Neurologists in Victoria have reported the details of an unusual case of COVID-19 disease in which a 75-year old man developed severe stroke-like neurological symptoms as a results of the immune response causing inflammatory injury in the brain.
Dr Tissa Wijeratne and colleagues at the Department of Neurology, Sunshine Hospital Western Health, say the man – who spent a month in ICU – subsequently made a full recovery but the case highlights how stroke-like symptoms may be missed in severe COVID-19 disease.
In their case report they describe how the previously healthy man developed neurological symptoms such as stupor from the 21st day of his hospital stay for COVID-19 pneumonia, during which time he was admitted to ICU for ventilation.
The symptoms were not due to dedation, and he was initially thought to be displaying hypoxic encephalopathy secondary to a blood pressure drop or an acute stroke secondary to hypoperfusion or large vessel disease related to COVID-19.
After referral for neurological assessment a brain MRI showed generalised cortical diffusion restriction, which was also present in the supra- and infratentorial white matter. The imaging showed no signs of venous nor arterial occlusion, but revealed typical features of intracranial hypertension in the appearance of optic nerve sheath distension and tortuosity.
A review of blood test results showed a peak of inflammatory markers such as CRP and systemic immune response markers such as neutrophil-lymphocyte ratio (NLR) on day 21 coincided with the onset of stroke-like neurological symptoms.
This was followed by persistent anaemia, leukocytosis and hypoalbuminemia and neurological manifestations during his hospital stay. However the patient made a gradual recovery from COVID-19 pneumonia, and normalisation of blood biochemistry, particularly white cell count (neutrophil, lymphocytes, and total white cell count), showed a significant correlation with his recovery process
Tests revealed there was no apparent clinical impact on his visual functions but some on his ability to complete a visuomotor task six weeks post initial hospitalisation.
“Our results suggest that a COVID-19-induced hyperimmune response led to significant inflammatory injury to the brain and suspected intracranial hypertension secondary to severe inflammation,” the clinicians write.
“This case illustrates the critical clinical value of regular assessment of NLR, LCRPR (Lymphocyte to CRP Ratio) and LPR (lymphocyte to platelet ratio) which are low-cost prognostic tools available in almost all health services across the world in comparison to sophisticated, expensive investigations including brain MRI,” they said.
However they also cautioned that ‘the significant delay in the patient’s referral to the neurology unit/team and a similar delay in the neuroimaging of the brain both indicate the possibility for underdiagnosis of stroke and other neurological disorders during this pandemic.”