Long-COVID Brain Fog: Patient Recovers After 2 nTMS Sessions

Patient History:

• Male, 34 years old
• No underlying diseases
• Engineer
• Had COVID-19 with pneumonia, but not severe
• Received high-flow oxygen for 2 weeks Isolated for another 2 weeks

Symptoms:

• Slow thinking and speaking
• Difficulty thinking clearly (“brain fog”)
• Takes 10-30 seconds to think of words
• Cannot remember names of close friends or phone numbers
• Difficulty working
• Symptoms persisted for over a month
• Developed depressive symptoms

Physical Examination:

• No signs of hemiplegia, numbness, or weakness
• TMSE score: 29/30 (normal)
• MoCA score: 27/30 (normal)
• However, the patient had a significantly slow response time (10-20 seconds) compared to the normal range (2-4 seconds)

Previous Treatment:

• Vitamins and brain supplements
• Exercise
• Memory training
• No improvement after over a month

Research Findings:

Meta-analysis of long-COVID found that 27% of patients experience attention disorder, memory loss, brain fog, or cognitive impairment.

Another study found that 12% of patients still had slow speech, slow memory, or other brain symptoms after 8 months.

In Thailand, with 1.7 million COVID-19 cases, this translates to 200,000 people with potential brain problems after COVID-19.

MRI, EEG, and CSF are often normal in these patients.

COVID-19 vaccination can also cause brain fog, but to a lesser extent.

Possible Causes:

1. COVID-19 or the body’s immune response causes inflammation in the nervous system, leading to systemic dysfunction, hypoxemia, metabolic dysregulation, proinflammatory state, and cytokine storm, all of which affect the brain.
2. Insufficient oxygen or blood supply to the brain can lead to cerebral cortex hypoxia, as this is the outermost part of the brain and receives blood and oxygen the farthest. The cerebral cortex is responsible for memory, speech, and intelligence.
3. Reduced gamma and beta waves, which are involved in long-range communication and learning, leading to long-range underconnectivity.
4. COVID-19 affects the limbic system and hypothalamus, leading to irritability, increased pain, sleep problems, autonomic system dysfunction, and increased brain toxicity.

Treatment:

In this case, nTMS was considered after 1 month of supportive treatment without improvement.

Reasons why nTMS was likely to be effective in this case:

1. Brain cells are still healthy, with no injury, no vascular occlusion, or severe inflammation (functional impairment, not structural damage).
2. nTMS directly stimulates the cerebral cortex.
3. nTMS can use specific frequencies (gamma and beta waves) that are relevant to learning, memory, and language.

Treatment Results:

• 1st nTMS: 80% improvement within 24 hours in memory, speech, and thinking time (reduced to 4-10 seconds). Improved mood. TMSE score: 30/30. MoCA score: 30/30.
• 2nd nTMS: 100% improvement. Thinking time is reduced to 2 seconds.

Cautions and Limitations:

1. This is a case report. Recovery time may vary in other cases, depending on the severity. On average, nTMS improves symptoms by 50-100% within 5 sessions.
2. The technique used in nTMS is different from rTMS for depression. The same machine cannot be used for both. Each person’s brain is different after COVID-19, so personalized and precision medicine is needed. Incorrect treatment can be harmful, e.g., worsening headache, insomnia, or seizures. There are specific assessment methods for this.