Neurological manifestations in patients with COVID-19 confer increased risk for mortality

Neurological syndromes on admission in patients with COVID-19, including altered mentation and stroke, predicted greater mortality risk in a large, single-center study in New York City, according to findings published in Neurology.

“It remains unclear whether acute neurologic manifestations impact mortality of SARS-CoV-2 illness and whether this risk is present in the absence of imaging findings,” the researchers wrote. “The objective of this study was to evaluate factors present on admission — sociodemographic data, medical comorbidities, vital signs, laboratory assessments and patterns neurological syndromes — as potential predictors of in-hospital mortality.”

Emad N. Eskandar, MD, MBA, professor in the departments of neurological surgery, psychiatry and behavioral sciences, and neuroscience and chair of the Leo M. Davidoff department of neurological surgery at Albert Einstein College of Medicine, and colleagues examined data from 4,711 patients with confirmed COVID-19 infection admitted to one medical center in New York City over 6 weeks. Twelve percent of these patients (n = 581) experienced neurological complications significant enough to warrant neuroimaging. The researchers compared this group with patients with COVID-19 who were not exhibiting neurological symptoms; those patients, who were admitted during the same period as the patients with neurological symptoms, were matched for age and disease severity.

Using a computer algorithm, researchers performed a random search of the other 4,130 patients to find patients of the same age who had a COVID-19 severity score with no neurological manifestations. That search resulted in a matched-control cohort of 1,743 patients, according to study data.

Eskandar and colleagues identified five patterns of neurological manifestations. These included altered mentation (present in 44% of patients in the neurological group vs. 5.5% of the total SARS-CoV-2 group), normal mentation with other neurological signs and symptoms compatible with COVID-19 (37% vs. 4.6%), stroke (9% vs. 1.2%), seizures (4% vs. 0.7%) and other brain lesions (4% vs. 0.6%).

The researchers observed an increased mortality risk in patients who experienced altered mentation (n = 258; OR = 1.39, 95% CI, 1.04-1.86) and radiologically confirmed stroke (n = 55; OR = 3.1, 95% CI, 1.65-5.92) compared with controls matched for age and COVID-19 severity. The results showed a trend for greater mortality risk among patients with impaired arousal compared with patients experiencing impaired cognition, both of which investigators considered symptoms of altered mentation, though this trend did not reach statistical significance.

The neurologic findings reported in the present study were like those reported in other large cohort studies, according to Eskandar and colleagues. However, unlike other reports, the present study did not reveal significant differences in mortality among Black and Latinx populations when controlling for underlying comorbid illnesses.

“This further suggests that variations in outcome based on race and ethnicity are less tied to bias within the healthcare-related bias and more likely a result of structural and systemic racism, leading to inequity of health as it pertains to comorbid conditions and overall health of populations,” the researchers wrote. “We believe these findings correspond in the neurologic realm as it does with the SARS-CoV-2 infection itself.”

The present study was the largest to date to analyze the neurological manifestations of COVID-19 and their impact on mortality, the researchers said. Documented central nervous system manifestations in patients hospitalized with COVID-19, including encephalopathy, stroke, seizure and syncope, are “relatively common,” though the actual incidence is likely “much higher” than the documented rate of 13%.

“Within the spectrum of CNS manifestations, altered mentation and stroke confer a higher risk of mortality above and beyond the severity of underlying illness,” Eskandar and colleagues wrote. “The presence of these syndromes may represent a different clinically important syndromic expression of SARS-Cov-2 infection which carries a greater risk of mortality and may benefit from targeted treatment.”