The COVID-19 outbreak has been the subject of considerable attention all over the world due to its high contagious properties. It primarily targets the respiratory epithelium but also has neuro-invasive potential. Indeed, neuropsychiatric manifestations, such as fatigue, headache, psychiatric symptoms, and delirium, are consistently observed in COVID-19. Neuro-COVID-19 is increasingly becoming an accepted term among scientists and clinicians. The neurobiological basis of viral infections pointed to an ongoing neuroinflammatory response to viral antigens and proinflammatory mediators/immune cells [5].
Interdisciplinary teams should be created to implement strategies for treating the wide range of neurological symptoms in Neuro-COVID-19 patients [4].
The prevalent neurological symptoms among individuals with COVID-19 disease should not be under-estimated during the current pandemic outbreak [6].
This study findings demonstrate that MRI imaging in neuro-COVID-19 has a high clinical impact. And pick up the prevalent and frequent neurological symptoms were the headache (80%), anosmia or olfactory dysfunction (62.9%) was the most frequent symptom. Other symptoms of great significance were stroke like manifestation (motor/ sensory impairment and transient ischemic attack in the form of temporary loss of vision), extrapyramidal manifestation (1.4%) was one of the least frequent symptoms. On the other side; anxiety and low mood (17.1%) is the most frequent psychiatric symptom followed by fatigue (14.3%). Depression (7.1%) is the least psychiatric symptom. These results were in concordance to cross-sectional study done by Carcamo Garcia et al. [7] who found that the most common neurological symptoms were headache (72%), hypogeusia or ageusia (41%), hyposmia or anosmia (40%). While they were in discordant to Study conducted by Soltani et al. [8] which indicated that, the prevalence of CNS or mental associated disorders was 50.68%. The most prevalent symptoms were hyposmia/ anosmia/ olfactory dysfunction, while the prevalence of depression and anxiety was 3.52%. Also study done by Ortelli et al. [9] stated that more than half of patients who recover from COVID-19 experience fatigue. The study conducted by Chuang et al. [10] revealed that impaired consciousness was the most common initial neurologic symptom, followed by stroke, unsteady gait, headache, seizure, syncopal event, acute vision changes, and intracranial hemorrhage.
On the opposite side, Goel et al. [11] proved that the most commonly reported COVID neurological complications are cerebrovascular accidents, encephalopathy, encephalitis, meningitis, and Guillain-Barr e syndrome (GBS).
The comorbidity is potentially complicating the course of COVID-19; 62.9% of patients had associated comorbidities, the most common is HTN in 20 (28.6%) patients, DM were 12 patient (17.1%), morbid obesity 8 (11.4%) patient, cardiac disease 6 (8.6%) patients, and lymphoma were 2 (2.9%) patients. Multiple patients had multiple comorbidities especially in SLE and CKD. These results were in agreement to studies done by Khedr et al. [12] and Gusev et al. [13] who stated that hypertension, diabetes mellitus, ischemic heart disease and rheumatic disorders were the most common comorbidities in patients with CNS affection. In contrast to study of Carcamo Garcia et al. [7] who found that majority (42%) had no prior comorbidities.
In the present study, most patients with Neuro-COVID-19 survived (n = 47); a considerable number of patients died (n = 12); and the rest had unclear outcomes (n = 11). This was in agreement to study of Collantes et al. [14] who demonstrated that most patients with Neuro-SARS survived.
In the present study, no statistical significance between severity of Neuro-COVID and respiratory COVID. In contrary to Gusev et al. [13] who found a relationship between the severity of COVID-19 and the severity and frequency of neurological manifestations. Severe neurological disorders are mostly seen in severe cases of COVID-19 and include acute cerebrovascular accidents (aCVA), acute necrotizing encephalopathy, and Guillain–Barre syndrome. The difference may be a result of different methodology as Gusev et al. [13] studies the hospitalized patients and did not include outpatient clinic cases.
The most common MRI findings were infarctions (acute, subacute, large or lacunar) followed by hematoma. Haemorrhage may be microbleeds in the white matter. Abnormalities in the white matter may results from ADEM or PRES. Post ictal edema can be depicted easily. In 2.8%, false negative imaging, MRI failed to pick up any abnormality to explain neurologic deficit. This was in agreement to studies done by Revzin et al. [15] and Ellul et al. [16] who described variety of cerebro-vascular stroke in neuro-COVID and opposite to Poyiadji et al. [17] who described acute necrotizing encephalopathy as post COVID complication.
Due to the urgency of the COVID-19 pandemic, this study had some limitations. First, it was a single institutional study. Second, as Neuro-COVID patients had varying degrees of disease severity, from light headache to critically ill patients and MRI was performed commonly in severely ill patients, patient selection bias is possible. Third, the lack of a control group limits our findings to Neuro-COVID-19. Forth, the lack of histopathologic data is also a limitation. Finally, the limited availability of long-term clinical outcomes.
These limitations necessitate international longitudinal studies for a more detailed analysis of co-morbidities and to determine the long-term neurological sequelae of COVID-19 during the acute and post-infectious period [18].