Post-COVID Neurological Sequelae

Introduction:

Though the infectivity rates of COVID-19 appear to decrease at certain intervals, they do not seem to leave this planet permanently. Simultaneous highs in infectivity rates cannot be ignored. The long-term complications of COVID in people who got infected and recovered successfully from COVID-19 continue to be a concern. And this article discusses in detail the possible long-term neurological health effects in COVID-affected people and ways to manage them.

What Does Post-COVID Sequelae Mean?

During the initial COVID wave, only the acute phase of this disease was concerned, and recovering from COVID symptoms meant being free from the deadly hold of COVID. But with time, the mutating Coronavirus has been challenging human survival and health by causing severe infections and lingering symptoms for months or years after complete recovery from acute COVID symptoms. People have been continuously suffering from one or the other health ailment such as insomnia, fatigue, clotting issues, depression, hair loss, etc., for months after initial infection and recovery. These are termed post-COVID sequelae or complications, long COVID, or long-term effects of COVID-19. These complications can affect any system of the human body, most commonly the cardiovascular, gastrointestinal, nervous, urinary, and respiratory systems.

Why Do Post-COVID Neurological Complications Occur?

In certain predisposed individuals, weak and dysregulated immune reactions towards the Coronavirus, its incomplete eradication, and invasion of the central nervous system by the virus with subsequent neurodegeneration are thought to be the cause of neurological complications in COVID survivors.

The Coronavirus is known to cross the blood-brain barrier. The virus is found to remain in the cerebrospinal fluid and cytoplasm of neurons. These viral particles can either attack the nerve tissue directly or indirectly due to immune-mediated reactions. The coronavirus can invade nerve tissues such as glial cells, astrocytes, etc., and attack the angiotensin-converting enzyme 2 (ACE2) receptors in them, which may be the cause of smell and taste loss in the acute phase.

These viral particles are also believed to reside in the nerve cells in a latent phase, and in the presence of triggering factors, they get reactivated to cause such post-COVID complications.

What Investigations Are Done In People With Post-COVID Neurological Complications?

Based on the type of neurological symptom and its severity, the following tests are ordered.

• Nerve conduction tests.

• Creatine phosphokinase test.

• MRI (magnetic resonance imaging) of the brain.

• Electroencephalogram (EEG).

• Blood pressure and heart rate measurements.

• Cerebrospinal fluid (CSF) analysis.

• Autoimmune antibody test.

• Polysomnogram.

• Kidney function test.

• Liver function test.

• Complete blood count.

• Blood sugar levels and ESR (erythrocyte sedimentation rate).

• Cognitive function assessment.

• Respiratory rate.

• Oxygen saturation.

What Are the Post-COVID Neurological Complications and Their Management?

After the so-called successful recovery from acute COVID, a majority of the population is still found to experience prevailing neurological symptoms affecting their quality of life. This cannot be underestimated as these too could cause life-threatening complications without any warning sign. Some of the important post-acute COVID neurological complications and treatment approaches are discussed below.

1. Fatigue - This is the most commonly encountered neurological symptom during and after COVID. This is a debilitating condition. In people experiencing chronic fatigue for more than six months of initial infection, chronic fatigue syndrome or myalgic encephalitis is suspected. In such individuals, the fatigue may be present all time, get aggravated with physical strain, and have an unrefreshing sleep. Such people sleep all night and still wake up exhausted—their ability to perform physical activities, which they used to perform well before COVID is impaired. Even after adequate rest, they feel tired. Their cognitive functions can also be impaired while under stress or with exertion.

• Management:

The following treatment strategies are advised for people with post-COVID fatigue for more than six months,

• Take adequate rest and sleep.

• Drink plenty of fluids (2 to 3 liters a day).

• Do not perform highly exertional activities that cause physical strain. Do not limit your daily tasks; instead, make ways to utilize your energy by spreading your tasks and working on them with equal minimal exertion over a longer period with alternating rest periods (pacing).

• Practice mild aerobic exercises such as walking, breathing exercises, strength training, etc., and increase the intensity gradually (graded exercise therapy).

• You can also take Vitamin C tablets after consulting your physician and avoid frequently self-medicating with painkillers.

2. Headache - COVID-affected people are known to experience headaches of different intensities and frequencies for months after testing positive for the infection. For some, the headache is a new onset, and for some, it exacerbates their existing migraines. Experts say that if you experience only a headache post-COVID, it might not actually be due to COVID and can be due to the weather, stress, allergies, etc.

• Management:

There is no definitive management strategy to handle COVID-related headaches.

• You can take over-the-counter painkillers but with caution. Do not self-medicate with these painkillers for more than a week, as the medication can itself cause rebound headaches.

• The same holds true for caffeine intake. Do not consume excessive amounts of caffeine to seek relief.

• Manage your stress and correct your allergies, vision problems, food habits, etc. These, too, are possible causes of headaches.

• If you have had migraines in the past, then consult your doctor to get your migraine medications prescribed.

3. Sleeping Disorders - COVID infection can leave you with sleeping disorders such as impaired sleep, sleeplessness, difficulty achieving sound sleep, difficulty falling asleep, etc. And this can persist for up to a year. Dealing with sleep issues for such a long period might cause adverse health effects such as hypertension, lack of focus and alertness, diabetes, weight gain, etc.

• Management:

For sleep disorders, initially, non-pharmacological management methods are suggested.

• Avoid using your smartphones or devices with blue light-emitting screens at least two hours before your bedtime.

• Limit your caffeine intake and make sure you do not consume caffeinated drinks and foods such as chocolate post late afternoon.

• Do not consume alcohol before bedtime.

• Make your bedroom surrounding sleep-friendly. Make your room temperature comfortable enough to sleep (not too cold, not too hot), listen to melodious sleep-inducing music or ASMR (autonomous sensory meridian response), sleep trigger sounds, and dim the lights.

• Before your bedtime, you can practice relaxation techniques like guided imagery, meditation, breathing techniques, etc.

• If all these efforts do not fetch the expected results, you can consult a physician to prescribe your sleeping doses.

4. Dysautonomia - In this condition, the autonomic nervous system that controls the involuntary functions of our body, such as heartbeat, breathing, digestion, etc., are affected. This leads to symptoms such as shortness of breath, fainting, tightness of the chest, palpitation, constipation, headache, low blood sugar, dizziness, focussing problems, etc. Since this condition can include symptoms specific to various systems, investigations are done to understand whether or not the symptoms are due to specific diseases like respiratory problems, endocrine disorders, etc., or are due to dysautonomia. This leads to effective cause-based management.

• Management:

• Avoid certain triggering factors such as alcohol, caffeine, dehydration, hot climatic conditions, and certain drugs (Nortriptyline, Duloxetine).

• Use compression garments.

• Include strength and resistance training.

• Drink plenty of fluids (2 to 3 liters per day).

• Include one to two tablespoons of salt in your diet.

5. Impaired Cognitive Function - The impaired cognitive functions might persist for more than a year of the initial infection. They include brain fog, problems focussing, lack of concentration, poor memory, confusion, dizziness, etc. Also, these cognitive impairments are pronounced in those who had severe COVID with ICU (intensive care unit) admission and ventilation.

• Management:

• At-home remedies are helpful, such as reading books or newspapers, solving puzzles, making daily calculations manually rather than using calculators or mobiles, etc.

• Measures should be taken to balance stress (if present) as this too could worsen the COVID-related cognitive impairment.

• Finally, the help of cognitive-behavioral therapists can be sought for better results.

6. Guillain-Barre Syndrome - This syndrome, if about to occur in COVID patients, can occur within 10 days of infection or weeks after recovery. It is an acute polyradiculoneuropathy where the viral infection triggers the body’s immune system to attack its own nerve cells. It is characterized by limb weakness, paraesthesia, muscle weakness, numbness, tingling sensations in the skin, respiratory insufficiency, cardiac arrhythmias, facial palsy, etc. Thankfully it is a rare post-COVID sequela.

• Management:

• Intravenous Immunoglobulins.

• Plasma therapy.

• In severe conditions, ventilator support might be needed.

7. Stroke - COVID-19 is known to trigger the inflammatory response to cause thrombotic or clotting events in certain infected people, especially those with severe infection and with underlying health conditions such as hypertension, cardiovascular diseases, and diabetes. Both ischemic and intracerebral hemorrhage is known to occur. Numbness on one side of the body, blurry vision, confusion, speaking difficulties, imbalance, loss of coordination, and headache are alarming signs. Immediate medical management is necessary.

• Management:

• If you experience any signs of stroke, you should reach a stroke management center within 4.5 hours for successful management.

• Clot dissolution or clot removal techniques will be performed based on the severity.

8. Epilepsy - This is also a rare post-COVID complication. Due to cytokine storms, seizures can also occur in an otherwise healthy individual.

• Management:

Epilepsy management in COVID patients is similar to that of the standard epilepsy treatment.

• Antiepileptic drugs such as Lorazepam, Phenytoin, Levetiracetam, Midazolam, etc., are given.

• Those with preexisting epilepsy should take their routine antiepileptic drugs without fail.

Conclusion:

The global concern for post-COVID complications is rising as these impact the quality of life. People who recovered from severe COVID, the elderly, and those with comorbid conditions are at risk of developing long COVID. Therefore, long COVID symptoms such as headache, fatigue, lack of mental clarity, etc., should not be underestimated, and prompt medical care should be sought.