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As the world learns more about COVID-19, medical providers are connecting the dots between neurological complications and the virus. From strokes, to seizures, to delirium – neurologist Pravin George, MD, explains how COVID-19 can affect your brain and nervous system. He also discusses prevention, treatment and who is most at risk.

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COVID-19: How the Virus Affects the Brain with Dr. Pravin George

Podcast Transcript

Cassandra Holloway:

Hi there. Thanks for joining us. You're listening to the Health Essentials podcast brought to you by Cleveland Clinic. My name is Cassandra Holloway and I'll be your host for this episode. Today, we're broadcasting virtually as we are practicing social distancing during the coronavirus pandemic. We're joined virtually by neurologist, Dr. Pravin George. Dr. George, thank you for taking the time out of your day to be here and speak with us.

Dr. Pravin George:

Thank you for having me. It's great to be here.

Cassandra Holloway:

So as we learn more about coronavirus, we're seeing the different effects that the virus can have on a person even after they've recovered from the illness. So today, we're going to be talking with Dr. George about the neurological effects that COVID-19 can have on someone. Before we dive into this episode's topic, we want to first remind our listeners that this is for informational purposes only and does not replace your own physician's advice. So Dr. George, I first want to start off by asking you how you're doing during this pandemic and in this crazy time and if you'll tell us a little bit about your practice at Cleveland Clinic and the type of patients you see.

Dr. Pravin George:

Of course. Yeah, so as you can imagine during this pandemic, it's been very busy in certain ways in the hospital. I practice as a neurocritical care physician. So that means that I take care mainly of patients that have brain diseases but that caused them to go to the ICU. So the main population that I saw prior to COVID here were patients that had a whole bunch of strokes, that had bleeds in their brain, that had uncontrollable epilepsy. Those would be the major brunt of the patients that I would see. Since COVID, a lot of those patients started to peter out from our population just because patients stopped coming into the hospital as a result of having concerns of COVID and things like that. That's another thing that has been brought up in the literature as well as the media. But one of the things that we've seen is a lot of issues with COVID within the hospital population.

Cassandra Holloway:

Sure. So I'm just going to launch right into the million dollar question here that I think as we learn more about the virus and and we see all of these different symptoms and conditions that it can cause, but I think it's interesting because we know that COVID-19 is a respiratory illness. So ultimately, how does a respiratory virus cause damage to our brain and nervous system?

Dr. Pravin George:

That's a very good question. So this coronavirus, it really enters the body and this is what we're starting to understand more and more is that it enters the body through the respiratory system. But what starts to happen is, is as it enters, it starts to cause more of a systemic problem for us. There are several different ways that coronavirus can actually affect the brain. The first way is that it can enter the body. It can cause this very bad respiratory illness. And in causing a bad respiratory illness, what starts to happen is, is that your body stops being able to take in as much oxygen. Your brain is very, very dependent upon oxygen as you can imagine. More than 80% of the blood that you actually pump from your heart that's oxygen goes to your brain. And it's very important that it gets all of that oxygen because it needs oxygen second to second.

              What starts to happen in a lot of these coronavirus patients that have very bad respiratory disease is that that amount of oxygen starts to drop that goes to their brain. And if that happens for long enough, you can start to have what's called hypoxic ischemic injury to your brain, which means that a lot of the brain tissue that normally is responsible for getting a lot of the oxygen and for the activities, for you to remember things, for you to be cognitively aware, all those brain tissue starts to get affected by this low levels of oxygen. And as that continues to happen, then you start to have longer lasting effects. We're starting to realize is one of the first feelings of this is a delirium where you're not fully aware of what's going on and you start to act in an abnormal way.

Cassandra Holloway:

So I read a little bit about these neurological conditions. You mentioned delirium was one of them. What other examples are there? Are there severe cases of it? Is delirium a severe case? Are there more mild symptoms? Walk us through what specific conditions besides delirium that you're seeing.

Dr. Pravin George:

So delirium is one of the first manifestations that we're seeing from this hypoxic damage, this hypoxic ischemic damage. Just recently a study was done on some of the patients that had actually passed away from COVID-19, and they looked at their brain just to get a feeling as to what was happening to these patients. And they saw evidence all throughout of this hypoxic ischemic damage throughout. So that is very concerning because a lot of these patients were not starting to wake up, and a lot of these patients started to have worsening and worsening damage to the brain. So depending on how severe the illness is, you can have a differing amount of damage as well as symptoms from that damage. COVID-19 then also has this other ability to attack your brain cells directly as well.

              So the first way that I was mentioning was this hypoxic ischemic damage where the lungs don't produce enough oxygen towards the body just because it's being affected by the virus. But then what happens is, is you can actually start to attack the brain ... sorry, the coronavirus can actually start to attack the brain in itself. And what it does is, is that same ACE receptor that's responsible for the coronavirus attaching to the lung tissue is actually expressed on several areas of the brain, and those areas deal with autoregulation of your blood pressure and autoregulation of your respiratory drive and your alertness centers and things like that. And when the coronavirus starts to attack those areas, it's starting to be theorized that those could be in relation to why the coronavirus is actually causing more delirium and potentially coma in some of these patients.

              The other thing that coronavirus also seems to do is cause a systemic inflammation, and this is seen several days and weeks out into the disease process, and these are in that severe case patient population. And what starts to happen is this inflammation takes over all throughout the body and it causes you to become very, very hypercoagulable, which means that you start to clot in all of your organs. We saw that originally in the lung. So a lot of people had a pulmonary embolism. We saw that in the kidneys and people would start to lose function of their [inaudible 00:08:05].

              We started to see this in the brain as well, and so people started to have strokes. Those strokes came in both varieties in which patients would come in and they would have what we would call microthrombosis. So little clots all throughout the brain, and this would cause a big function of delirium, and then we would see patients that would have micro-clots that would turn into bleeds. So then they would have bleeding inside the brain as well. So you'd see both bleeding and clotting in the brain at the same time. So this is why neurologists and especially neurointensivists were getting very involved in the management of these patients because we started to see these neurological complications.

              The other manifestation, and we saw this at the Cleveland Clinic, was that some of our patients really started to have seizures as a result of this. And we started to recognize that a lot of this was probably due to a direct inflammatory process that was happening because of the COVID-19 disease process in itself.

Cassandra Holloway:

Yeah, absolutely. So since the beginning of this pandemic, it's really been brought to everyone's attention that those most at risk are those with the underlying chronic medical conditions. Are you in your practice seeing that a lot of these patients who are experiencing these neurological effects, the seizures, the delirium, the brain inflammation, are you seeing that a lot of them have underlying conditions? Is it just the older patients? Is it just the younger patients? Walk us through who is most at risk for this?

Dr. Pravin George:

Absolutely. So the patients that are at risk for more severe disease for good or for bad, it seems to be that the majority of the patients having a severe disease are in the older population. It's in the patient population that has more medical comorbidities. The two medical comorbidities that seem to be playing the biggest role in this seem to be obesity and some kind of prior respiratory illness. So if you have one of those two issues, then you have a higher chance of having the severe disease. But obesity for whatever reason seems to be a very big player into this. And it seems to be that there is also this ACE2 receptor on a lot of the fat tissue in your body, and it could be that the coronavirus is actually starting to cause some inflammation as a result of that as well, causing more systemic inflammation. That's still being looked at as one of the primary players in the severe COVID-19 population.

              But out of those patients that are starting to pass away from this disease, it seems to be that we're really seeing it in the elderly population and those with more risk. And so the thing is, is that once you start to fall into that more severe population, those are also the patients that are also starting to have more of these other manifestations, whether that be delirium or strokes or seizures. Those are the patients that we're really starting to see all of these complications in.

Cassandra Holloway:

Sure. So I want to pick your brain about a topic that we keep seeing coming up in the news and on websites about these "coronavirus long haulers," the people who have had the virus and they've recovered from it and they're still experiencing symptoms two, three months after the fact. A lot of them are just saying that they're very fatigued. They're constantly worn down. They're very tired. They have muscle pain. Is this something that your practice sees, that neurological manifestation of the long-term symptoms? Is that something that you're involved with at all?

Dr. Pravin George:

So that's a great question. We've seen a lot of long-term issues with the coronavirus. A lot of it stems from long-term effects of any kind of illness. So let's say you were to break a bone, that arm doesn't feel as good as it did prior, and you will have long lasting effects from that. When you take a systemic virus, something like the coronavirus that affects the lungs, then it starts to affect the heart and the kidneys and the brain itself. You start to see systemic effects of such things and the recovery from something like that in some patients, especially with those with severe disease, it'll last for a longer time.

              Now, some of these patients, and we're starting to see this more and more often, the ones that have this hypoxic ischemic damage or hypoxic ischemic injury in the brain, you're going to see very long lasting effects just because the brain effects, some of those are irreversible, and some of those actually take a long time for the brain to actually rewire itself. The brain does and it has the innate ability to rewire itself, which is one of the primary reasons why so many people do well after a stroke or a bleed or something like that. But when a patient has something like the coronavirus, and it's a slow deterioration of brain tissue, it takes a longer time sometimes for the brain to get better from something like that. It can take weeks, months, potentially even years. We're not sure yet as to that, but we're still following up on some of those patients.

Cassandra Holloway:

I imagine it's also so frustrating and scary for these patients who have recovered and they're still experiencing these symptoms. It's got to be emotionally and mentally taxing as well.

Dr. Pravin George:

Absolutely. I mean, a lot of the patients that we've seen are suffering from that hyper and hypoactive delirium. And we've had several patients here with a hyperactive delirium component, which is really you start to hear auditory hallucinations. You can actually see visual hallucinations, those kinds of things. And you can imagine how terrifying that can be at some point and realizing that you're actually having manifestations of this disease. The hypoactive component is also it's a harder to treat one because we don't have any really good medications for it at all. I mean, at least with the hyperactive, sometimes we can give a couple of medications that can help out with some of those manifestations. But hypoactive, we start to see patients withdraw themselves, and that can be very, very long lasting. And these patients start to really fall out from our community. They don't want to talk anymore. They're unable to talk at some points. And so those patients, we really have to follow up on them to make sure that we give them all of the supports that they need to come back into it.

Cassandra Holloway:

Absolutely. I love that call to action with support. So making sure that your physician is involved in your care, making sure your patients have the resources that they need, if it's speaking to someone, if it's therapy, just making sure you have that relationship and support system for this as if the pandemic wasn't stressful enough with the scary virus and all the other negative stuff that comes along with it.

Dr. Pravin George:

Yeah, absolutely. I mean, the scary thing that we're seeing is that in any particular population of COVID patients, especially in the severe patient population, we're starting to see that the numbers of people with delirium, whether it be hypoactive or hyperactive, is nearing that 65 to 75% of patients. So two out of three almost with this severe disease are actually having this kind of thing.

Cassandra Holloway:

Yeah. Absolutely worth mentioning, worth getting this information out there for sure. So I want to talk a little bit about the symptom that I think has been around since the beginning of this, the new loss of taste or loss of smell symptom that we've heard about. I think it's really interesting. Do we know what causes that? Is there some sort of neurological link in there somewhere?

Dr. Pravin George:

So that's a great question. People have seen this ever since the virus was back in China mainly, and it was reported I think first in neurological papers back from its days in Wuhan. But basically what starts to happen is, is as the coronavirus enters through the respiratory tract, it does affect the lungs when it gets down there. But there's some concern that the ACE2 receptors that are right there in the nasal area, right in that nasopharyngeal area, that's the area where we test with those swabs. There are a lot of neural tissue there and brain tissue that's right there. And that's what's responsible for a lot of your smell and your taste ability.

              What can happen is, is that you have those ACE2 receptors right there on some of those brain cells, and there's some concern that the coronavirus enters through that mechanism. It enters some of those cells and it potentially can either cause inflammation to those cells right there in the brain tissue, and once that inflammation starts to happen, you start to lose a sense of smell. You start to lose that sense of taste. And then as that goes into your brain stem, it can cause some of those neurological effects of COVID-19. So that's one of the first things that we've started to realize about it. And because so many patients have had this anosmia and ageusia, the inability to smell and the inability to taste, that got added to our list of primary symptoms of COVID-19.

Cassandra Holloway:

So the last thing I want to talk to you about here, Dr. George, is prevention. What can listeners do to help protect themselves from getting COVID-19 first and foremost, which can ultimately turn into these negative neurological issues? What parting advice do you have for our listeners?

Dr. Pravin George:

Right. So the biggest thing, and we've seen this time and time again, the best way to really prevent yourself from getting it is frequent hand washing, I mean, because it lives on surfaces. So if somebody sneezes on a surface or coughs on a surface or talks by a surface and some of their droplets get on that surface and you touch that, you now have it on your hands. So frequent hand washing is similar to when the flu is out, that's one big way. The other thing is, is staying away, that six foot distance from other people. Because prior to getting it, and the whole thing about COVID-19 is that it takes about six or seven days to actually start to recognize any type of symptoms. So people could be out at your barbecue, they could be having fun, doing whatever, they may have been exposed to somebody. All of a sudden, you could be exposed to somebody that is presymptomatic.

              So basically staying more than six feet away is generally a good thought as of the time of this whole pandemic has gone on because it's actively spreading. Staying more than six feet away does ensure that when they're talking to you, when they're coughing or sneezing and things like that, all of those droplets don't get to you because you're far enough away. And that's where that six feet comes from. Then the whole thing about wearing a mask is going to be very important. The reason for mask wearing is really just to cover yourself from spreading those virus particles, and that lets you spread it less than six feet, obviously. So when you're starting ... Because people don't want to be away from or people can't be away from everybody six feet all the time.

              I mean, we're very densely populated, as you can imagine. So walking by people, walking through a city, walking through a building, especially when you're indoors, I mean the ability to just aerosolize some of these particles if you're presymptomatic is very, very high. And so what you would want to do is you'd want to wear a covering just to make sure that you're not spreading it out to other people. Getting the disease through a mask, I mean, is also found to be a little bit reduced from that as well. So depending on the type of mask and things like that, you can reduce your risk as well of getting it if somebody else releases their droplets by wearing a mask in some ways as well. So those are helpful.

              If you're in the healthcare environment, you work in healthcare or something like that, I mean, depending on the type of environment that you work in, if you're working around patients constantly, or if you're working in high risk units, I mean, you would have to wear different types of protective equipment and we call that PPE. But I mean, depending on the type of environment that you're working in, you would want to upgrade some of that equipment, and those are all up to the managers in those areas because that's really, I mean, the most looked at type of thing.

              As of right now, there are ongoing studies looking at some of what we should be wearing and how we should be wearing what we're wearing. But the thing is, is that there's a lot of debate out there because the solid data is not out there yet. So once that is there, I think we'll start to have a lot of this debate end. But I think as far as it goes right now, we have seen, and it's been pretty solid in the evidence showing that social distancing, so keeping at least six feet apart from everybody, and then wearing masks seems to be the best way to really prevent spread of this.

Cassandra Holloway:

Sure, absolutely. It's kind of like the golden rules of the pandemic now, wear your face mask, social distance, don't touch your face, wash your hands. But I think it always bears repeating just because our listeners are out there. We got to make sure that everyone's together in this for sure.

Dr. Pravin George:

Yeah, absolutely. Children as well. It seems like people are looking into how we can prevent ourselves from touching our faces while you bring this up. One of the things that a lot of people are noticing is that when they are wearing a mask, they're drawn to touching their face, they're drawn to adjusting their mask a lot. It's been a social faux pas to do things like that and to not do that. So we have to try and work on that as well. Some people have found that wearing a face shield helps a little bit just because it blocks you from being able to touch your face. So that may be a benefit to the community as well on top of wearing masks. It seems to help in that.

              I think going out from here, a couple of the things that we really need to do is follow up with some of these patients also. So some of the people that have COVID-19, especially with the severe disease and some of these patients that have had a lot of the neurological complications, just looking into how they're doing, following them up, making sure that we have clinics for them so that we can follow them up in neurological clinics. I think that's going to be very, very important. We at the Cleveland Clinic are setting those type of things up as well to make sure they're not lost to follow-up.

Cassandra Holloway:

Absolutely. Again, yeah, just making sure that the patients have the resources, the relationship is there and people are getting the care they need for sure, to help them through this crazy, crazy time. So Dr. George, I want to give our listeners some parting advice, especially those who have previous or prior neurological conditions such as MS or Parkinson's, or maybe they're already taking immunosuppressant medications. What advice do you have for them in this time of COVID-19 in still continuing to take their medications and seeing their provider? What advice would you give to them?

Dr. Pravin George:

I think the most important thing to take back regarding this whole thing, even in the setting of this huge pandemic, is that it is very, very important to continue your medical care. If you have a stroke, or if you're having a stroke and you're having stroke-like symptoms, don't avoid coming to the hospital. It's very, very important to get care. In the hospital, like I said, we do still take care of both strokes as well as COVID at the same time. In our patient population, we have seen brain tumor patients come in with COVID and without COVID and we're taking care of them. We're taking care of the patients that have COVID and a brain tumor as that, and so we're treating them with both of the medications that can potentially help both. It's something that's a new reality for us, and so that's why we're taking it to our patients, and we're able to offer them the care between both at the same time.

              It's very important as far as if you have any movement disorders, I mean, MS, we actually just did a recent study ... there was a study that was just recently done showing that MS patients were actually not at a higher risk of developing further severe disease from COVID-19 as a result of having MS or being on their MS medications. These are all reassuring things, especially for our neuro population. Brain tumor patients, they're doing fine with or without the disease process. And if you have COVID-19 and you have a brain tumor, we're able to go forward with your therapy for both the brain tumors and all the immunosuppression that comes along with it, as well as treating it for the COVID-19 type of things. But yeah, no, those are the major things. I mean, obviously if you have any kind of a stroke-like symptoms and it's related to COVID, we lump you into the severe COVID potential population, and we start treating you with the medications that we know are more therapeutic for the severe disease.

Cassandra Holloway:

All right, Dr. George, thank you so much for taking the time out of your day to speak with us. You've offered so many great advice and insight onto this neurological conditions that we're seeing with COVID-19. So thank you for taking the time to speak with us.

Dr. Pravin George:

Definitely. Thank you for having me. This has been a great experience.

Cassandra Holloway:

For the latest news about COVID-19, visit clevelandclinic.org/coronavirus. If you want to listen to more Health Essentials podcasts featuring experts at Cleveland clinic, subscribe wherever you get your podcasts from or visit clevelandclinic.org/hepodcasts. Don't forget, follow us on Facebook, Twitter, and Instagram @clevelandclinic, all one word, to stay up to date on the latest news and information about coronavirus as well as your own health and wellness. Thanks for listening and stay safe.

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