Brain Scans Reveal Long-Term Neurological Effects of COVID-19

In the eight months since contracting COVID-19, 31-year-old artist Nora Lieberman knows the disease’s physical manifestations well: the memory loss, the migraines, the muscle aches, the fatigue, the nerve pain, the GI distress, and the breaths that never seem to find their way out. She falls into the first wave of patients who contracted the virus before there were enough tests to keep up with it; the “healthy, young, and fit” demographic who were told they would not get sick, only to paradoxically become the symbol of who may get the sickest. Or, at least, stay the sickest. 

This is Lieberman’s first self-portrait. And it is her attempt to capture what COVID-19 did to her.

“The symptoms are unrelenting,” Lieberman tells Verywell. “A big problem for me is the virus’s effect on the brain. The brain fog is insane. I can forget what I’m doing while I’m doing it. I forget what I’m thinking about while I’m thinking about it mid-sentence. I can’t watch TV or read anymore because I can’t focus or understand anything. It’s all too over-stimulating.”

At the beginning of the pandemic, doctors’ most pressing concern was keeping hospitalized patients alive, with the respiratory and cardiovascular sides of COVID-19 taking the spotlight. Stories of long-haulers like Lieberman were simply vignettes of neurological symptoms, with no data to quantify or explain them. Now, more researchers are looking beneath the surface, using scans and surveys to show how COVID-19 may be impacting the brain. 

Frontal Lobe Disturbances

The neurological impact of COVID-19 is complex and extensive. The disease can induce strokes, seizures, and hemorrhages. It can trigger symptoms such as memory loss, difficulty concentrating, headaches, speech aphasia, confusion, and dizziness in up to 80% of patients. 

Multiple theories account for why COVID-19 can impact the brain: direct viral entry, systemic inflammation, blood clots, cardiac arrests, and more. While the mechanisms are still being uncovered, new information may point to which areas are affected. 

A recent study published in the European Journal of Epilepsy analyzed the electroencephalogram (EEG) results of COVID-19-positive patients from 84 reports. An EEG records electrical activity in different areas of the brain, and in this case, detected abnormalities in the brain’s frontal lobe in over 600 patients—one-third of the people studied. 

“Frontal lobe damage can cause all of these symptoms that patients are complaining of. We call the frontal lobe the ‘master executor’ because it manages all the executive functioning of the brain,” Neha Dixit, PhD, a clinical neuropsychologist in private practice in Philadelphia, Pennsylvania, tells Verywell. “The frontal lobe is involved in behavioral self-control, connecting plans, ideas, and goal-oriented thoughts to behaviors, sequencing, abstract thinking, verbal fluency, initiating behavior, and the speed of thinking, processing, and fluidity of thoughts.”

Dixit describes the frontal lobe as the CEO of the brain, as it connects multiple brain areas and regulates almost all cognitive activity. Damage to this region can lead to personality and mood changes, attention deficits, memory issues, and communication dysfunction (particularly with regards to speech production, as the frontal lobe houses the main region responsible for speech, called Broca’s area).

The study found overall slowing in the frontal lobe, which could be indicative of potential brain damage. However, it gave no clear prognosis about whether or not this damage is permanent. Dixit says that if the findings are accurate, then recovery, or at least partial recovery, is possible.

“Our brains are amazing; they can withstand a lot," Dixit says. "If you think about a stroke patient who regained function in an arm that was limp when they first had a stroke or learned to talk again, it’s because of the plasticity in the brain—the brain’s ability to change and to withstand damage."

While Dixit can't predict for sure what outcomes will look like for COVID-19 patients with frontal lobe damage, she remains optimistic.

"Is a full recovery possible? I can never answer that question. But is recovery possible? Yes," she says. "Sometimes with cognitive rehabilitation, speech therapy, or other therapies, people can regain an amount of functionality even if they still live with the chronic effects of a brain injury. However, it doesn’t always go away, and depending on the injury, sometimes you can have permanent frontal lobe damage.”

Barbara Malamut, PhD, a neuropsychologist who diagnoses and treats the impact of brain disorders on cognition and behavior, says that with time and training, other regions of the brain can take over the function that was lost.

“Patients can practice certain skills so that they can strengthen parts of the brain that aren’t damaged," she tells Verywell. "They’re not regenerating new tissue in their frontal lobe, but they are reorganizing their brain. For example, language is something you can retrain, and even memory retrieval."

However, she says it’s too early to make any conclusions because more research is needed.

“This is completely unchartered territory. This virus is unlike any other virus, and the effects it has on the brain are unlike anything we've seen before with previous viruses,” she says.  

Oxygen Deprivation Patterns 

Breathing difficulties plague patients both in the acute phase of COVID-19 and in the months that follow. According to Dixit, even non-hospitalized patients like Lieberman who exhibit a low blood oxygen level for a prolonged period of time can develop brain dysfunction. This is known as hypoxia. 

Researchers at Massachusetts General Hospital were the first to assess this through a specialized magnetic resonance (MR) technique. They examined the brains of six COVID-19 patients and found similar metabolic abnormalities to those found in hypoxia. 

“Usually, the first area to be affected in hypoxia is the hippocampus (located outside of the frontal lobe). It is the most critical structure for memory and helps us learn, store, and recall information,” Malamut says. “The first and biggest complaint from patients with hypoxia usually involves memory—they have trouble remembering and learning new information—followed by difficulties with attention. If the oxygen deprivation is prolonged, then it’s likely that other brain structures can be affected.”  

Dixit says she sees this phenomenon in her practice in patients with respiratory illnesses such as chronic obstructive pulmonary disease (COPD). Sustained oxygen deprivation leaves patients more susceptible to mood disorders, depression, and memory complaints. 

“These kinds of pulmonary diseases can lead to this entire race of global cognitive changes like decreases in attention and speed of processing," Dixit says. "If we see that in people who have decreased oxygenation over time like with COPD or chronic asthma, then it’s possible that with COVID, you’re seeing that same kind of etiology where the body is not sending enough oxygen to the brain."

Uncovering this type of information is important because understanding the source of brain abnormalities in COVID-19 can aid in modulating treatment. 

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Potential Brain Aging 

Before COVID-19, Lieberman's life never stood still. Her full-time job as a nanny meant she was always physically active, and her artistic work meant she was often in front of a canvas, exploring her cognitive and creative side. Now, she says she is shocked when she remembers the things she was physically and mentally capable of doing—they’re completely unimaginable now. Though she was only 30 when she contracted the virus, she feels like it has aged her in a way her self-portrait can’t portray. 

And she might be right. Some researchers theorize that COVID-19 is actually aging the brain by a decade. A preliminary study in the U.K. analyzed questionnaires from over 84,000 people who had suspected or confirmed COVID-19. These tests gauged patients' spatial reasoning, memory, attention, and emotional processing skills using the same approach that both Nixit and Malamut use in their offices to diagnose cognitive decline. From this, the researchers deduced that patients’ mental facilities were aged by 10 years in comparison to a COVID-free cohort.

While Malamut says that brain aging is consistent with frontal lobe damage, it’s usually accompanied by shrinkage in multiple areas of the brain as well. Studies like this one need to be taken with a grain of salt, she says, because one cannot diagnose brain aging without adequate scans.

“It’s impossible to know if COVID is actually aging brains by 10 years," she says. "I think that in this case, there is probably atrophy in some very small and specific areas in the frontal lobe in the brain; I don’t think there’s this huge loss that you can see. In Alzheimer’s, in the very early stages where people are just beginning to complain of memory loss, the brain actually looks pretty normal. But as the disease progresses, you see more and more shrinkage everywhere in the brain, so it usually takes time.” 

Incorporating Brain Tests into Treatment 

The authors behind the EEG study suggest that EEG abnormalities can serve as a biomarker for COVID-related brain damage or disease. However, Dixit emphasizes that EEGs are notoriously unspecific—they show us more of a blanket finding as opposed to pinpointing areas with direct damage.

Instead, she recommends a combination of EEGs, functional MRIs, and neuropsychology testing to assess proper brain function and localization in acute and long-term COVID-19 patients. If patients develop cognitive disruptions, then these tests need to be done as soon as possible, she says.

However, for many patients like Lieberman, who do not have health insurance and cannot work due to debilitating long-term COVID-19 complications, that type of diagnostic testing feels like a pipe dream. But it's one that Lieberman desperately needs. If she were to take a written cognitive test like the one that discovered COVID-induced brain aging, it might help her understand why she now writes out words phonetically—why “idea” becomes “eye-de-a,” and “house” becomes “how-s.” If she were able to get an EEG or an MRI of her brain, she might know if there is damage to her frontal lobe or hippocampus, which could explain why she forgets which faucet is for hot water and which is for cold, and why she is too afraid to drive because she can't differentiate between the gas pedal and the brake.

Unfortunately, that type of information is a luxury she simply cannot afford.

“It’s no secret that COVID-19 has terrible neurological consequences, and I do believe that more tests need to be conducted to help us understand the potential long-term effects of the virus on the brain. However, all patients need to have access to these tests for us to understand the true neurological impact,” Abigail Schmelz, a public health graduate student at the University of Miami (UM) and a Research Assistant in UM’s neurology department, tells Verywell. “From a public health perspective, it’s more important than ever for young people to stay home and adhere to social distancing guidelines, because our healthcare system is strained beyond capacity right now, so this will make it even harder to receive diagnostic testing and treatment for these neurological problems.” 

As her brain and body continue to collapse from the long-term ramifications of COVID-19, Lieberman's canvases also collect dust. When she does gather the strength to paint, the only color she can reach for is black.

“This virus is crazy. Things change from hour to hour sometimes. Time doesn’t exist for me anymore,” Lieberman says. “People are like, ‘We have to get out of our house for our mental health,’ but they don’t realize how housebound you can get when you’re sick. And I just want to remind them to stay vigilant because you don’t want this. It’s bad. It’s not fun. It sucks. And I have no idea when it will end.”

The information in this article is current as of the date listed, which means newer information may be available when you read this. For the most recent updates on COVID-19, visit our coronavirus news page.