Clinical Characteristics and Outcomes of Critically Ill Neurological Patients with COVID-19 Infection in Neuro-intensive Care Unit: A Retrospective Study
Rohini M Surve, Rajeeb K Mishra, Soumya R Malla, Sriganesh Kamath, Dhritiman R Chakrabarti, Karthik Kulanthaivelu, Mahendranath Musunuru
COVID-19, Mortality, Neurocritical care, Neurological functional outcome, Predictors of outcome
Citation Information :
Surve RM, Mishra RK, Malla SR, Kamath S, Chakrabarti DR, Kulanthaivelu K, Musunuru M. Clinical Characteristics and Outcomes of Critically Ill Neurological Patients with COVID-19 Infection in Neuro-intensive Care Unit: A Retrospective Study. Indian J Crit Care Med 2021; 25 (10):1126-1132.
Background: There are insufficient data about clinical outcomes in critically ill neurological patients with concomitant coronavirus disease (COVID-19). This study describes the clinical characteristics, predictors of mortality, and clinical outcomes in COVID-19-positive neurological patients managed in a dedicated COVID-19 neurointensive care unit (CNICU).
Methods: This single-center, retrospective cohort study was conducted in critically ill neurological and neurosurgical patients with concomitant COVID-19 infection admitted to the CNICU at the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, from July to November 2020. Patients’ demographic, clinical, laboratory, imaging, treatment, and outcome data were retrieved from the manual and electronic medical records. Predictors of mortality and neurological outcome were identified using logistic regression.
Results: During the study period, 50 COVID-19-positive neurological patients were admitted to the CNICU. Six patients were excluded from the analysis as they were managed in the CNICU for <24 hours. A poor outcome, defined as death or motor Glasgow Coma Scale <5 at hospital discharge, was observed in 34 of 44 patients (77.27%) with inhospital mortality in 26 of 44 patients (59%). Worst modified sequential organ failure assessment (MSOFA) score, lactate dehydrogenase maximum levels (LDHmax), and lymphocyte count were predictors of inhospital mortality with an odds ratio (OR) of 1.88, 1.01, and 0.87, respectively, whereas worst MSOFA and LDHmax levels were predictors for poor neurological outcome with OR of 1.99 and 1.01, respectively.
Conclusions: Mortality is high in neurological patients with concomitant COVID-19 infection. Elevated inflammatory markers of COVID-19 suggest the role of systemic inflammation on clinical outcomes. Predictors of mortality and poor outcome were higher MSOFA score and elevated LDH levels. Additionally, lymphopenia was associated with mortality.
Lai CC, Shih TP, Ko WC, Tang HJ, Hsueh PR. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease-2019 (COVID-19): the epidemic and the challenges. Int J Antimicrob Agents 2020;55(3):105924. DOI: 10.1016/j.ijantimicag.2020.105924.
Johnson KD, Harris C, Cain JK, Hummer C, Goyal H, Perisetti A. Pulmonary and extra-pulmonary clinical manifestations of COVID-19. Front Med 2020;7:526. DOI: 10.3389/fmed.2020.00526.
Paterson RW, Brown RL, Benjamin L, Nortley R, Wiethoff S, Bharucha T, et al. The emerging spectrum of COVID-19 neurology: clinical, radiological and laboratory findings. Brain 2020;143(10):3104–3120. DOI: 10.1093/brain/awaa240.
Cagnazzo F, Arquizan C, Derraz I, Dargazanli C, Lefevre PH, Riquelme C, et al. Neurological manifestations of patients infected with the SARS-CoV-2: a systematic review of the literature. J Neurol 2021;268(8):2656–2665. DOI: 10.1007/s00415-020-10285-9.
Pilotto A, Benussi A, Libri I, Masciocchi S, Poli L, Premi E, et al. COVID-19 impact on consecutive neurological patients admitted to the emergency department. J Neurol Neurosurg Psychiatry 2021;92(2):218–220. DOI: 10.1136/jnnp-2020-323929.
Mao L, Jin H, Wang M, Hu Y, Chen S, He Q, et al. Neurologic manifestations of hospitalized patients with coronavirus disease 2019 in Wuhan, China. JAMA Neurol 2020;77(6):683–690. DOI: 10.1001/jamaneurol.2020.1127.
Harapan BN, Yoo HJ. Neurological symptoms, manifestations, and complications associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease 19 (COVID-19). J Neurol 2021;268(9):3059–3071. DOI: 10.1007/s00415-021-10406-y.
Zirpe K, Dixit S, Kulkarni AP, Sapra H, Kakkar G, Gupta R, et al. Pathophysiological mechanisms and neurological manifestations in COVID-19. Indian J Crit Care Med 2020;24(10):975–980. DOI: 10.5005/jp-journals-10071-23592.
Honardoost M, Janani L, Aghili R, Emami Z, Khamseh ME. The association between presence of comorbidities and COVID-19 severity: a systematic review and meta-analysis. Cerebrovasc Dis 2021;50(2):132–140. DOI: 10.1159/000513288.
Borghesi A, Zigliani A, Golemi S, Carapella N, Maculotti P, Farina D, et al. Chest X-ray severity index as a predictor of in-hospital mortality in coronavirus disease 2019: a study of 302 patients from Italy. Int J Infect Dis 2020;96:291–293. DOI: 10.1016/j.ijid.2020.05.021.
Yang R, Li X, Liu H, Zhen Y, Zhang X, Xiong Q, et al. Chest CT severity score: an imaging tool for assessing severe COVID-19. Radiol Cardiothorac Imag 2020;2(2):e200047. DOI: 10.1148/ryct.2020200047.
Grissom CK, Brown SM, Kuttler KG, Boltax JP, Jones J, Jephson AR, et al. A modified sequential organ failure assessment score for critical care triage. Dis Med Publ Health Prep 2010;4(4):277–284. DOI: 10.1001/dmp.2010.40.
Vanamoorthy P, Singh GP, Bidkar PU, Mitra R, Sriganesh K, Chavali S, et al. The Neurocritical Care Society of India (NCSI) and the Indian Society of Neuroanaesthesiology and Critical Care (ISNACC) joint position statement and advisory on the practice of neurocritical care during the COVID-19 pandemic. J Neuroanaesth Crit Care 2020;7(03):128–139. DOI: 10.1055/s-0040-1714648.
Mokhtari T, Hassani F, Ghaffari N, Ebrahimi B, Yarahmadi A, Hassanzadeh G. COVID-19 and multi-organ failure: a narrative review on potential mechanisms. J Mol Histol 2020;51(6):613–628. DOI: 10.1007/s10735-020-09915-3.
Malik P, Patel U, Mehta D, Patel N, Kelkar R, Akrmah M, et al. Biomarkers and outcomes of COVID-19 hospitalisations: systematic review and meta-analysis. BMJ Evid Based Med 2021;26(3):107–108. DOI: 10.1136/bmjebm-2020-111536.
Dong X, Sun L, Li Y. Prognostic value of lactate dehydrogenase for in-hospital mortality in severe and critically ill patients with COVID-19.Int J Med Sci 2020;17(14):2225–2231. DOI: 10.7150/ijms.47604.
Thomson RJ, Hunter J, Dutton J, Schneider J, Khosravi M, Casement A, et al. Clinical characteristics and outcomes of critically ill patients with COVID-19 admitted to an intensive care unit in London: a prospective observational cohort study. PLoS One 2020;15(12):e0243710. DOI: 10.1371/journal.pone.0243710.
Xu J, Yang X, Yang L, Zou X, Wang Y, Wu Y, et al. Clinical course and predictors of 60-day mortality in 239 critically ill patients with COVID-19: a multicenter retrospective study from Wuhan, China. Crit Care 2020;24(1):394. DOI: 10.1186/s13054-020-03098-9.
Kramer AH, Zygun DA. Declining mortality in neurocritical care patients: a cohort study in Southern Alberta over eleven years. Can J Anesth 2013;60(10):966–975. DOI: 10.1007/s12630-013-0001-0.
Ting HW, Chen MS, Hsieh YC, Chan CL. Good mortality prediction by Glasgow Coma Scale for neurosurgical patients. J Chin Med Assoc 2010;73(3):139–143. DOI: 10.1016/S1726-4901(10)70028-9.
Benussi A, Pilotto A, Premi E, Libri I, Giunta M, Agosti C, et al. Clinical characteristics and outcomes of inpatients with neurologic disease and COVID-19 in Brescia, Lombardy, Italy. Neurology 2020;95(7): e910–e920. DOI: 10.1212/WNL.0000000000009848.
Shah VA, Nalleballe K, Onteddu SR. Critically ill neurologic patients during the COVID-19 pandemic: a short communication. Brain Behav Immun Health 2021;12:100207. DOI: 10.1016/j.bbih.2021.100207.
National Institutes of Health. Clinical spectrum of SARS-CoV-2 infection. 2020. Available from: https://www.covid19treatmentguidelines.nih.gov/overview/clinical-spectrum/.
Abrahão LR, De Marco FVC, Maciel FMB, Giudicissi M, Bianco ACM, Mora MA. Application of SOFA score to neurological patients admitted to intensive care unit. Crit Care 2002;6(Suppl. 1):P237. DOI: 10.1186/cc1704.
Popat C, Ruthirago D, Shehabeldin M, Yang S, Nugent K. Outcomes in patients with acute stroke requiring mechanical ventilation: predictors of mortality and successful extubation. Am J Med Sci 2018;356(1):3–9. DOI: 10.1016/j.amjms.2018.03.013.
Juul S, Nielsen EE, Feinberg J, Siddiqui F, Jørgensen CK, Barot E, et al. Interventions for treatment of COVID-19: a living systematic review with meta-analyses and trial sequential analyses (The LIVING Project) [published correction appears in PLoS Med 2020 Dec 29;17(12):e1003517]. PLoS Med 2020;17(9):e1003293. DOI: 10.1371/journal.pmed.1003293.
Kelleni MT. Tocilizumab, remdesivir, favipiravir, and dexamethasone repurposed for COVID-19: a comprehensive clinical and pharmacovigilant reassessment. SN Compr Clin Med 2021;1–5. DOI: 10.1007/s42399-021-00824-4.
Thachil J, Tang N, Gando S, Falanga A, Cattaneo M, Levi M, et al. ISTH interim guidance on recognition and management of coagulopathy in COVID-19. J Thromb Haemost 2020;18(5):1023–1026. DOI: 10.1111/jth.14810.
Jiménez-Soto R, Aguilar-Soto M, Rodríguez-Toledo CA, Camiro-Zúñiga A, Demichelis R; ARMII Study Group. The impact of different prophylactic anticoagulation doses on the outcomes of patients with COVID-19. Thromb Res 2021;202:14–16. DOI: 10.1016/j.thromres.2021.02.031.