Patients with COVID-19 who have disorders of consciousness (COVID-DoC) are highly likely to reawaken and recover from disability, US neurologists say.
Their study of 12 hospitalised COVID-19 patients in comas, vegetative or minimally conscious states saw 11 regain consciousness within 25 days of continuous intravenous sedation cessation.
All eight discharged patients were cognitively impaired and needed significant assistance upon leaving the hospital, yet, five were out of inpatient rehabilitation facilities with normal or nearly normal cognition and mild weakness and pain-related disability in under three months and six were home with normal cognition and minimal or no disability at six months.
Two remained in inpatient care for more constant support after their recovery was hindered by severe polyneuropathy, the authors wrote in Neurology.
The findings are positive despite radiological signs of white matter and neuronal activity depletion, with the cohort’s structural connectivity mirroring that of patients with severe traumatic brain injuries.
Though small and somewhat limited, the study provides critical information that could help justify life-sustaining treatment in un- or minimally-conscious COVID patients, the authors suggested.
“Among the countless tragedies of the COVID-19 pandemic, COVID-DoC has presented unique and profound challenges,” they wrote.
“Rendering patients unable to communicate, and with uncertain prospects for recovery, COVID-DoC has forced families and clinicians to decide whether to continue life-sustaining treatment with little data available for guidance.”
This creates the “alarming possibility” that patients with little chance of meaningful recovery might stay plugged in, and others who might have recovered could be withdrawn.
Any data clinicians did have came mostly from individual case reports and while more information on risk factors and prognosis is needed, enrolling and capturing advanced neuroimaging for critically ill COVID patients is challenging, the authors noted.
They did try to clarify some of these elements, however, with little success. For example, COVID patients with and without DoC had similar comorbidities including hypertension, diabetes and asthma; combined with older age, these factors may predispose patients to severe illness, but not necessarily consciousness disorders.
Similarly, while brain connectivity-affecting microhaemorrhages and/or leukoencephalopathy, have been seen in most COVID patients, and it’s possible the findings could cause or predispose to COVID-DoC, their absence in some consciousness-disordered patients means they’re “not necessary” for the condition.
It’s not even clear whether related neurological injuries are a result of systemic inflammation, toxic-metabolic insults, the effects of prolonged intubation and intensive care, direct viral infection, hypoxaemia, or a combination of these and other factors, they wrote.
High sedative doses needed to treat severe COVID-19 have also been nominated as a cause of COVID-DoC, and although COVID-DoC patients “were indeed sedated longer than those with severe COVID-19 but no DoC”, “sedatives alone may not necessarily explain the differences between these two small cohorts, given potential confounds such as illness severity”.
While clinicians await clearer information, this study could support treatment decision making and hopefully, prevent plugs being pulled on COVID-DoC patients too soon, the authors suggested.