation
    Treatment:Supportive: Improvement noted by 2 weeks post-symptom onset
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