Neurologic Outcomes of Survivors of COVID-19-Associated Acute Respiratory Distress Syndrome Requiring Intubation.

OBJECTIVES: To describe 3-6-month neurologic outcomes of survivors of COVID-19-associated acute respiratory distress syndrome, invasively ventilated in the ICU. DESIGN: A bicentric prospective study during the two first waves of the pandemic (March to May and September to December, 2020). SETTING: Two academic hospital ICUs, Paris, France. PATIENTS: Adult COVID-19-associated acute respiratory distress syndrome survivors, invasively ventilated in the ICU, were eligible for a neurologic consultation between 3 and 6 months post ICU discharge. INTERVENTIONS: Follow-up by face-to-face neurologic consultation. MEASURES AND MAIN RESULTS: The primary endpoint was favorable functional outcome defined by a modified Rankin scale score less than 2, indicating survival with no significant disability. Secondary endpoints included mild cognitive impairment (Montreal Cognitive Assessment score < 26), ICU-acquired weakness (Medical Research Council score < 48), anxiety and depression (Hospital Anxiety and Depression score > 7), and posttraumatic stress disorder (posttraumatic stress disorder checklist for Diagnostic and Statistical Manual of Mental Disorders 5 score > 30). Of 54 eligible survivors, four non-French-speaking patients were excluded, eight patients were lost-to-follow-up, and one died during follow-up. Forty-one patients were included. Time between ICU discharge and neurologic consultation was 3.8 months (3.6-5.9 mo). A favorable functional outcome was observed in 16 patients (39%) and mild cognitive impairment in 17 of 33 patients tested (52%). ICU-acquired weakness, depression or anxiety, and posttraumatic stress disorder were reported in six of 37 cases (16%), eight of 31 cases (26%), and two of 27 cases (7%), respectively. Twenty-nine patients (74%) required rehabilitation (motor, cognitive, or psychologic). ICU and hospital lengths of stay, tracheostomy, and corticosteroids were negatively associated with favorable outcome. By contrast, use of alpha-2 agonists during ICU stay was associated with favorable outcome. CONCLUSIONS: COVID-19-associated acute respiratory distress syndrome requiring intubation led to slight-to-severe functional disability in about 60% of survivors 4 months after ICU discharge. Cognitive impairment, muscle weakness, and psychologic symptoms were frequent. A large multicenter study is warranted to allow identification of modifiable factors for improving long-term outcome.

COVID-19-Associated Neurological Manifestations: An Emerging Electroencephalographic Literature.

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.