Altered mentation or stroke on admission associated with higher risk of in-hospital mortality in patients with COVID-19

DG Aleerts

The incidence of altered mentation or stroke on admission predicts a modest but significantly higher risk of in-hospital mortality independent of disease severity among patients with coronavirus disease 2019 (COVID-19), according to a study published in Neurology.

“We present the largest inpatient cohort of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infected patients to date, in evaluating predictors of inpatient mortality as they relate to neurologic syndromes at presentation,” Emad Nader Eskandar, MD, Montefiore Medical Center, Bronx, New York, and colleagues. “A small but substantial subset of patients had associated neurological presentations of sufficient severity to warrant imaging of the neuraxis. Although the majority had normal neuro-imaging, the distinction between those with altered cognition or arousal and those exhibiting other neurological signs and symptoms associated with COVID-19 infection (neuroCOVID-19 complex) appears to be important.”

“Even when controlling for biomarker abnormalities, patients with impaired cognition or arousal without abnormal neuro-imaging findings exhibited an increased risk of inpatient mortality – suggesting that other yet-to-be determined mechanisms may be at play,” the authors noted. “Irrespective of the etiological factors, such neurological presentations can be subtle but important indications of more severe [COVID-19] illness and should be taken seriously in hospital emergency rooms.”

Between March 1 and April 16, 2020, 4711 patients with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection were admitted to one medical system in New York City. Of the patients, 581 (12%) had neurological issues of sufficient concern to warrant neuro-imaging. Neurological manifestations included altered mentation with normal imaging (n=258; 44%), normal mentation with other neurological signs and symptoms compatible with COVID-19 (n=216; 37%), stroke (n=55; 9%), seizures (n=26; 4%), and other brain lesions (n=26; 4%). These patients were compared to 1743 nonneurological COVID-19 patients matched for age and disease-severity admitted during the same period to assess the risk of death.

Among patients in the altered mentation group, 61 (23.6%) had no clear toxic, metabolic disturbances or history of dementia or other premorbid cognitive disturbances. Meanwhile, within the stroke cohort, 36 patients had large vessel occlusions whereby 8 (22.2%) received intravenous thrombolysis and 12 (33.3%) underwent endovascular thrombectomy and 3 exhibited hemorrhagic transformation. Furthermore, 31 (56.4%) patients of the stroke cohort did not have any underlying comorbidities.

The researchers found that patients with stroke (odds ratio [OR], 3.1; 95% confidence interval [CI], 1.65-5.92; P = 0.001) and patients with altered mentation (OR, 1.39; 95% CI, 1.04-1.86; P = 0.04) had a higher risk of mortality compared with age- and severity-matched controls.

However, the researchers noted that there was no significant increase in risk for patients with new or recurrent seizures, neuro-COVID-19 complex, or those with incidentally discovered brain lesions.

In addition, study data showed there was a significant association between altered mentation and increasing age, Black race, Latino ethnicity, prior history of stroke, chronic obstructive pulmonary disease, congestive heart failure, and renal disease. Other significant correlates were mean arterial pressure <70 mmHg, D-dimer >3 mg/liter, platelets <150,000 per mm3 , international normalized ratio (INR) >1.2, blood urea nitrogen >30 mg/dL, creatinine >1.5 µmol/liter, procalcitonin >0.1 ng/ml, and troponin >0.1 ng/ml.

“While other biomarker findings such as hypotension, D-dimer, coagulopathy, and renal failure may be more predictive of illness severity, and mortality, neurologic syndromes of itself still portends a higher risk of mortality, and can be easily assessed early on in a patient encounter,” the authors wrote.

“The presence of these syndromes may represent a different clinically important syndromic expression of SARS-CoV-2 infection which carries a greater risk of mortality and may benefit from targeted treatment,” the authors added.