Neurological

Patients with COVID-19 associated impaired consciousness who are likely to recover

A prospective longitudinal study found that most patients with COVID-19 Disorders of Consciousness (COVID-DoC) regained consciousness. These results were published in Neurology.

Neurological manifestations have been observed in up to 20% of patients with COVID-19. These patients often experience prolonged infection, the outcome of which is unknown. The researchers claimed that DoC presents a unique challenge as patients are unable to communicate and recovery remains uncertain, leading clinicians and families to make difficult decisions about continuing or ending life-sustaining treatment in the absence of robust clinical data.

The aim of the current study was to characterize the long-term recovery from COVID-DoC and to assess the brain connectivity profile.

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All patients (n=12) admitted or transferred to the Massachusetts General Hospital Intensive Care Unit (ICU) with COVID-DoC between July 2020 and March 2021 were included in this study. Disease characteristics and clinical outcomes were compared to age-matched ICU patients with COVID-19 but without DoC (n=12), and neuroimaging data were compared to data from healthy controls.

Patients admitted to the ICU with COVID-DoC had a median age of 63.5 years (interquartile range [IQR], 55-76.3) years and 42% were males. Upon admission to the ICU, they were in a vegetative state (67%), comatose (17%), or minimally conscious (17%). Most had comorbidities such as hypertension (92%), obesity (67%), diabetes (67%) and hyperlipidemia (58%). This patient population remained hospitalized for a mean of 49.5 (IQR, 36.8-62) days and all were intubated.

The patients admitted to the ICU with COVID-19 and without DoC had similar comorbidities and disease severity.

Patients with DoC remained on intravenous sedation longer than controls (t[22], 3.65; P<0.005).

With the exception of the patient who died before MRI, the remaining 11 patients with DoC regained consciousness between 0 and 25 (median 7) days after cessation of continuous sedation. Patients were discharged to an inpatient rehabilitation facility (n=6), a long-term acute care facility (n=2), or died (n=4).

Compared to healthy controls, the COVID-DoC population had less positive intra-network connectivity within the default mode network (F[22], 3.88; P<.001) and less negative intra-network connectivity between the standard mode network and the salient network (F[22], 2.86; P<0.01). In addition, COVID-DoC associated with reduced total brain (F[21], 9.06; P<1'10-8) and brainstem (F[21], 4.27; P<0.001) fractional anisotropy. All findings remained significant after Bonferroni correction.

This study found that patients with DoC who survived severe COVID-19 were likely to regain consciousness, but disability rates remained high immediately after hospital discharge. In addition, COVID-DoC was associated with a loss of functional and structural brain connectivity, likely caused by brain injury.

This study was limited by its performance despite being the largest study on COVID-DoC to date.

The researchers concluded that while future research is needed, “these prospective results inform the prognosis and pathophysiology of COVID-DoC.”

relation

Fischer D, Snider SB, Barra ME, et al. Disorders of consciousness associated with COVID-19: A prospective, multimodal study of recovery and brain connectivity. Neurology. Published online December 3, 2021. doi:10.1212/WNL.00000000000013067

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