Neurological and Neuropsychological Sequelae of COVID-19 Infection

Study Overview
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Brief Summary
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COVID-19 is known to affect the respiratory system but may also have an impact on other organ systems, including the brain. A number of severely ill patients also presents neurological symptoms that may be the result of COVID-19 associated brain damage. The aim of this study is to investigate the presence, type, and severity of brain damage as well as the neurological and neuropsychological sequelae of COVID-19 infection. Further, the impact of this infection on daily life functioning, quality of life, and the emotional well-being of family members will be assessed. In this multicenter study, 6-9 months after hospital discharge patients will undergo a 3-T MRI scan and a neuropsychological examination. Additionally, both patients and their family members will answer several questionnaires at 6- 9 and 12-15 months after hospital discharge. COVID-19 patients previously admitted to a general hospital ward will be compared with patients previously admitted to the intensive-care unit. The proposed study will create a more comprehensive picture of the prolonged COVID-19 effects on the brain, mental, and cognitive well-being. The findings will aid patient care and rehabilitation.

Detailed Description
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Coronavirus disease 2019 (COVID-19) is an infectious disease caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV2). COVID-19 primarily affects the respiratory system. However, in severely ill patients damage is also reported to other organ systems including the heart, the kidneys, the circulatory, and gastrointestinal system. Further, research indicates an impact of the virus on the brain and, thereby, on cognition. Patients experience neurological symptoms, MR imaging implies the presence of brain abnormalities, specifically in severely ill patients and studies on cognition suggest problems with memory, attention, information processing and executive function. Preliminary clinical data also show that COVID-19 is associated with neurological and neuropsychiatric illness. Brain damage and therefrom resulting emotional and cognitive deficits in ICU-treated patients are not uncommon findings. Post-intensive care syndrome (PICS) summarizes physical, cognitive, and mental impairments associated with ICU admission. PICS is assumed to be induced by a combination of patient-specific (e.g., psychiatric history), disease-related (e.g., hypoxemia), and ICU factors (e.g., invasive procedures). These factors can cause a variety of pathophysiologic states including atrophy, encephalopathy, and neuropathy, eventually leading to impairment and reduced quality of life. Additionally, ICU-admission has been found to also affect the mental health of patients´ family members (PICS-F). Many of these PICS-inducing factors can be assumed to occur during severe COVID-19 illness and treatment. Therefore, it is likely that COVID-19 patients and their family members exhibit PICS symptoms. To date, it is not known to what extend COVID-19 related brain injury and therewith associated symptoms are present after the (sub)acute stages of illness and whether this will lead to long-term deficits in function. Further, it is to be determined whether COVID-19 patients develop PICS syndrome and if so, whether the therewith associated symptoms are limited to ICU-treated patients or may generally affect the broader group of hospitalized COVID-19 patients. The aim of this research is to fill these gaps in research through: (1) the identification of COVID-19 related brain abnormalities, cognitive impairments, and emotional deficits after the (sub)acute stages of illness (i.e., 6-9 months post-hospital discharge), 2) a comparison of COVID-19 related brain abnormalities, cognitive impairments, and emotional deficits to historical PICS cohorts 3) a comparison between COVID-19 ICU survivors and COVID-19 non-ICU patients in order to assess a potential PICS gradient and 3) a follow-up examination of the aforementioned groups 6 months after the first assessment to gain insight into the persistence of deficits.

Official Title
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Neurological and Neuropsychological Sequelae of COVID-19 Infection

Conditions
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COVID-19 Infection

Intervention / Treatment
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* Diagnostic Test: MRI
* Diagnostic Test: Neuropsychological assessment
* Diagnostic Test: Questionnaires Patient
* Diagnostic Test: Questionnaires Family


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patients: Objectified COVID-19 infection for which ICU or non-ICU hospital admission was necessary at one of the participating hospitals Age > 18 years Sufficient command of the Dutch language to follow test instructions and understand questionnaires Informed consent. Family members (if present): Within the scope of this study, the term family member will be defined as a person who has good insight into the patient´s daily life functioning (before and after COVID-19 infection). This person can be the spouse, partner, adult child or, in some cases, another individual that plays the most significant role in the patient´s life. The patient will decide who this family member is. We will check the following criteria: Family member of a participant with COVID-19 infection as described above; Requires participation of the aforementioned family member as COVID-19 patient Age > 18 years Sufficient command of the Dutch language to understand questionnaires Informed consent. Exclusion Criteria: Patients: objectified cognitive impairments before the hospital admission for the COVID-19 infection an unexpected incident leading to severe neurological damage occurring after hospital discharge (such as stroke or traumatic brain injury) contra-indications for MRI scanning (e.g. metal implants, cardiac pacemaker, claustrophobia, pregnancy). Family member: no exclusion criteria.
Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| COVID-19 non-ICU patients<br>Patients who were admitted to one of six recruiting hospitals in the Netherlands due to COVID-19 during the first patient wave (march-june 2020) and who were not admitted to an intensive care unit. | Diagnostic Test: MRI<br>* 3T cranial MRI with T1-, and T2 weighted imaging, a FLAIR sequence, diffusion-weighted imaging and susceptibility-weighted sequence<br>Diagnostic Test: Neuropsychological assessment<br>* Montreal Cognitive Assessment (MoCA), Rey-Auditory Verbal Learning Test (RAVLT), Trail making A/B, Stroop, Digit Span Coding, Judgement of line orientation (JOLO), Boston Naming Task (BNT), Controlled Oral Word Associations Task (COWAT), Category Fuency, Test of Memory Malingering (TOMM)<br>Diagnostic Test: Questionnaires Patient<br>* EuroQol-5D-5L (EQ-5D-5L), Utrecht Scale for Evaluation of Rehabilitation-Participation - Restrictions (USER-P-R), NeNeSCo-Q (questionnaire created for this study, including common neurological symptoms), Checklist for post-IC cognitive complaints (CLC-IC self-report), Hospital Anxiety and Depression Scale (HADS), Primary Care Post-Traumatic Stress Disorder (PC-PTSD-5), Utrecht Coping List (UCL) (subscale passive coping), PROMIS physical functioning short form, Items of Insomnia Severity Index (ISI) & Pittsburgh Sleep Quality Index (PSQI), Fatigue Severity Scale (FSS), Social Support List (SSL-12-I)<br>|
| COVID-19 ICU patients<br>Patients who were admitted to one of six recruiting hospitals in the Netherlands due to COVID-19 during the first patient wave (march-june 2020) and who were admitted to an intensive care unit. | Diagnostic Test: MRI<br>* 3T cranial MRI with T1-, and T2 weighted imaging, a FLAIR sequence, diffusion-weighted imaging and susceptibility-weighted sequence<br>Diagnostic Test: Neuropsychological assessment<br>* Montreal Cognitive Assessment (MoCA), Rey-Auditory Verbal Learning Test (RAVLT), Trail making A/B, Stroop, Digit Span Coding, Judgement of line orientation (JOLO), Boston Naming Task (BNT), Controlled Oral Word Associations Task (COWAT), Category Fuency, Test of Memory Malingering (TOMM)<br>Diagnostic Test: Questionnaires Patient<br>* EuroQol-5D-5L (EQ-5D-5L), Utrecht Scale for Evaluation of Rehabilitation-Participation - Restrictions (USER-P-R), NeNeSCo-Q (questionnaire created for this study, including common neurological symptoms), Checklist for post-IC cognitive complaints (CLC-IC self-report), Hospital Anxiety and Depression Scale (HADS), Primary Care Post-Traumatic Stress Disorder (PC-PTSD-5), Utrecht Coping List (UCL) (subscale passive coping), PROMIS physical functioning short form, Items of Insomnia Severity Index (ISI) & Pittsburgh Sleep Quality Index (PSQI), Fatigue Severity Scale (FSS), Social Support List (SSL-12-I)<br>|
| COVID-19 non-ICU family members<br>Close family members of patients who were admitted to one of six recruiting hospitals in the Netherlands due to COVID-19 during the first patient wave (march-june 2020) and who were not admitted to an intensive care unit. | Diagnostic Test: Questionnaires Family<br>* EuroQol-5D-5L (EQ-5D-5L), Utrecht Scale for Evaluation of Rehabilitation-Participation - Restrictions (USER-P-R), Checklist for post-IC cognitive complaints (CLC-IC proxy-report), Hospital Anxiety and Depression Scale (HADS), Primary Care Post-Traumatic Stress Disorder (PC-PTSD-5), Utrecht Coping List (UCL) (subscale passive coping), Social Support List (SSL-12-I), Caregiver Strain Index (CSI)<br>|
| COVID-19 ICU family members<br>Close family members of patients who were admitted to one of six recruiting hospitals in the Netherlands due to COVID-19 during the first patient wave (march-june 2020) and who were admitted to an intensive care unit. | Diagnostic Test: Questionnaires Family<br>* EuroQol-5D-5L (EQ-5D-5L), Utrecht Scale for Evaluation of Rehabilitation-Participation - Restrictions (USER-P-R), Checklist for post-IC cognitive complaints (CLC-IC proxy-report), Hospital Anxiety and Depression Scale (HADS), Primary Care Post-Traumatic Stress Disorder (PC-PTSD-5), Utrecht Coping List (UCL) (subscale passive coping), Social Support List (SSL-12-I), Caregiver Strain Index (CSI)<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in participation | Life participation (social, occupational, mobility) measured by the Utrecht Scale for Evaluation of Rehabilitation-Participation - Restrictions subscale (USER-P-R). The subscale consists of 11 items. Each item score ranges from 0 (not possible at all) to 3 (no difficulty at all), resulting in a total minimum score of 0 and a total maximum score of 33 points, with a higher score indicating less participation restrictions. | 1) 6-9 months and 2) 12-15 months after hospital discharge | 
| Change in patient quality of life | Quality of life measured by the EuroQol-5D-5L (EQ-5D-5L). The EQ-5D-5L consists of 5 items with 5 levels. The minimum total score is 5 and the maximum total score is 25, with higher scores indicating more problems. | 1) 6-9 months and 2) 12-15 months after hospital discharge | 
| Presence of MRI abnormalities | Presence or absence of MRI abnormalities assessed with a 3T cranial MRI scan | 6-9 months after hospital discharge | 
| Neurological symptoms | Measures with the neurological and neuropsychological sequelae of COVID-19 questionnaire (NeNeSCo-Q), a questionnaire that has been created for the purpose of this study to assess the most common neurological symptoms (e.g., reduced sense of taste and/or smell, headaches, neuropathic pain) experienced by patients infected with COVID-19. The questionnaire consists of 9 items being rated with present (yes = 1) and not present (no = 0), resulting in a minimum total score of 0 and a maximum total score of 9. | 6-9 months after hospital discharge | 
| Deficits in cognition | Deficits in general cognition are measured with the Montreal Cognitive Assessment (MoCA). | 6-9 months after hospital discharge | 
| Deficits in memory | Measured with the Rey's auditory verbal learning test (RAVLT) | 6-9 months after hospital discharge | 
| Deficits in visual attention & task switching | Measured with Trail Making Test A/B (TMT) | 6-9 months after hospital discharge | 
| Deficits in selective attention, cognitive flexibility & processing speed | Measured with Stroop Test | 6-9 months after hospital discharge | 
| Deficits in working memory, attention & executive function | Measured with Digit Span Coding | 6-9 months after hospital discharge | 
| Change in subjective cognitive complaints | Assessed with the Checklist for post-IC cognitive complaints (CLC-IC) | 1) 6-9 months and 2) 12-15 months after hospital discharge | 
| Change in depression/anxiety | Measured with the Hospital anxiety and depression scale | 1) 6-9 months and 2) 12-15 months after hospital discharge | 
| Change in post-traumatic stress symptoms | Measured with the Primary Care Post-Traumatic Stress Disorder (PC-PTSD-5) questionnaire | 1) 6-9 months and 2) 12-15 months after hospital discharge | 
| Change in family burden | Measured with the Caregiver Strain Index (CSI) | 1) 6-9 months and 2) 12-15 months after hospital discharge | 
| Change in family quality of life | Measured by the EQ-5D-5L. The EQ-5D-5L consists of 5 items with 5 levels. The minimum total score is 5 and the maximum total score is 25, with higher scores indicating more problems. | 1) 6-9 months and 2) 12-15 months after hospital discharge | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| MRI abnormalities (specific) | MRI abnormalities such as cerebral micro-infarctions / bleedings, and white matter hyperintensities. | 6-9 months after hospital discharge | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Neurological, Neuropsychological, ARDS, Coronavirus, Severe acute respiratory syndrome coronavirus-2, SARS-CoV-2, Infection, Inflammation