Cited by 159Long-Term Effects of COVID-19Neuroinflammation and Neurodegeneration MechanismsSARS-CoV-2 and COVID-19 Research

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Neuropathobiology of COVID-19: The Role for Glia

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Tremblay, Marie-Eve, Madore, Charlotte, Bordeleau, Maude, Tian, Li, Verkhratsky, Alexei·2020·Frontiers in Cellular Neuroscience

DOI 10.3389/fncel.2020.592214PMC PMC7693550

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Abstract

SARS-CoV-2, which causes the Coronavirus Disease 2019 (COVID-19) pandemic, has a brain neurotropism through binding to the receptor angiotensin-converting enzyme 2 expressed by neurones and glial cells, including astrocytes and microglia. Systemic infection which accompanies severe cases of COVID-19 also triggers substantial increase in circulating levels of chemokines and interleukins that compromise the blood-brain barrier, enter the brain parenchyma and affect its defensive systems, astrocytes and microglia. Brain areas devoid of a blood-brain barrier such as the circumventricular organs are particularly vulnerable to circulating inflammatory mediators. The performance of astrocytes and microglia, as well as of immune cells required for brain health, is considered critical in defining the neurological damage and neurological outcome of COVID-19. In this review, we discuss the neurotropism of SARS-CoV-2, the implication of neuroinflammation, adaptive and innate immunity, autoimmunity, as well as astrocytic and microglial immune and homeostatic functions in the neurological and psychiatric aspects of COVID-19. The consequences of SARS-CoV-2 infection during ageing, in the presence of systemic comorbidities, and for the exposed pregnant mother and foetus are also covered.

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Figure 1 Scheme illustration of the neurotropism, neuroinflammatory processes, and effects on brain cells triggered by COVID-19 in patients. (A) Immune cells from the periphery and the central nervous system (CNS) produce effector molecules that include pro-inflammatory cytokines and autoantibodies. (B) SARS-CoV-2 infection also causes leakage of the blood-brain barrier leading in some cases to haemorrhage and cerebral infarct, as well as eliciting leukocytes infiltration. (C) In the parenchyma, the CNS cells become infected by SARS-CoV via angiotensin-converting enzyme 2 (ACE2) endocytosis mediated by the two-pore channel 2 (TCP2). (D) SARS-CoV-2 infection leads to loss of physiological functions of the brain cells, including neurones, astrocytes, microglia, and oligodendrocytes. Cell types are identified in the following manner; A, Astrocyte; L, Leukocyte; M, Microglia; N, Neurone; O, Oligodendrocyte.CC BY · PubMed Central

Figure 2 Physiological functions of astrocytes and microglia are altered with age, which may render the brain vulnerable to SARS-CoV-2 detrimental effects. (Upper panel) Under adult homoeostatic conditions, astrocytes notably contribute to the regulation of neuronal activity and neurovascular function (e.g., blood flow and permeability), while microglia participate to myelination, synaptic plasticity, and clearance processes. Upon SARS-CoV-2 infection, these physiological roles are altered, potentially contributing to the COVID-19 associated cognitive and neuropsychiatric symptoms. (Lower panel) In aged brain, dystrophic astrocytes and microglia decrease their efficient contribution to brain homeostasis due to impaired physiological functions. These dysfunctions of glial cells promote neurodegenerative processes, potentially leading to worsened cognitive decline upon SARS-CoV-2 infection.CC BY · PubMed Central

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Background
COVID ‐19 Induces Neuroinflammation and Suppresses Peroxisomes in the Brain
Roczkowsky, A., Limonta, D., Fernandes, J. P., Branton, W. G., Clarke, M., Hlavay, B. A., Noyce, R. S., Joseph, J. T., Ogando, N. S., Das, S., et al. (2023) · Annals of Neurology · doi:10.1002/ana.26679 · Cited by 29
Principles of Astrogliopathology
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“These conditions include neurotrauma (Burda et al. 2016; Faulkner et al. 2004), systemic inflammation and sepsis (Shulyatnikova and Verkhratsky 2019; Tremblay et al. 2020), microbial or viral neuroinfection (Soung and Klein 2018; Zorec et al. 2019), toxic encephalopathies (Li et al. 2021;…”
BackgroundSelf-citation
Single-nucleus RNA sequencing reveals the shared mechanisms inducing cognitive impairment between COVID-19 and Alzheimer’s disease
Fu, Y., Guo, Z., Wang, Y., Zhang, H., Zhang, F., Xu, Z., Shen, X., Roppongi, R. T., Mo, S., Gu, W., et al. (2022) · Frontiers in Immunology · doi:10.3389/fimmu.2022.967356 · Cited by 22
Persisting Shadows: Unraveling the Impact of Long COVID-19 on Respiratory, Cardiovascular, and Nervous Systems
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“This cascade of events can dysregulate neurogenesis and disrupt the normal functioning of neurons, oligodendrocytes, and neuroglial cells [100].”
Background
Factors Associated with Delirium in COVID-19 Patients and Their Outcome: A Single-Center Cohort Study
Giorgio, A. D., Mirijello, A., Gennaro, C. D., Fontana, A., Alboini, P. E., Florio, L., Inchingolo, V., Zarrelli, M. M., Miscio, G., Raggi, P., et al. (2022) · Diagnostics · doi:10.3390/diagnostics12020544 · Cited by 19
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Sex-Specific Microglial Activation and SARS-CoV-2 Receptor Expression Induced by Chronic Unpredictable Stress
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“Glia-induced neuroinflammation is a common pathological observation in neurological cases of COVID-19 (Tremblay et al., 2020; Vargas et al., 2020), as microglia and astrocytes are key pathogen-combating players in the brain during SARS-CoV-2 infection (McMahon et al.”
BackgroundSelf-citation
Neuropsychiatric Manifestations of Long COVID-19: A Narrative Review of Clinical Aspects and Therapeutic Approaches
Căliman-Sturdza, O. A., Gheorghita, R. E., & Lobiuc, A. (2025) · Life · doi:10.3390/life15030439 · Cited by 32
Neurocircuitry Hypothesis and Clinical Experience in Treating Neuropsychiatric Symptoms of Postacute Sequelae of Severe Acute Respiratory Syndrome Coronavirus 2
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“24 In addition, studies of single-nucleus transcriptomes of frontal cortex and the choroid plexus in 30 SARS-CoV-2 patients reveal cellular changes in COVID-19-associated microglia and astrocytes that share features with pathological cell states in neurodegenerative disorders, such as Alzheimer…”
Fetal brain vulnerability to SARS-CoV-2 infection
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Alterations in microbiota of patients with COVID‐19: implications for therapeutic interventions
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“119 Glial activation and neuroinflammation may play an important role in cognitive impairment caused by COVID-19.”
Background
Hypothesis: Neuroglia Activation Due to Increased Peripheral and CNS Proinflammatory Cytokines/Chemokines with Neuroinflammation May Result in Long COVID
Hayden, M. R. (2021) · Neuroglia · doi:10.3390/neuroglia2010004 · Cited by 19
“Furthermore, the major histocompatibility complex (MHC)positive antigen presenting cells will present these viral antigens to the acquired immune system’s auto-reactive T-cells that will form the antibody which will then develop the antigen–antibody complex [94,99].”
Background
Immunological Interfaces: The COVID-19 Pandemic and Depression
Perlmutter, A. (2021) · Frontiers in Neurology · doi:10.3389/fneur.2021.657004 · Cited by 18
Genetics of COVID ‐19 and myalgic encephalomyelitis/chronic fatigue syndrome: a systematic review
Tziastoudi, M., Cholevas, C., Stefanidis, I., & Theoharides, T. C. (2022) · Annals of Clinical and Translational Neurology · doi:10.1002/acn3.51631 · Cited by 19
“Microglia have been implicated in COVID-19(228) and were also associated with neuroinflammation.(229) Microglia have important functions both in health and disease of the central nervous system (CNS), especially with respect to neuroinflammation 232 and neurodegenerative diseases.”
Background
Astrocytes in the pathophysiology of neuroinfection
Zorec, R., & Verkhratsky, A. (2022) · Essays in Biochemistry · doi:10.1042/ebc20220082 · Cited by 16
Self-citation
SARS-CoV-2 Infection: Paving Way for Sleep Disorders in Long Term!
Gupta, R. M., & Pandi-Perumal, S. R. (2021) · Sleep and Vigilance · doi:10.1007/s41782-021-00145-5 · Cited by 16
“, brainstem, circumventricular organ, subfornical area, paraventricular nucleus, and rostroventrolateral medulla [10].”
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Post‐COVID‐19 neuropsychiatric syndrome: Is maladaptive glial recovery to blame?
Steardo, L., Steardo, L., Verkhratsky, A., & Scuderi, C. (2021) · Acta Physiologica · doi:10.1111/apha.13717 · Cited by 15
Self-citation
Long‐term neurological dysfunction associated with COVID ‐19: Lessons from influenza and inflammatory diseases?
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Microglia as potential key regulators in viral-induced neuroinflammation
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Differences in brain structure and cognitive performance between patients with long-COVID and those with normal recovery
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“We found lower MD in the long COVID group, but no differences in other DTI metrics or cognitive performance.”
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Natural Products with Tandem Anti-inflammatory, Immunomodulatory and Anti-SARS-CoV/2 Effects: A Drug Discovery Perspective against SARS-CoV-2
da Cunha, L. N. O. L., Tizziani, T., Souza, G. B., Moreira, M. A., Neto, J. S. S., Santos, C. V. D. D., de Carvalho, M. G., Dalmarco, E. M., Turqueti, L. B., Scotti, L., et al. (2021) · Current Medicinal Chemistry · doi:10.2174/0929867328666210726094955 · Cited by 12
Neuroinvasion and neurotropism by SARS-CoV-2 variants in the K18-hACE2 mousePreprint
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A nutraceutical strategy for downregulating TGFβ signalling: prospects for prevention of fibrotic disorders, including post-COVID-19 pulmonary fibrosis
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Systemic Inflammation and Astrocyte Reactivity in the Neuropsychiatric Sequelae of COVID-19: Focus on Autism Spectrum Disorders
Valenza, M., Steardo, L., Steardo, L., Verkhratsky, A., & Scuderi, C. (2021) · Frontiers in Cellular Neuroscience · doi:10.3389/fncel.2021.748136 · Cited by 12
Self-citation
Why antidiabetic drugs are potentially neuroprotective during the Sars-CoV-2 pandemic: The focus on astroglial UPR and calcium-binding proteins
Gonçalves, C., Sesterheim, P., Wartchow, K. M., Bobermin, L. D., Leipnitz, G., & Quincozes‐Santos, A. (2022) · Frontiers in Cellular Neuroscience · doi:10.3389/fncel.2022.905218 · Cited by 11
“Another very important aspect of COVID-19 is the greater vulnerability of elderly patients; possibly the aging of astrocytes makes these individuals more susceptible to Sars-CoV-2-induced dysfunction (Tremblay et al., 2020).”
Background
Predicting brain-regional gene regulatory networks from multi-omics for Alzheimer’s disease phenotypes and Covid-19 severity
Khullar, S., & Wang, D. (2023) · Human Molecular Genetics · doi:10.1093/hmg/ddad009 · Cited by 12
Autopsy findings of pediatric COVID-19: a systematic review
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SARS-CoV-2 infection is associated with increased odds of insomnia, RLS and dream enactment behavior
Kumar, N., Goyal, A., Hussain, A., Saini, L. K., Chawla, O., Arora, P. K., Daga, R., Tikka, S. K., Goyal, S., Kanchan, S., et al. (2022) · Indian Journal of Psychiatry · doi:10.4103/indianjpsychiatry.indianjpsychiatry_586_21 · Cited by 10
“[17] Thus, the present study was planned to study the effect of SARS-CoV-2 infection to the occurrence of insomnia, RLS and DEB.”
Peripheral nervous system involvement associated with COVID-19. A systematic review of literature
Hanganu, A. R., Constantin, A. M., Moise, E.-S., Niculae, C., Olaru, I. D., Băicuş, C., & Hristea, A. (2023) · PLoS ONE · doi:10.1371/journal.pone.0283827 · Cited by 10
SARS-CoV-2 hampers dopamine production in iPSC-derived dopaminergic neurons
Cappelletti, G., Carsana, E. V., Lunghi, G., Breviario, S., Vanetti, C., Fonzo, A. D., Frattini, E., Magni, M., Zecchini, S., Clerici, M., et al. (2023) · Experimental and Molecular Pathology · doi:10.1016/j.yexmp.2023.104874 · Cited by 10
Dialogue between Neuroinflammation and Neurodegenerative Diseases in COVID-19
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SARS-CoV-2-Induced Amyloidgenesis: Not One, but Three Hypotheses for Cerebral COVID-19 Outcomes
Gonçalves, C., Bobermin, L. D., Sesterheim, P., & Netto, C. A. (2022) · Metabolites · doi:10.3390/metabo12111099 · Cited by 10
“Note that the brain endothelium is closely surrounded by the feet of astrocytes, forming the BBB [19].”
BackgroundInfluential
Evidence of Microglial Immune Response Following Coronavirus PHEV Infection of CNS
Zhang, J., Li, Z., Lu, H., Shi, J., Gao, R., Ma, Y., Lan, Y., Guan, J., Zhao, K., Gao, F., et al. (2022) · Frontiers in Immunology · doi:10.3389/fimmu.2021.804625 · Cited by 10
COVID‐19 and cognitive impairment: From evidence to SARS‐CoV‐2 mechanism
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Crosstalk between SARS-CoV-2 Infection and Neurological Disorders: A Review
Azhar, A., Wali, M. A., Rashid, Q., Khan, W. H., Alhosaini, K. A., Owais, M., & Kamal, M. A. (2022) · CNS & Neurological Disorders - Drug Targets · doi:10.2174/1871527321666220418114009 · Cited by 8
Post-Acute Sequelae of SARS-CoV-2 Infection: A Descriptive Clinical Study
Gutiérrez-Martínez, L., Karten, J., Kritzer, M. D., Josephy‐Hernandez, S. E., Kim, D. D., Newhouse, A. L., Pasinski, M., Praschan, N. C., Razafsha, M., Rubin, D. B., et al. (2022) · Journal of Neuropsychiatry · doi:10.1176/appi.neuropsych.21070193 · Cited by 8
Human Brain In Vitro Model for Pathogen Infection-Related Neurodegeneration Study
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“During severe COVID-19, the increase in circulating chemokines and interleukins can compromise the BBB, allowing these inflammatory mediators to affect glial cells [174].”
Background
Role Of Retroelements In The Development Of COVID-19 Neurological Consequences
Mustafin, R. N., Kazantseva, A. V., Kovas, Y. V., & Хуснутдинова, Э. К. (2022) · Russian Open Medical Journal · doi:10.15275/rusomj.2022.0313 · Cited by 7
“The key factor in CNS inflammation caused by SARS-CoV-2 is the activation of astrocytes and microglia [95], which are the main sources of cytokines in the inflamed CNS, including interferon and interleukins involved in the development of a cytokine storm in the brain [96].”
Background
Neuromasts and Olfactory Organs of Zebrafish Larvae Represent Possible Sites of SARS-CoV-2 Pseudovirus Host Cell Entry
Choi, S. S. A., Chan, H. H., Chan, C. M., Wang, X., Webb, S., Leung, K. W., Tsim, K. W. K., & Miller, A. L. (2022) · Journal of Virology · doi:10.1128/jvi.01418-22 · Cited by 7
“It has been proposed that such entry pathways might contribute to the long-term effects of COVID-19 (long-COVID) infection (75, 115, 116, 150), which at present are not well understood and might have the potential to be targeted by antiviral agents (53, 114, 151).”
Background
Developing brain under renewed attack: viral infection during pregnancy
Recaioglu, H., & Kolk, S. M. (2023) · Frontiers in Neuroscience · doi:10.3389/fnins.2023.1119943 · Cited by 6
“Exceptionally, yolk sac-derived microglial cells appearing and migrating to the developing brain (GW4-24; Menassa and Gomez-Nicola, 2018) not only participate in brain development in critical stages but also are the resident macrophages of the brain acting as first-line defenders against pathogens (Tremblay et al., 20…”
Background
Oneyear longitudinal study on biomarkers of blood–brain barrier permeability in COVID-19 patients
Wallensten, J., Havervall, S., Power, Y., Åsberg, M., Borg, K., Nager, A., Thålin, C., & Mobarrez, F. (2024) · Scientific Reports · doi:10.1038/s41598-024-73321-y · Cited by 7
“One hypothesis is that SARS-CoV-2 activates microglia and astrocytes, inducing an inflammatory response and increasing cytokine production, which results in a feedback loop that affects glia cells in the brain 9 and subsequently the BBB integrity 3 .”
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On the prevention and treatment of Alzheimer’s disease: Control the promoters and look beyond the brain
Goldstein, M. R., & Cheslock, M. (2021) · Medical Hypotheses · doi:10.1016/j.mehy.2021.110645 · Cited by 8
Neurotropic SARS-CoV-2: Causalities and Realities
Pardasani, M., & Abraham, N. M. (2022) · IntechOpen eBooks · doi:10.5772/intechopen.108573 · Cited by 5
Impact of COVID-19 on Anxiety and Depression - Biopsychosocial Factors
Bertollo, A. G., Galvan, A. C. L., Mingoti, M. E. D., Dallagnol, C., & Ignácio, Z. M. (2023) · CNS & Neurological Disorders - Drug Targets · doi:10.2174/1871527322666230210100048 · Cited by 6
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Neurological Impact of Respiratory Viruses: Insights into Glial Cell Responses in the Central Nervous System
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BackgroundInfluential
iPSC ‐derived human cortical organoids display profound alterations of cellular homeostasis following SARS ‐ CoV ‐2 infection and Spike protein exposure
Cappelletti, G., Brambilla, L., Strizzi, S., Limanaqi, F., Melzi, V., Rizzuti, M., Nizzardo, M., Saulle, I., Trabattoni, D., Corti, S. P., et al. (2025) · The FASEB Journal · doi:10.1096/fj.202401604rrr · Cited by 5
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Lipid metabolism, microglia, and stroke
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“Microglia are extremely dynamic and constantly responding to episodes of health or disease by adapting diverse states and fulfilling different functions (Vay et al., 2018; Tremblay et al., 2020).”
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CRISPR/CasRx-Mediated RNA Knockdown Reveals That ACE2 Is Involved in the Regulation of Oligodendroglial Cell Morphological Differentiation
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Wszędybył-Winklewska, M., Czuba, E., Malinowski, K. S., Waśkow, M., Michalak, K., & Winklewski, P. J. (2026) · Journal of Neuroinflammation · doi:10.1186/s12974-025-03652-8 · Cited by 5
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Microglia and putative macrophages of the subfornical organ: structural and functional features
Гусельникова, В. В., Razenkova, V. A., Суфиева, Д. А., & Korzhevsky, D. E. (2022) · Bulletin of Russian State Medical University · doi:10.24075/brsmu.2022.020 · Cited by 4

Authors: Tremblay, M.-E., Madore, C., Bordeleau, M., Tian, L., & Verkhratsky, A.
Affiliations: Institut National de Recherche pour l'Agriculture, l'Alimentation et l'Environnement (FR)
Université Laval (CA)
Peking University (CN)
Ikerbasque (ES)
ORCID: Madore, Charlotte
Tian, Li
Verkhratsky, Alexei
Venue: Frontiers in Cellular Neuroscience
Publisher: Frontiers Media SA
Published: 2020-11-11
Volume: 14
Pages: 592214-592214
ISSN: 1662-5102 (ISSN-L)
DOI: 10.3389/fncel.2020.592214
PMC: PMC7693550
OpenAlex: W3101561456
Cited by: 159
References: 188
Citations by year: 2026: 7 · 2025: 10 · 2024: 20 · 2023: 25 · 2022: 60 · 2021: 36 · 2020: 1
FWCI: 3.42
Type: journal article
Language: en
Open access: gold
doi.org
Licence: cc-by
creativecommons.org/licenses/by/4.0/ (vor)
Locations: Frontiers in Cellular Neuroscience (publishedVersion, cc-by)
PubMed Central (publishedVersion, cc-by)
PubMed (publishedVersion)
HAL (submittedVersion, cc-by)
HAL (submittedVersion)
cIRcle (University of British Columbia) (submittedVersion, cc-by-nc-nd)
DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
eScholarship@McGill (McGill) (submittedVersion)
Oskar-Bordeaux (Universite de Bordeaux) (submittedVersion, cc-by)
Research Explorer (The University of Manchester) (submittedVersion, other-oa)
Open Collections
Funders: European Commission
Eesti Teadusagentuur (MOBTT77)
Fondation pour la Recherche Médicale
Canadian Institutes of Health Research (Tier 2)
Topics: Health Sciences › Medicine › Clinical Neurology › Long-Term Effects of COVID-19
Life Sciences › Neuroscience › Neurology › Neuroinflammation and Neurodegeneration Mechanisms
Health Sciences › Medicine › Infectious Diseases › SARS-CoV-2 and COVID-19 Research
Keywords: COVID-19 pandemic, SARS-CoV-2, glial cells, astrocytes, microglia, neurotropism, ACE2 receptor, blood-brain barrier, neuroinflammation, chemokines, interleukins, circumventricular organs, autoimmunity, innate immunity, adaptive immunity, neurological complications, psychiatric aspects, aging, comorbidities, pregnancy, fetus

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Neuropathobiology of COVID-19: The Role for Glia

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