COVID-19 Neurological Complications More Likely in Those with Hypertension, Diabetes

Colbey W. Freeman, M.D

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A new study suggests that COVID-19-positive patients who have hypertension and type 2 diabetes are more likely to experience neurological complications such as intracranial hemorrhage and stroke.¹

Investigators from the Perelman School of Medicine at the University of Pennsylvania looked at computerized tomography (CT) and magnetic resonance imaging (MRI) images to determine critical neurological findings. They found the most common comorbidities with critical neurological conditions were hypertension (72.2%; n = 13) and type 2 diabetes mellitus (50%; n = 9).²

“COVID-19’s effects extend far beyond the chest,” said lead study author Colbey W. Freeman, MD, chief resident, Penn Medicine radiology department, in a statement.¹ “While complications in the brain are rare, they are an increasingly reported and potentially devastating consequence of COVID-19 infection.”

Freeman’s team, including Jonathan Masur, MD, Mougnyan Cox, MD, and Suyash Mohan, MD, will present their findings during this year’s upcomcing Radiological Society of North America (RSNA) annual meeting, November 29–December 5, 2020.

Freeman and colleagues examined head CT and/or MRI images for patients positive for the virus who presented to the University of Pennsylvania Health System from January 2020 to April 2020. Of the 1357 COVID-19-positive patients who were admitted, 81 underwent a brain scan prompted by either altered mental state or focal neurological deficits, including speech and vision problems.

READ MORE: James Grotta, MD: The Impact of COVID-19 on Stroke Care

Based on the team’s analysis, 18 patients—slightly more than 20%—had findings that were considered critical, such as strokes, brain bleeds, or blocked blood vessels. The critical group was 50% male with a mean age of 60.5 years (standard deviation, 12.6), and at least half also had a pre-existing history of high blood pressure or type 2 diabetes. Two-thirds of the patients who had critical findings were African American, indicating COVID-19 positive patients in that minority group should be monitored more closely. Three patients in this group died while in the hospital.

“COVID-19 is associated with neurological manifestations, and hypertension and type 2 diabetes mellitus are common in individuals who develop these manifestations,” Freeman said. “These populations may be at higher risk for neurologic complications and should be monitored closely.”

Although this study revealed a role for high blood pressure and type 2 diabetes in the neurological impact of the virus, investigators still do not know exactly what causes those complications. The mechanisms could be multi-factorial, and the generally accepted belief is that infection-associated inflammation is responsible, they said. In this study in particular, blood markers for inflammation were high in patients who had critical results.

“When your body is in an inflammatory state, it produces all these molecules called cytokines to help recruit the immune system to perform its function,” Freeman said. “Unfortunately, if cytokines are over-produced, the immune response actually starts doing damage.”

Using data from this study, the team is also looking at the how frequently COVID-19-positive patients on extracorporeal membrane oxygenation (ECMO)—a pump system that circulates and replenishes oxygen in the blood – experience neurological complications. Many patients included in this study required ECMO during hospitalization.

The authors plan to later pursue a larger prospective study to investigate delayed, long-term, and chronic neurologic manifestations that have not currently been identified but that might manifest later.

This work is among a growing set of literature highlighting the neurologic complications of the disease. Additional, unrelated but recent research from northern Italy has suggested that there is an increased incidence of Guillain-Barré syndrome (GBS) during the COVID-19 outbreak, supporting the hypothesis of a pathogenic link.1 The study consisted of GBS cases diagnosed in 12 referral hospitals in March and April 2020 that were retrospectively collected and compared with a control population of GBS cases diagnosed in March and April 2019 within the same hospitals.

The findings revealed an incidence of GBS in March and April 2020 of 0.202 per 100,000/month (estimated rate, 2.43 per 100,000/year) with 34 cases compared to 0.077 per 100,000/month (estimated rate 0.93 per 100,000/year) and 13 cases in the same months of 2019, equating to a 2.6-fold increase. The 30 COVID-19 positive patients with GBS (88%) represented 0.178 per 100,000 (estimated rate, 2.14 per 100,000/year), while patients who tested negative for COVID-19 with GBS (4 cases) represented 0.024 per 100,000/month (estimated 0.29 per 100,000/year).3

REFERENCES

1. Diabetes, hypertension may increase risk of COVID-19 brain complications. News release. RSNA. November 18, 2020. Accessed November 20, 2020. https://press.rsna.org/timssnet/media/pressreleases/14_pr_target.cfm?ID=2226
2. Freeman CW, Masur J, Cox M, Mohan S. Coronavirus Disease in the Brain: Incidence of Neurologic Complications of COVID-19 and Its Supportive Treatments. Presented at: RSNA annual meeting; November 29–December 5, 2020. Poster NR-1A-53.
3. Filosto M, Piccinelli SC, Gazzina S, et al. Guillain-Barre syndrome and COVID-19: an observational multicentre study from 2 Italian hotspot regions. J Neurol Neurosurg Psychiatry. Published online November 6, 2020. doi: 10.1136/jnnp-2020-324837