COVID-19: Stroke and agraphia

The study highlights how SARS-COV-2 manifests itself through respiratory or mental symptoms, and also through very specific neuropsychological signs such as agraphia and conduction aphasia.

A COVID-19 infection may also manifest itself through neuropsychological symptoms

Published in "Neurological Sciences", the study by Professor Konstantinos Priftis (Department of General Psychology, University of Padua, Italy) highlights, for the first time, how SARS-COV-2 can manifest itself not only through respiratory signs or generalized mental symptoms but also through highly specific neuropsychological signs such as agraphia and conduction aphasia.

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Severe acute respiratory syndrome Coronavirus-2 (SARS-COV-2) is the name given to the new 2019 coronavirus. COVID-19 is the name given to the disease associated with the virus. As is known, SARS-CoV-2 is a new strain of coronavirus that has not previously been identified in humans. WHO data as of 28 September (Source: Health Emergency Dashboard) show that 32,968,853 cases have been confirmed worldwide since the beginning of the pandemic with a tragic death toll of 995,836.

The symptoms of COVID-19 vary according to the severity of the disease, from the absence of symptoms (asymptomatic) to fever, cough, sore throat, weakness, fatigue, and muscle pain; and in the most severe cases, pneumonia, acute respiratory distress syndrome (ARDS), sepsis and septic shock, potentially leading to death. The most common are: fever ≥ 37.5°C and chills, recent onset of coughing, breathing difficulties, sudden loss of sense of smell (anosmia) or decreased sense of smell (hyposmia), loss of taste (ageusia), or altered taste (dysgeusia), colds or runny nose, sore throat and diarrhea (especially in children).

However, there is also an impact on the mental and behavioral spheres: the literature has indicated cases of patients suffering from confusion, agitation, and psychotic signs. To date, no detailed descriptions have been published for patients affected by COVID-19 and suffering from specific cognitive difficulties (e.g. oral/written language disorders, distinct components of memory, higher motor functions, mathematical skills, etc.).

The published study

The study by Professor Konstantinos Priftis (Department of General Psychology, University of Padua, Italy), in collaboration with the psychologists Dr. Lorella Algeri and Dr. Simonetta Spada and the physiatrist Dr. Stella Villella of the Pope John XXIII Hospital in Bergamo, has been published in the journal Neurological Sciences (Springer Nature editorial group) under the title "COVID-19 presenting with agraphia and conduction aphasia in a patient with left-hemisphere ischemic stroke". 

A patient was investigated for the first time for whom COVID-19 manifested itself not only with mild respiratory symptoms but also with generalized, regressed, and highly specific neuropsychological symptoms. The publication by Professor Priftis' group analyzed the patient's clinical path from a neuropsychological point of view, describing the specific cognitive difficulties encountered.

The research highlights how, in addition to the need to treat the consequences of respiratory and brain damage, one of the future frontiers that the healthcare system will have to face will be to evaluate a COVID-19 patient also from a neuropsychological point of view as a sentinel sign of virus affection and start a systematic cognitive rehabilitation.

The medical case

"We studied a patient in whom COVID-19 caused a stroke located in the left brain hemisphere," said Prof. Konstantinos Priftis. After a few days of fever, the man was hospitalized not so much because of lung complications, but because of language difficulties and behavioral agitation. To all intents and purposes, from a clinical point of view, he would not have been a COVID-19 patient. 

The routine serological protocol tests adopted for the hospitalization revealed the presence of antibodies to SARS-COV-2 while the MRI revealed the presence of multiple embolisms in the left cerebral hemisphere. This is where, compared to the clinical practice followed for inpatients, “we also subjected the patient to a very thorough neuropsychological examination. After the tests, we noticed how the patient was unable to write (agraphia) and how conduction aphasia, i.e. the inability to repeat the words heard, appeared more mildly, while the rest of the mental functions remained intact" explained Prof. Priftis.

The study highlights, for the first time, how SARS-COV-2 can manifest itself not only through respiratory signs or generalized mental symptoms but also through highly specific neuropsychological signs (agraphia, conduction aphasia, etc.).

"This case is important because it is a sort of ‘sentinel’ of similar situations that could escape the COVID-19 patients once the emergency has passed. This is why, for Prof. Priftis, it becomes very important to include a careful neuropsychological evaluation among the diagnostic tests of the consequences of SARS-COV-2. “Some patients, like ours, came to clinical observation because of their neuropsychological signs and not because of classic respiratory signs”, he added. 

Not only that, once these cases come to light, beyond neuropsychological evaluation, many of these patients will have to be followed up for their systematic cognitive rehabilitation. “This circumstance constitutes a new challenge, not only clinical but also financial, to be faced immediately in the context of the cerebral consequences of SARS-COV-2" concluded Prof. Priftis.

Sources: 
1. Comunicato stampa. COVID-19, ictus e perdita della capacità di scrivere. Università degli Studi di Padova. 30 settembre 2020
2. Priftis, K., Algeri, L., Villella, S. et al. COVID-19 presenting with agraphia and conduction aphasia in a patient with left-hemisphere ischemic stroke. Neurol Sci (2020). https://doi.org/10.1007/s10072-020-04768-w

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