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Although respiratory symptoms are the hallmark of infection with COVID-19, some data suggest that patients also experience neurological symptoms such as dizziness or headache, yet the impact of these symptoms on disease outcomes has been poorly characterised.
In recognising that the effect of neurological symptoms and mortality has been poorly studied, a team from the department of neurological surgery, Albert Einstein College of Medicine, New York, US, sought to retrospectively examine whether the presence of neurological symptoms on admission among those infected with COVID-19 impacted on in-hospital mortality. The study was undertaken in four hospitals in the New York area between March and April 2020 and researchers focused on patients with neurological symptoms of sufficient severity to warrant radiographic imaging, for example, computed tomography, magnetic resonance imaging, diagnostic cerebral angiography. In the group of patients for which there were no obvious abnormalities detected on imaging, these were further divided into two groups: those with or without altered mentation. Altered mentation was determined via a review of the medical notes generated on admission and defined in terms of altered cognition, that is, evidence of disorientation, confusion, agitation or delirium or impaired arousal, that is, drowsiness or somnolence. The group without altered mentation, that is, normal orientation and arousal, still had neurological symptoms but these were consistent with those known to be associated with COVID-19 such as headache, anosmia, ageusia, chemesthesis, vertigo. The primary outcome measure was in-hospital mortality and patients identified with neurological symptoms were age-matched on a 1:3 ratio with patients admitted with COVID-19 with equal disease severity but no documented neurological manifestations.
Findings
A total of 4711 patients were admitted to hospital with COVID-19 during the study period including 581 (12%) with neurological manifestations. This latter group comprised 258 with altered mentation, 216 with normal mentation and recognised COVID-19 neurological symptoms. The remaining patients had either a stroke (55), seizures (26) or other brain lesions (26). Multivariate analysis revealed that patients with altered mentation, but an absence of imaging abnormalities, had a statistically significant increased risk of in-hospital mortality (odds ratio, OR = 1.39, 95% CI 1.04 – 1.86, p = 0.04), as did those with a radiologically confirmed stroke (OR = 3.1, 95% CI 1.65 – 5.92, p = 0.001). The authors were unable to explain the finding of an increased mortality risk with altered mentation, despite a normal imaging and suggested that this might be due to some yet-to-be determined mechanism.
They concluded that altered mentation might represent a different clinically important expression of COVID-19 infection that carries a greater risk of mortality beyond the severity of the underlying illness.
Citation
Eskandar EN et al. Neurologic syndromes predict higher mortality in COVID-19. Neurology 2020 DOI: 10.1212/WNL.0000000000011356
