One of the main reasons why Covid-19 is still so misunderstood by the general public is that it often doesn’t kill directly but causes additional complications instead. That’s why we often hear people complaining about patients being misdiagnosed. We hear questions such as “He died of a stroke, why was he listed as a Covid-19 victim?!”
Of course, the medical reasoning is clear – there are always additional factors, and the cause of death is often a secondary complication. However, Covid-19 is still a key part of the problem as the chronic inflammation it causes is usually the driving force behind those complications.
What happens to the brain?
Seizures, strokes, mental confusion and hallucinations, paralysis, and even coma – the list is as long as it’s unpleasant to go through. The virus’s tendency to affect the brain has already been well documented. The immune system can also start damaging the brain in its overreaction to the virus resulting in excessive inflammation.
Why are brain and neurological complications such a major problem?
Aside from the obvious reason that brain and neurological problems are highly dangerous and unpleasant, they are very difficult to diagnose.
For example, when doctors suspect a stroke, they usually order an MRI. However, Covid-19 often makes patients too weak and unstable to get to the MRI scanner. Another issue is that Covid-19 will contaminate the scanner and might infect other patients and staff members.
“Our hands are much more tied right now than before the pandemic,” said Dr. Sherry Chou, an associate professor of critical care medicine, neurology, and neurosurgery at the University of Pittsburgh School of Medicine.
Another common problem is doctors not being able to test the patients’ reflexes because they need to be heavily sedated at all times.
“We may not know if they’ve had a stroke,” said Dr. Kevin Sheth, a professor of neurology and neurosurgery at the Yale School of Medicine.
How common are these neurological problems and symptoms?
A common objection to even just pointing out these neurological issues is that they are exceedingly rare and therefore – aren’t noteworthy. Yet, study after study proves otherwise.
One study from Wuhan, China, showed that 36% of the affected patients had neurological symptoms such as headaches, strokes, insufficient muscle coordination, and drifting in and out of consciousness.
Another study from France observed such symptoms in 84% of their (albeit smaller) test group. Many of the symptoms also persisted after the patients had recovered from the virus and were discharged from the hospital.
What are doctors doing to deal with these problems?
Many hospitals and healthcare centers are too underfunded and overworked to have the opportunity to look for newer and more effective solutions. Nevertheless, innovations are still popping left and right. For example, New York’s Northwell Health has started utilizing a mobile MRI machine for Covid-19 patients.
Dr. Richard Temes, the health system’s director of neurocritical care explained that the mobile MRI scanner uses a low-field magnet to be wheeled safely around the hospital. Yet, procedures such as EEGs or brain electrical activity tests are still worrying the hospital’s staff, Temes added.
“Right now, we actually don’t know enough to say definitely how Covid-19 affects the brain and nervous system,” said Dr. Sherry Chou. She is leading an international study on neurological effects of the virus. “Until we can answer some of the most fundamental questions, it would be too early to speculate on treatments.”
Are brain autopsies helping doctors get a clearer picture?
While testing patients may be complicated, getting data from brain autopsies should be easier, right? It turns out that’s not the case either. Lena Al-Harthi, a professor and the chair of the microbial pathogens and immunity department at Rush Medical College in Chicago points out that performing autopsies on Covid-19 victims is quite difficult.
That’s because autopsies on Covid-19 patients run the risk of aerosolization of the virus and contamination of the facility. As a result, pathologists need more specialized facilities and equipment to perform autopsies safely and such facilities and equipment are still in short supply.
Why does all this matter?
Brain and neurological symptoms and complications are not just unfortunate – they can also be used for better identification and diagnostics of the disease.
Dr. Robert Stevens, an associate professor of anesthesiology and critical care medicine at Johns Hopkins University points out that many of the most well-known symptoms of Covid-19 are related to the virus invading the brain.
According to a German study, the coronavirus can enter a cell through the molecular getaway ACE-2 receptor. These receptors are found in multiple organs aside from the lungs, including our brain, which is why Covid-19 is so invasive.
Another study from Japan showed that Covid-19 can even be found in the cerebral fluid that surrounds our brains.
It’s problems like these that may eventually explain not only the main symptoms that we already understand but some of the more bizarre ones such as the loss of smell and taste in many patients. These symptoms have also been well-detailed by studies such as this one from May. They are believed to be caused by neurological complications as well since nasal congestions and inflammations have already been ruled out.
There’s also a recent JAMA study which showed how Covid-19 invades the brain. That study also delved deeper into the loss of smell and taste abnormalities.
Another condition that’s linked to Covid-caused neurological problems is “sleep hypoxia”. This condition is characterized by a stark plummeting of the oxygen levels in the brain that’s isn’t registered by the patient. According to Temes, most specialists believe the problem is in the brain stem which prevents the brain from signalling when an issue arises.
The risk of collateral damage
Another big problem all hospitals face is that even as they are trying their best, their efforts often lead to collateral damage. That’s due to the highly infectious nature of the disease, as well as of how hard it can be to diagnose.
One such tragic yet common example is doctors putting patients into a deep sleep when they are on mechanical ventilators. Doctors do that to prevent the patients from accidentally pulling the tubes out and killing themselves, said Dr. Pratik Pandharipande, chief of anesthesiology and critical care medicine at Vanderbilt University School of Medicine in Nashville, Tennessee.
However, the same sedatives used to induce this deep sleep often cause hallucinations, memory problems, and delirium, as explained by Dr. Jaspal Singh, a pulmonologist and critical care specialist at Atrium Health in Charlotte, North Carolina. Many recovered patients have shared their experience of terrifying hallucinations, nightmares, and post-traumatic stress disorder while in the ICU as well as after it.
Problems like these have caused many people to dub ICUs as “Delirium factories”.
Some research shows that up to 70% or 75% of patients on medical ventilators have reported experiencing delirium and hallucinations.
“[They] don’t realize they’re in the hospital,” Singh said. “They don’t recognize their family.”
A French study published in the New England Journal of Medicine has estimated that ~33% of Covid-19 patients also experience “dysexecutive syndrome” which is expressed through disorientation, poorly organized movements, and inattention.
Research also shows that delirious patients also have a higher death rate. Even when they survive, they often require longer hospitalization periods and are at risk of developing long-term disabilities.
Hospitals’ ban on visitors further complicates things
Dr. Lee Fleisher, chair of an American Society of Anesthesiologists Committee on brain health is one of many specialists to point out that delirious patients recover much better when they can interact with their friends and family. It also helps when they can walk around and orient themselves about their environment.
Because of Covid-19, however, family members are usually banned from entering hospital grounds and patients are restricted to their beds. This makes their recoveries much harder.
“You can decrease the need for some of these drugs just by talking to patients and providing light touch and comfort,” Fleisher said. According to him, the rate of delirium can be reduced with as much as 50% of patients can be allowed to move around and interact more with their relatives.
Another reason why delirium rates are increasing is that many doctors are placing ventilator patients on their stomachs rather than on their backs. This is called “a prone position” and it’s done because it’s been shown to increase the survival rate of Covid-19 patients. However, the prone position also necessitates more medication which leads to more delirium.
“The way we’re having to care for patients right now is probably contributing to more mortality and bad outcomes than the virus itself,” said Dr. Sharon Inouye, a geriatrician at Harvard Medical School and Hebrew SeniorLife, a long-term care facility in Boston. “A lot of the things we’d like to do are just very difficult.”