Dr MV PADMA SRIVASTAVA talks with KAUNAIN SHERIFF M about the evolving science around ‘long Covid’ and its impact on the brain, explains the difference between general post-Covid fatigue and severe symptoms that require a specialist, elaborates on the link between Covid and stroke and the biomarkers that can help anticipate it, and says not all headaches warrant an MRI.
Why Dr Srivastava: With many patients suffering from lingering health issues even after recovering from Covid-19 – including severe illness, severe headaches and brain fog – concerns about the “long Covid” have grown. As head of the Center for Neuroscience at AIIMS, Dr. Srivastava is at the center of the nation’s efforts to identify the reasons, impact and solutions to some of these long-term Covid-related health issues. The eminent neurologist is also known for starting the Acute Stroke Program (Code-Red), a medical initiative to support stroke and epilepsy patients.
We are learning about the “long Covid” as we go. What has science learned so far about the impact of Covid-19 on the brain?
A lot. But we don’t yet have all the answers to all the questions; it’s still a work in progress. The story is still ongoing. Still, I think we have definitive answers. If the question is, does Covid-19 affect the brain during the infection process and after the infection is gone? So the answer is a resounding yes.
But beyond that, the spectrum of how the brain and nervous system are affected during Covid infection, and even more so after infection – what is now called the ‘long Covid’ – which is an evolving science. There has been tremendous interest as well as research into how it affects the brain and nervous system… There is also a conundrum of mental health issues – which can influence how a patient may present their complaints – and what is the spectrum of illnesses that might be. So, in the long run, what it’s going to be, in terms of memory and degeneration, is still in the realm of research. From now on, very interesting information is collected. It’s a whole new platform. We have some answers as to how it would affect the brain during infection and also after infection.
We have brain scans of ‘long Covid’ patients in the UK who had very mild disease that reveal tissue damage and reduced gray matter. There is also evidence of brain shrinkage. Do we know if these results really mean anything for a patient’s quality of life?
At this point, I would say no. But again, I would go back to the disclaimer that this is still a work in progress. It’s actually that group that we’re trying to study over a period of time—six months, a year, two years from now. This research is not just in the UK or India. It is a multi-centric and multinational effort, which incorporates caveats of race, ethnicity and geographic uniqueness. This will help to better understand this spectrum.
Do they develop memory problems later, do they develop a degenerative disease? We do not know. Perhaps this assumption is wrong. But that being said, that’s what’s being looked at. At this point, however, this brain shrinkage means nothing. This does not mean that such a person will end up with a major problem. We have no evidence that they would be affected. The process of understanding is still ongoing. Maybe we will know a few years later.
Could these brain changes make Covid patients more prone to other neurological deficits or dementia in the future?
This is what is examined. Hopefully not. But the changes that occur clinically correlate with serial long-term assessments: do you continue to have headaches, do you continue to have memory problems? There are scales that have been developed to address these issues. There are certain clinical scales by which we will know if there are subclinical or very subtle memory problems. So we will know the answers later. It is very premature to say this now.
There are a few papers that suggest an association between Covid-19 and strokes, even in younger people. Can Covid-19 cause a stroke?
There is a vertical pathogenic mechanism that suggests that Covid-19 infection can cause increased clotting in the brain, and thus cause clots in the arteries and stroke. This has been seen in all areas, but generally in older people and in people with comorbid conditions such as diabetes, hypertension, and chronic smokers.
But there have also been case reports of young men, who had sudden clotting in large vessels causing strokes, with no other vascular risk factors. In fact, at AIIMS we have seen cases of people who had pneumonia or fever, and who had just had a stroke and tested positive for Covid. They had bleeding in the brain. There were ruptured blood vessels. Some of them didn’t even have blood pressure.
Now we have very large data coming in from New York and Europe. There have been groups that have looked at this big data and found that yes, Covid-19 caused a stroke. But in general, if you look at the whole spectrum, it doesn’t seem like a huge increase. It wasn’t like that was the only prevalent complication with Covid-19.
But what was important is that there are now ways to prevent this from happening. It has evolved. There were biomarkers… We found that if these levels are very high, we can anticipate things. We can institute a therapeutic mechanism like an anti-clotting drug and a tide on some cases.
We have also come up with some precautionary measures, in terms of how much physical activity one can do when inflammatory markers are high after Covid. All of these things have evolved and we can prevent these problems and make a person recover normally.
So when should you consult a specialist?
So let’s talk about headaches. Common migraine is an extremely common phenomenon. What is important to note is when the character of the headache changes. If I go out in the sun, or if I haven’t eaten, I have a headache; that’s not the thing. But if there is a change in frequency and intensity, consult a specialist.
Second, see if there is the onset of a new type of vertigo. When you’re recovering from a viral illness and feeling weak or tired, you probably need supplements. There is also body fatigue. For this, you can simply go to a general practitioner. But if the vertigo is such that every time you change your posture, you have a lot of palpitations, you feel dizzy and almost want to fall and lose your balance, then go to a specialist.
And if there’s kind of a general feeling that I’m not as sharp as I used to be; I forget things… Generally, when there are complaints of forgetfulness, we dig deeper. If you tell me you’re not as sharp as you used to be, you make a to-do list because you tend to forget. It’s usually not so much a pathological process. When this oversight impacts your daily life, especially financially, then you must contact a specialist. This mental fog is probably different.
Any kind of weakness, which is on one side, or anything abnormal in terms of loss of sensation, loss of power, loss of balance, then go to a specialist. Apart from that, you can be under the supervision of a general practitioner, and probably follow a course of supplementation, focus on nutrition, gradually increase your physical activity and maintain a positive attitude. It would help you get through the long Covid.
How do you deal with brain fog symptoms?
Brain fog is a very loose term. It’s basically a constellation of features that made you unable to perform those tasks or task sequences, or multitasking, or things you had taken for granted before. Or you don’t have the attention span, the foresight, or the insight to figure things out. It’s a kind of executive dysfunction, a kind of fog. Generally, it is associated with certain mental health issues and sleep problems.
First, if it impacts your daily life, go and consult because we may be missing something. Maybe you need tests or neuroimaging. Second, doctors may give you supplements in addition to your normal diet. Third, tips can hopefully help with the rest. Because the brain and the mind are so closely linked that it is sometimes difficult to tell them apart.
Fourth, a positive outlook. Be with friends, connect, sleep well, regulate your lifestyle. These things will surely pass away. It’s just a matter of time.
You mentioned neuroimaging. There are people who have brain MRIs. Is it necessary? What tests would you recommend?
I generally don’t recommend too much testing. There is really no point in going through expensive, high-level investigations for every case. Many Covid infections would probably do nothing at all. But when they have complaints, as I told you, some of the red flags that we just listed, the red flags where you have to go to a specialist… And when you actually go to a specialist, they can recommend neuro-imaging after you’ve been examined… For every headache, or every time you feel tired, you don’t need a deluge of tests; you don’t need an MRI at all. This is only for certain specialized situations when a problem has been detected.
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