Neurological Aspects of COVID-19: Acute and Long-Term Manifestations in Adults and Children

Abstract

Coronavirus disease 2019 (COVID-19) is now recognized as a multisystem illness with prominent neurological involvement. Both acute infection and post-acute sequelae (“long COVID”) are frequently accompanied by neurologic and neuropsychiatric symptoms in adults and children. This narrative review summarizes current evidence on the neurological aspects of COVID-19, including mechanisms, clinical manifestations, imaging findings and treatment. SARS-CoV-2 may access the nervous system via hematogenous routes and possibly cranial nerves, but most injury appears to result from systemic inflammation, endothelial dysfunction, coagulopathy and post-infectious autoimmunity rather than widespread direct neuronal infection. In adults, acute presentations range from headache, anosmia and encephalopathy to ischemic and hemorrhagic stroke, inflammatory CNS syndromes, seizures and Guillain–Barré syndrome. Children show a similar but age-dependent spectrum, with neurologic complications particularly prominent in multisystem inflammatory syndrome in children (MIS-C). Long COVID is characterized by persistent cognitive impairment, fatigue, sleep disturbance, dysautonomia, chronic headache, neuropathic symptoms and mood disorders, with generally milder but comparable patterns in adolescents. Acute neuroimaging often demonstrates infarcts, hemorrhage, microbleeds, leukoencephalopathy, PRES or transient splenial lesions, whereas conventional imaging in long COVID is usually normal despite subtle changes on advanced MRI and PET. Early recognition, guideline-based management of acute events, and multidisciplinary rehabilitation for long-term sequelae are crucial while ongoing studies clarify mechanisms and optimal therapies.