Multimodal Neuroimaging in Port-COVID Syndrome and Correlation with Cognition

Seminar Report.

Name: Aradi Tiyasha Wickramasinghe Arachchige and Bailey Loft

Student Id: 104089728 and 102098803
Due Date: 30th May 2024 (9.00am).
Word Count: 2135
 Covid-19 which is caused by the virus SARS-CoV-2 virus has profound long-term impacts
resulting in Post-Covid Syndrome (PCS) (Long COVID, 2023). Post-COVID syndrome
which is also known as long-COVID involves the continuation and development of
symptoms like fatigue, anosmia, and pain, 3 months after the initial infection of COVID
(Long COVID, 2023). Among those who recover, 10-20% experience long-COVID, with one
of the most concerning symptoms being cognitive dysfunction (WHO, 2021). As past
research has elaborated, the virus can cause inflammation in the brain decreasing the blood
brain barrier leading to detrimental changes in the brain (Reiss et al., 2023). For example,
cognitive decline can be observed due to changes in areas like the hippocampus that
experience decline in the hippocampal neurogenesis, and enlargement of the cingulate gyrus
(Nouraeinejad, 2023; Lu et al., 2020). Even though past literature has highlighted
physiological impacts of long-COVID on the brain few studies have conducted
neurophysiological assessments exploring cognitive decline through a wide range of
perspectives like attention, memory, and executive functioning. Moreover, lack of studies has
illustrated the relationship between brain damages and cognitive decline.

One aspect that has not been explored enough through past literature, due to the novel
nature of long-COVID, are the alteration taking place in the brain especially the changes in
grey matter volume (GM), white matter (WM), and presence of white matter hyperintensities
(WMH). Among the limited studies conducted, one study that assessed changes in volumes of
the brain using AI-based MRI volumetry, demonstrated significant reduction in brain volume
specifically in the grey matter, white matter, frontal and parietal lobes (Zeynep Bendella et
al., 2023). In contrast, other studies have outlined increased grey matter volumes in several
regions of the brain when measuring GM volume using 3T-MRI scans (Besteher et al., 2022)
This highlights that further research employing a different methodology is required to assess
the changes in GM, WM, and presence of WMH.

Another change that has been observed in some studies related to the impacts of long-
COVID on the brain are changes in functional connectivity (FC). Past studies have
demonstrated significant enhanced functional connectivity changes in the basal ganglia and
precuneus networks which could explain changes in cognitive functions like speech among
PCS patients (Hafiz et al., 2022). As demonstrated through past literature functional
connectivity is often associated with changes in grey matter and white matter volume,
however, it is unclear whether this connection is persistent even among PCS patients, as
rearrangements of FC have been observed after exposure to COVID (Zhao et al., 2019; Yao et
al., 2023). Building on the existing literature this study employed three major aims; firstly, it
aimed in evaluating the changes in functional connectivity of the brain among PCS patients.
Secondly, it aimed in exploring whether changes in functional connectivity was accompanied
with changes in grey matter or white matter alterations. Finally, the study aimed in exploring
the relationship between functional and structural changes in the brain and cognitive decline.
As past research demonstrated contradictory results when assessing similar aims using one
specific measure like resting state MRI, the present study decided to employ a multimodal
neuroimaging system (Besteher et al., 2022). This can be considered as a strength of the study
since limited studies have used a multimodal neuroimaging system to assess the changes in
the brain of PCS patients. Moreover, a multimodal neuroimaging system improves both
spatial and temporal resolution and effectively helps to explore the anatomical changes in
functional connectivity helping to address the aims of the study.

While the above literature explains the rationale for the study, the current research addresses
several gaps in literature such as lack of multimodal neuroimaging assessment, lack of study
on changes of the brain in PCS patients and its relationship to cognitive decline. The
following study could inform better treatment strategies and bring awareness about the
potential cognitive impairments among PCS patients helping to opt for early intervention
mechanisms like mental activities, physical exercise, and changes in dietary (Shariff et al.,
n.d).

Method

Participants

The study included a PCS group and a healthy control group. The PCS group consisted of
86 participants with cognitive complaints recruited through the Department of Neurology at
Hospital Clinico San Carlos between November 2020 and December 2021 and were recruited
based on an inclusion and exclusion criteria. The health control group consisted of 36 healthy
individuals who had no exposure to SARS-CoV-2.

Materials

The inclusion criteria for the PCS group compromised of COVID-19 diagnosis by
polymerase chain reaction (PCR) with reverse transcription at least 3 months before the study
and cognitive complaints due to long-COVID. Exclusion criteria for the PCS patients were:
cognitive complaints prior to COVID-19, history of stroke, traumatic brain injury, other
neurological disorders associated with cognitive impairment, active psychiatric disorders or
previous psychiatric diseases with potential cognitive effects, history of alcohol or substance
abuse, drugs or uncontrolled medical conditions affecting cognition at the time of assessment,
sensory disorders biasing cognitive assessments, and deep white matter (WM) cerebral small
vessel disease.

Clinical evaluations used scale measures for fatigue, anxiety, depression, smell, and sleep
quality. Neuropsychological assessments included tests for memory, attention, executive
function, visuospatial abilities, and language. For the neuroimaging acquisition, resting-state
functional MRI, T1 weighted images, T2 flair and diffusion weighted images (DWI) were
obtained. MRI and T1 images helped to assess GM, WM, and FC in the brain, 3D fair
evaluated white matter changes and white matter lesion, and DWI changes in white matter.

Statistical Analysis

Statistical analyses were conducted using SPSS v.26. The normality of data was assessed
using the Kolmogorov–Smirnov test. For sociodemographic, clinical, and cognitive
characteristics, Mann–Whitney U-tests were used for quantitative data, and chi-squared tests
were used for categorical data.

Demographics

Data on age, sex, educational years, health data and vaccination status were also collected.

Procedure

Clinical and neurophysiological assessment was conducted on the PCS group and then all
the 122 participants were scanned for the resting-state functional MRI, T1 weighted images,
T2 FLAIR images and the diffusion-weighted images. Only 2 controls were excluded due to
differences in the diffusion-weighted imaging parameter acquisition. Written consent and
approval from Hospital Clinico San Carlos was obtained.
 Results

Clinical and neurophysiological characteristics.

Table 1 shows the mean, standard deviation, and percentage prevalence for the clinical
profile of PCS patients.

Table 1

Mean, standard deviation, and percentage prevalence for the clinical profile of PCS patients.

Condition Mean (SD) Percentage %

Fatigue 53.76 (15.19) 82.4

Depression 14.42 (8.94) 27.1

Sleep quality dysfunction 9.71 (4.73) 82.1

Olfaction problems 9.12 (2.36) 32.9

Anxiety symptoms 21.36 (11.90) 9.3

Note. Mean age for the PCS group was 50.71 and 67.44% were females.

Cognitive impairment was observed in the attention and working memory, memory,
visuospatial ability and language.

Brain alterations.

Functional connectivity.

Reduced FC was observed between left and right parahippocampal gyrus and reduced
connectivity in the left cerebellar vermis to the left and right frontal superior orbital cortex
compared to controls.

Grey matter volume.

Reduced GM volume in parahippocampal gyrus, frontal gyrus, anterior cerebellar, occipital

lobe, and bilateral superior temporal lobe compared to controls but this was not statistically
significant.
White matter hyperintensities.

No significant difference in WHM total lesion volume and number of lesions compared to
controls. However, when age was controlled a significant increase in both the factors was
observed (P< 0.001).

White matter alterations.

PCS patients had decreased mean and axial diffusivity in the corpus callosum, forceps
minor, middle longitudinal fasciculus, uncinate tract, and fronto-occipital fasciculus (P<0.05,
FWE corrected). These mean diffusivity alterations were primarily in the right hemisphere,
whereas axial diffusivity changes were bilateral, affecting frontal, temporal, parietal,
occipital, and subcortical regions. There were no significant variations in fractional
anisotropy or radial diffusivity between the groups in individual tracts. In addition, PCS
patients had lower whole-brain mean values for fractional anisotropy, mean diffusivity, radial
diffusivity, and axial diffusivity compared to controls.

Cognitive and brain correlation is PCS group.

GM changes significantly correlated with cognitive dysfunction. There was a positive
correlation between GM changes and memory and visuo-spatial performance. Strong
correlations were observed between attention and processing speed and FC changes.

Hospitalised vs Non-hospitalised.
29 patients were hospitalised, and they showed greater cognitive decline compared to non-
hospitalised patients. Hospitalized individuals demonstrated distinct brain changes compared
to non-hospitalized patients, with impaired functional connectivity between the left and right
parahippocampal areas and lower grey matter volume in the superior temporal gyrus, frontal
areas, and cerebellum. Additionally, they demonstrated enhanced white matter mean
diffusivity.

There were no statistical differences between vaccinated and unvaccinated participants.

 Discussion.

The first aim of the study was to evaluate FC changes in the PCS patients. According to
the results of the study there were reduced functional connectivity in several regions of the
brain including the orbitofrontal and cerebellar areas. This aligns with findings of previous
research which showed reduced functional connectivity in the hippocampal and cerebellar
regions (Philippe Voruz et al., 2022) and longitudinal studies which demonstrated reduction
in FC in orbitofrontal and parahippocampal areas (Douaud et al., 2022).

The second aim of the study was to evaluate whether FC were accompanied by GM and
WM structural changes. The results of the study demonstrated that FC alteration was
associated with reductions in WM diffusivity. This change was widespread in the lateral
region of the right hemisphere. Even though past literature has mentioned association of FC
and GM, results demonstrate an increase in diffusivity rather than a decrease which was
observed in the current study (Zhao et al., 2019).

The third aim of the study was to determine the relationship between these structural
changes in the brain and cognitive decline which is often observed among PCS patients. The
results demonstrated significant relationship between changes in functional connectivity in
the brain and cognitive decline. There was also an association between changes in grey matter
and performance in cognitive tasks. This is supported by past literature which shows that
damage to orbitofrontal and cerebellar areas result in decline of learning memory (Duarte et
al., 2010).

The methodology used in this study demonstrates several limitations that need to be
addressed. The study employs a cross-sectional design with absence of neuroimaging or
cognitive data prior to COVID infection. This means that the study can only draw
comparisons compared to the control group with inability to determine whether these were
pre-existing conditions or results from COVID. Another significant limitation in the
methodology is that the study did not evaluate any cognitive or mood aspect of the control
group. Without assessing this aspect, it is difficult to determine whether the changes observed
in the study are solemnly due to COVID or due factors like anxiety or depression which
could also result in structural changes of the brain (Han & Ham, 2021). This limitation limits
the validity and generalizability of the results as the study cannot isolate the impacts of
COVID-19. Another limitation of this study is the lack of variability in the sample. The mean
age of the PCS sample was 50.71, raising the question whether the outcomes observed part of
the aging process. Additionally, the study does not assess cognitive impairment in relation to
pre-morbid functioning. The study does not use any methodology to assess the observed
cognitive decline against previous cognitive ability challenging the assessment of impact of
COVID on cognitive decline. Finally, the study does not consider potential comorbidities like
diabetes, in the exclusion criteria that may exacerbate the consequences of COVID and
structural changes in the brain (Moheet et al., 2015).

Future studies may consider the following suggestions, a longitudinal design would help to
assess whether the observations obtained through the study are persistent. Next, future studies
could collect neuroimaging data from databases to understand the structure of the brain prior
to COVID. Followingly, they could employ a sample of health controls, COVID-19 patients
with several co-morbidities, and COVID-19 patients with few co-morbidities to address the
possible effect of co-morbidities in structural changes of the brain. Next, a comprehensive
clinical and neurophysiological assessments could be done on all the 3 samples. Another
suggestion for future studies is increasing the sample size of hospitalised patients as they
underwent severe cognitive impairment, hence observing a larger sample of hospitalised
COVID-19 patients would provide greater insight on the effects of COVID. Finally, the study
could be applied to different age categories and contrasted to see whether changes in the
physiology of the brain are due to COVID-19 or due to biological process like aging.

In conclusion, the current study aimed in exploring the functional changes in the brain and
see whether it was associated with white matter and grey matter changes. The study also
aimed in identify any relationship between cognitive decline and functional and structural
alterations in the brain. Even though there are several observations, the study is limited in
several ways as discussed before highlighting the need for further studies that would address
the limitations of the current study.
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