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Hutch MR, Son J, Le TT, Hong C, Wang X, Shakeri Hossein Abad Z, Morris M, Gutiérrez-Sacristán A, Klann JG, Spiridou A, Batugo A, Bellazzi R, Benoit V, Bonzel CL, Bryant WA, Chiudinelli L, Cho K, Das P, González González T, Hanauer DA, Henderson DW, Ho YL, Loh NHW, Makoudjou A, Makwana S, Malovini A, Moal B, Mowery DL, Neuraz A, Samayamuthu MJ, Sanz Vidorreta FJ, Schriver ER, Schubert P, Talbert J, Tan ALM, Tan BWL, Tan BWQ, Tibollo V, Tippman P, Verdy G, Yuan W, Avillach P, Gehlenborg N, Omenn GS, Visweswaran S, Cai T, Luo Y, Xia Z. Neurological diagnoses in hospitalized COVID-19 patients associated with adverse outcomes: A multinational cohort study. PLOS DIGITAL HEALTH 2024; 3:e0000484. [PMID: 38620037 PMCID: PMC11018281 DOI: 10.1371/journal.pdig.0000484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 03/06/2024] [Indexed: 04/17/2024]
Abstract
Few studies examining the patient outcomes of concurrent neurological manifestations during acute COVID-19 leveraged multinational cohorts of adults and children or distinguished between central and peripheral nervous system (CNS vs. PNS) involvement. Using a federated multinational network in which local clinicians and informatics experts curated the electronic health records data, we evaluated the risk of prolonged hospitalization and mortality in hospitalized COVID-19 patients from 21 healthcare systems across 7 countries. For adults, we used a federated learning approach whereby we ran Cox proportional hazard models locally at each healthcare system and performed a meta-analysis on the aggregated results to estimate the overall risk of adverse outcomes across our geographically diverse populations. For children, we reported descriptive statistics separately due to their low frequency of neurological involvement and poor outcomes. Among the 106,229 hospitalized COVID-19 patients (104,031 patients ≥18 years; 2,198 patients <18 years, January 2020-October 2021), 15,101 (14%) had at least one CNS diagnosis, while 2,788 (3%) had at least one PNS diagnosis. After controlling for demographics and pre-existing conditions, adults with CNS involvement had longer hospital stay (11 versus 6 days) and greater risk of (Hazard Ratio = 1.78) and faster time to death (12 versus 24 days) than patients with no neurological condition (NNC) during acute COVID-19 hospitalization. Adults with PNS involvement also had longer hospital stay but lower risk of mortality than the NNC group. Although children had a low frequency of neurological involvement during COVID-19 hospitalization, a substantially higher proportion of children with CNS involvement died compared to those with NNC (6% vs 1%). Overall, patients with concurrent CNS manifestation during acute COVID-19 hospitalization faced greater risks for adverse clinical outcomes than patients without any neurological diagnosis. Our global informatics framework using a federated approach (versus a centralized data collection approach) has utility for clinical discovery beyond COVID-19.
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Affiliation(s)
- Meghan R. Hutch
- Department of Preventive Medicine, Northwestern University, Chicago, Illinois, United States of America
| | - Jiyeon Son
- Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Trang T. Le
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America
| | - Chuan Hong
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, United States of America
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, United States of America
| | - Xuan Wang
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, United States of America
| | - Zahra Shakeri Hossein Abad
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Michele Morris
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Alba Gutiérrez-Sacristán
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Jeffrey G. Klann
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Anastasia Spiridou
- Digital Research, Informatics and Virtual Environments (DRIVE), Great Ormond Street Hospital for Children, London, United Kingdom
| | - Ashley Batugo
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America
| | - Riccardo Bellazzi
- Department of Electrical, Computer and Biomedical Engineering, University of Pavia, Pavia, Italy
| | - Vincent Benoit
- IT Department, Innovation & Data, APHP Greater Paris University Hospital, Paris, France
| | - Clara-Lea Bonzel
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, United States of America
| | - William A. Bryant
- Digital Research, Informatics and Virtual Environments (DRIVE), Great Ormond Street Hospital for Children, London, United Kingdom
| | - Lorenzo Chiudinelli
- UOC Ricerca, Innovazione e Brand reputation, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Kelly Cho
- Population Health and Data Science, VA Boston Healthcare System, Boston Massachusetts, United States of America
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston Massachusetts, United States of America
| | - Priyam Das
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, United States of America
| | | | - David A. Hanauer
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, Michigan, United States of America
| | - Darren W. Henderson
- Center for Clinical and Translational Science, University of Kentucky, Lexington, Kentucky, United States of America
| | - Yuk-Lam Ho
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston Massachusetts, United States of America
| | - Ne Hooi Will Loh
- Department of Anaesthesia, National University Health System, Kent Ridge, Singapore
| | - Adeline Makoudjou
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Simran Makwana
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Alberto Malovini
- Laboratory of Informatics and Systems Engineering for Clinical Research, Istituti Clinici Scientifici Maugeri SpA SB IRCCS, Pavia, Italy
| | - Bertrand Moal
- IAM Unit, Bordeaux University Hospital, Bordeaux, France
| | - Danielle L. Mowery
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America
| | - Antoine Neuraz
- Department of biomedical informatics, Hôpital Necker-Enfants Malade, Assistance Publique Hôpitaux de Paris (APHP), University of Paris, Paris, France
| | | | - Fernando J. Sanz Vidorreta
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Emily R. Schriver
- Data Analytics Center, University of Pennsylvania Health System, Philadelphia, Pennsylvania, United States of America
| | - Petra Schubert
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston Massachusetts, United States of America
| | - Jeffery Talbert
- Division of Biomedical Informatics, University of Kentucky, Lexington, Kentucky, United States of America
| | - Amelia L. M. Tan
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Byorn W. L. Tan
- Department of Medicine, National University Hospital, Singapore, Kent Ridge, Singapore
| | - Bryce W. Q. Tan
- Department of Medicine, National University Hospital, Singapore, Kent Ridge, Singapore
| | - Valentina Tibollo
- Laboratory of Informatics and Systems Engineering for Clinical Research, Istituti Clinici Scientifici Maugeri SpA SB IRCCS, Pavia, Italy
| | - Patric Tippman
- Institute of Medical Biometry and University of Freiburg, Medical Center, Freiburg, Germany
| | | | - William Yuan
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Paul Avillach
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Nils Gehlenborg
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Gilbert S. Omenn
- Departments of Computational Medicine & Bioinformatics, Internal Medicine, Human Genetics, Public Health, University of Michigan, Ann Arbor, Michigan, United States of America
| | | | - Shyam Visweswaran
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Tianxi Cai
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Yuan Luo
- Department of Preventive Medicine, Northwestern University, Chicago, Illinois, United States of America
| | - Zongqi Xia
- Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
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2
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Zaa CA, Espitia C, Reyes-Barrera KL, An Z, Velasco-Velázquez MA. Neuroprotective Agents with Therapeutic Potential for COVID-19. Biomolecules 2023; 13:1585. [PMID: 38002267 PMCID: PMC10669388 DOI: 10.3390/biom13111585] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/19/2023] [Accepted: 10/20/2023] [Indexed: 11/26/2023] Open
Abstract
COVID-19 patients can exhibit a wide range of clinical manifestations affecting various organs and systems. Neurological symptoms have been reported in COVID-19 patients, both during the acute phase of the illness and in cases of long-term COVID. Moderate symptoms include ageusia, anosmia, altered mental status, and cognitive impairment, and in more severe cases can manifest as ischemic cerebrovascular disease and encephalitis. In this narrative review, we delve into the reported neurological symptoms associated with COVID-19, as well as the underlying mechanisms contributing to them. These mechanisms include direct damage to neurons, inflammation, oxidative stress, and protein misfolding. We further investigate the potential of small molecules from natural products to offer neuroprotection in models of neurodegenerative diseases. Through our analysis, we discovered that flavonoids, alkaloids, terpenoids, and other natural compounds exhibit neuroprotective effects by modulating signaling pathways known to be impacted by COVID-19. Some of these compounds also directly target SARS-CoV-2 viral replication. Therefore, molecules of natural origin show promise as potential agents to prevent or mitigate nervous system damage in COVID-19 patients. Further research and the evaluation of different stages of the disease are warranted to explore their potential benefits.
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Affiliation(s)
- César A. Zaa
- School of Biological Sciences, Universidad Nacional Mayor de San Marcos (UNMSM), Lima 15081, Peru;
| | - Clara Espitia
- Department of Immunology, Institute of Biomedical Research, Universidad Nacional Autónoma de México (UNAM), Mexico City 04510, Mexico; (C.E.); (K.L.R.-B.)
| | - Karen L. Reyes-Barrera
- Department of Immunology, Institute of Biomedical Research, Universidad Nacional Autónoma de México (UNAM), Mexico City 04510, Mexico; (C.E.); (K.L.R.-B.)
| | - Zhiqiang An
- Texas Therapeutics Institute, Brown Foundation Institute of Molecular Medicine, University of Texas Health Science Center, Houston, TX 77030, USA;
| | - Marco A. Velasco-Velázquez
- Texas Therapeutics Institute, Brown Foundation Institute of Molecular Medicine, University of Texas Health Science Center, Houston, TX 77030, USA;
- School of Medicine, Universidad Nacional Autónoma de México (UNAM), Mexico City 04510, Mexico
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3
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Boz PB, Aslan-Kara K, Şanlı ZS, Peköz MT, Acar D, Bozdemir H. Seizures in COVID-19: the relationship between biomarkers and prognosis. Acta Neurol Belg 2023; 123:1763-1772. [PMID: 35907150 PMCID: PMC9362485 DOI: 10.1007/s13760-022-02054-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 07/20/2022] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To assess the prevalence of seizure, associated risk factors, and prognosis in patients with SARS-CoV-2 infection and identify predictive biomarkers in SARS-CoV-2 patients with seizure. METHODS A cohort of 17,806 patients with SARS-CoV-2 infection admitted to two university hospitals in Adana between March 11, 2020 and January 1, 2021 was analyzed retrospectively. The patients' demographic characteristics, laboratory findings, and systemic and neurological symptoms at admission and on the day of seizure onset were evaluated. RESULTS Neurological findings were detected in 877 of the 17,806 patients. Of these, 45 patients (0.25%) had seizure (status epilepticus in 4/45 patients, 8.9%). Patients with seizure had a mean age of 55.3 years (range 17-88) and 57.8% were male. Seizure was more common in the 18-44 (24.4%) and ≥ 65 age groups (44.4%) and in those with multiple comorbidity. The case fatality rate for patients with seizure among all SARS-CoV-2 patients was 0.135% (95% CI 80.86-188.71). However, no patient with a previous diagnosis of epilepsy died during SARS-CoV-2 infection. High neutrophil, platelet, and ferritin levels and low lymphocyte and calcium levels on the day of seizure development compared to admission were associated with higher mortality (p = 0.004, 0.008, 0.028, 0003, and 0.002, respectively). CONCLUSIONS Seizures are not uncommon during SARS-CoV-2 infection, with a higher risk of mortality in older patients and those with higher inflammatory markers.
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Affiliation(s)
- Pınar Bengi Boz
- Health Scıences Unıversıty Adana Faculty of Medıcıne Adana Cıty Traınıng and Research Hospıtal Neurology Clınıc, Adana, Turkey.
| | - Kezban Aslan-Kara
- Department of Neurology, Cukurova Unıversıty Faculty of Medıcıne Balcalı Hospıtal, Adana, Turkey
| | - Zeynep Selcan Şanlı
- Health Scıences Unıversıty Adana Faculty of Medıcıne Adana Cıty Traınıng and Research Hospıtal Neurology Clınıc, Adana, Turkey
| | - Mehmet Taylan Peköz
- Department of Neurology, Cukurova Unıversıty Faculty of Medıcıne Balcalı Hospıtal, Adana, Turkey
| | - Dilek Acar
- Health Scıences Unıversıty Adana Faculty of Medıcıne Adana Cıty Traınıng and Research Hospıtal Neurology Clınıc, Adana, Turkey
| | - Hacer Bozdemir
- Department of Neurology, Cukurova Unıversıty Faculty of Medıcıne Balcalı Hospıtal, Adana, Turkey
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4
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O’Leary J, McAndrew J, Shukralla A, Murphy K. Neuropsychiatric manifestations in a patient with prolonged COVID-19 encephalopathy: case report and literature review. Ir J Psychol Med 2023; 40:487-490. [PMID: 34544516 PMCID: PMC8523973 DOI: 10.1017/ipm.2021.67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 08/31/2021] [Accepted: 09/06/2021] [Indexed: 11/06/2022]
Abstract
While the respiratory complications of COVID-19 infection are now well known, psychiatric manifestations are an emerging issue. We report a case of prolonged encephalopathy secondary to COVID-19 which was associated with prominent neuropsychiatric features. The patient went on to develop sub-clinical seizures, a rare but recognised complication of SARS-CoV-2.
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Affiliation(s)
- J. O’Leary
- Department of Liaison Psychiatry, Beaumont Hospital, Dublin, Ireland
| | - J. McAndrew
- Department of Liaison Psychiatry, Beaumont Hospital, Dublin, Ireland
| | - A. Shukralla
- Department of Neurology, Beaumont Hospital, Dublin, Ireland
| | - K.C. Murphy
- Department of Liaison Psychiatry, Beaumont Hospital, Dublin, Ireland
- Department of Psychiatry, Royal College of Surgeons in Ireland, Dublin, Ireland
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5
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Kumar M, Bhoi SK, Jha M, Naik S. Super refractory status epilepticus as a possible manifestation of COVID-19 disease. J Neurosci Rural Pract 2023; 14:522-524. [PMID: 37692812 PMCID: PMC10483183 DOI: 10.25259/jnrp_60_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 03/14/2023] [Indexed: 09/12/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) is one of the worst pandemics in history, caused by severe acute respiratory syndrome coronavirus-2, a novel zoonotic coronavirus. COVID-19 disease can present from asymptomatic or mild infection to rapidly progressive, acute respiratory distress syndrome, and death. Neurological presentation is not so uncommon now. Super refractory status epilepticus (SRSE) can be a possible manifestation of COVID-19 disease. Here, we report a patient affected by COVID-19 who presented with SRSE.
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Affiliation(s)
- Mukesh Kumar
- Department of Neurology, AIIMS, Bhubaneswar, Odisha, India
| | | | - Menka Jha
- Department of Neurology, AIIMS, Bhubaneswar, Odisha, India
| | - Suprava Naik
- Department of Radiology, AIIMS, Bhubaneswar, Odisha, India
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6
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Sculier C, Gaspard N. New-onset refractory status epilepticus and febrile infection-related epilepsy syndrome. Curr Opin Neurol 2023; 36:110-116. [PMID: 36762646 DOI: 10.1097/wco.0000000000001137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
PURPOSE OF REVIEW The concept and understanding of new-onset refractory status epilepticus (NORSE), and its subtype with prior fever known as febrile infection-related epilepsy syndrome (FIRES) have evolved in the recent past. This review aims to summarize the recent developments in the pathophysiology, diagnosis and management of these challenging conditions. RECENT FINDINGS NORSE and FIRES can have many different causes. Although the list of possible causes is still growing, they mostly fall in the categories of autoimmune encephalitis and genetic disorders. However, despite extensive investigations, most cases of NORSE and FIRES remain cryptogenic. Recent studies have pointed towards the key role of autoinflammation as a unifying pathophysiological mechanism in these cases. These findings also support the use of immunomodulatory treatment in this setting. Consensus recommendations on the management of NORSE and FIRES have recently been published. SUMMARY NORSE and FIRES remain challenging conditions to diagnose and treat. Recent findings from clinical and basic research and new recommendations, reviewed in this article, contribute to an emerging framework for management and future research.
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Affiliation(s)
- Claudine Sculier
- Service de Neurologie Pédiatrique, Hôpital Universitaire de Bruxelles - Hôpital Erasme
| | - Nicolas Gaspard
- Service de Neurologie, Hôpital Universitaire de Bruxelles - Hôpital Erasme, Bruxelles, Belgique
- Neurology Department, Yale University School of Medicine, New Haven, Connecticut, USA
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Korchut A, Rejdak K. Late neurological consequences of SARS-CoV-2 infection: New challenges for the neurologist. Front Neurosci 2023; 17:1004957. [PMID: 36845421 PMCID: PMC9947479 DOI: 10.3389/fnins.2023.1004957] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 01/16/2023] [Indexed: 02/11/2023] Open
Abstract
Objective In this study, a systematic review of the literature was performed to study the frequency of neurological symptoms and diseases in adult patients with COVID-19 that may be late consequences of SARS-CoV-2 infection. Methods Relevant studies were identified through electronic explorations of Scopus, PubMed, and Google Scholar. We followed PRISMA guidelines. Data were collected from studies where the diagnosis of COVID-19 was confirmed and its late neurological consequences occurred at least 4 weeks after initial SARS-CoV-2 infection. Review articles were excluded from the study. Neurological manifestations were stratified based on frequency (above 5, 10, and 20%), where the number of studies and sample size were significant. Results A total of 497 articles were identified for eligible content. This article provides relevant information from 45 studies involving 9,746 patients. Fatigue, cognitive problems, and smell and taste dysfunctions were the most frequently reported long-term neurological symptoms in patients with COVID-19. Other common neurological issues were paresthesia, headache, and dizziness. Conclusion On a global scale of patients affected with COVID-19, prolonged neurological problems have become increasingly recognized and concerning. Our review might be an additional source of knowledge about potential long-term neurological impacts.
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Affiliation(s)
| | - Konrad Rejdak
- Department of Neurology, Medical University of Lublin, Lublin, Poland
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8
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Silvagni D, Soloni P, Biban P, Baggio L, Darra F. Self-limited focal epilepsy in a young child with SARS-CoV-2. Minerva Pediatr (Torino) 2023; 75:135-136. [PMID: 34098709 DOI: 10.23736/s2724-5276.21.06058-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Davide Silvagni
- Unit of Pediatric Emergency, Department of Neonatal and Pediatric Critical Care, Integrated University Hospital of Verona, Verona, Italy
| | - Pietro Soloni
- Unit of Pediatric Emergency, Department of Neonatal and Pediatric Critical Care, Integrated University Hospital of Verona, Verona, Italy
| | - Paolo Biban
- Unit of Pediatric Emergency, Department of Neonatal and Pediatric Critical Care, Integrated University Hospital of Verona, Verona, Italy -
| | - Laura Baggio
- Unit of Pediatric Emergency, Department of Neonatal and Pediatric Critical Care, Integrated University Hospital of Verona, Verona, Italy
| | - Francesca Darra
- Unit of Child Neuropsychiatry, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
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Zafar S, Aydemir S, Karceski S, Doria JW, Schaefer C, Swarnkar R, Afra P. COVID-19 Continuous-EEG Case Series: A Descriptive Study. J Clin Neurophysiol 2022; 39:575-582. [PMID: 33606430 DOI: 10.1097/wnp.0000000000000832] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Corona virus disease 2019 (COVID-19) refers to coronavirus disease secondary to SARS-CoV2 infection mainly affecting the human respiratory system. The SARS-CoV2 has been reported to have neurotropic and neuroinvasive features and neurological sequalae with wide range of reported neurological manifestations, including cerebrovascular disease, skeletal muscle injury, meningitis, encephalitis, and demyelination, as well as seizures and focal status epilepticus. In this case series, we analyzed the continuous video-EEGs of patients with COVID-19 infection to determine the presence of specific EEG features or epileptogenicity. METHODS All continuous video-EEG tracings done on SARS-CoV2-positive patients during a 2-week period from April 5, 2020, to April 19, 2020, were reviewed. The demographics, clinical characteristics, imaging, and EEG features were analyzed and presented. RESULTS Of 23 patients undergoing continuous video-EEG, 16 were COVID positive and were included. Continuous video-EEG monitoring was ordered for "altered mental status" in 11 of 16 patients and for "clinical seizure" in 5 of 16 patients. None of the patients had seizures or status epilepticus as a presenting symptom of COVID-19 infection. Instead, witnessed clinical seizures developed as results of COVID-19-related medical illness(es): anoxic brain injury, stroke/hemorrhage, lithium (Li) toxicity (because of kidney failure), hypertension, and renal disease. Three patients required therapeutic burst suppression because of focal nonconvulsive status epilepticus, status epilepticus/myoclonus secondary to anoxic injury from cardiac arrest, and one for sedation (and with concomitant EEG abnormalities secondary to Li toxicity). CONCLUSIONS In this observational case series of 16 patients with COVID-19 who were monitored with continuous video-EEG, most patients experienced a nonspecific encephalopathy. Clinical seizures and electrographic status epilepticus were the second most commonly observed neurological problem.
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Affiliation(s)
- Saman Zafar
- Department of Neurology, Weill-Cornell Medicine, New York, New York, U.S.A.; and
| | - Seyhmus Aydemir
- Department of Neurology, Weill-Cornell Medicine, New York, New York, U.S.A.; and
| | - Steve Karceski
- Department of Neurology, Weill-Cornell Medicine, New York, New York, U.S.A.; and
| | - Joseph W Doria
- Department of Neurology, Weill-Cornell Medicine, New York, New York, U.S.A.; and
| | - Candace Schaefer
- Department of Neurology, Weill-Cornell Medicine, New York, New York, U.S.A.; and
| | - Rohit Swarnkar
- Department of Neurology, Weill-Cornell Medicine, New York, New York, U.S.A.; and
| | - Pegah Afra
- Department of Neurology, Weill-Cornell Medicine, New York, New York, U.S.A.; and
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, Utah, U.S.A
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10
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Noviawaty I. New-Onset Non-convulsive Status Epilepticus in Previously Healthy COVID-19 Patient. Cureus 2022; 14:e28254. [PMID: 36158334 PMCID: PMC9490793 DOI: 10.7759/cureus.28254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2022] [Indexed: 11/05/2022] Open
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11
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Westman G, Zelano J. Epilepsy diagnosis after Covid-19: A population-wide study. Seizure 2022; 101:11-14. [PMID: 35842976 PMCID: PMC9270960 DOI: 10.1016/j.seizure.2022.07.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 07/07/2022] [Accepted: 07/09/2022] [Indexed: 12/16/2022] Open
Abstract
Background We aimed to investigate whether SARS-CoV-2 infection was associated with an increased risk of incident epilepsy. Methods National register-based matched study. Verified cases of SARS-CoV-2 infection were acquired from the system for communicable disease surveillance in Sweden (SmiNet) and linked to data from the National Patient Register (NPR) and Cause of Death register in Sweden. Cases and non-infected controls were compared using a Cox proportional hazards model. Results A total of 1,221,801 SARS-CoV-2 infected patients and 1,223,312 controls were included. Infection was not associated with an increased risk of epilepsy on a whole population level (HR 1.01, 95% CI 0.92–1.12). Statistically significant effects were observed in patients between 61 and 80 years (HR 1.66, 95% CI 1.37–2.02), also when adjusting for stroke, traumatic brain injury, tumours (same age group HR 1.50, 95% CI 1.24–1.82) and mechanical ventilation (HR 1.28, 95% CI 1.05–1.57). In patients 81–100 years, a similar significant difference was observed (HR 1.77, 95% CI 1.30–2.42), which remained after adjustment for stroke, traumatic brain injury and tumours (HR 1.51, 95% CI 1.10–2.05) but not when mechanical ventilation was included as a covariate (HR 1.34, 95% CI 0.97–1.84). Conclusions On a whole population level, SARS-CoV-2 infections is not associated with an increased risk of epilepsy. In patients above 60 years, a moderately increased risk of epilepsy was observed. However, considering potential non-controllable bias and that Covid-19 patients in intensive care present with a lower risk than the general ICU population, the virus-induced epileptogenic effect is likely very small.
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Affiliation(s)
- Gabriel Westman
- Department of Medical Sciences, Infectious Diseases, Uppsala University, Uppsala 75185, Sweden.
| | - Johan Zelano
- Department of clinical neuroscience, Institute of neuroscience and physiology, Sahlgrenska Academy, University of Gothenburg, Sweden; Department of Neurology, Sahlgrenska University Hospital, Blå stråket 7, Gothenburg 41345, Sweden; Wallenberg Center for Molecular and Translational Medicine, University of Gothenburg, Sweden.
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12
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Kheradmand M, Hemasian H, Khorvash F, Najafi MR, Ghadimi K, Forouharnejad K, Najafi MA. Status epilepticus due to COVID-19; a cases series and literature review. AMERICAN JOURNAL OF NEURODEGENERATIVE DISEASE 2022; 11:34-45. [PMID: 35874940 PMCID: PMC9301094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 05/23/2022] [Indexed: 06/15/2023]
Abstract
Complications are increasingly recognized with SARS-CoV-2, the causative pathogen for COVID-19. Various mechanisms have been proposed to justify the cause of seizures in Covid-19 patients. To our knowledge, 13 cases of status epilepticus (SE) associated with COVID-19 have been reported so far. Here, we present a single-center case series, including the clinical, laboratory, and imaging characteristics, and the EEG and the outcome of SE in 5 Iranian patients with laboratory-confirmed SARS-CoV-2 virus. SE was para-infectious in four patients and post-infectious in one other patient. In Three patients, the causes of seizure were included severe hyponatremia, acute ischemic stroke, and meningoencephalitis. However, in two other patients, no specific reason for seizure was found, but there are possibilities for lesser-known mechanisms of Covid-19 that play roles in developing SE. Two of the patients recovered, and three patients, older and with higher comorbidities, failed to recover and died.
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Affiliation(s)
- Mohsen Kheradmand
- Isfahan Neurosciences Research Center, Alzahra Hospital, Isfahan University of Medical SciencesIsfahan, Iran
- Department of Neurology, Isfahan University of Medical SciencesIsfahan, Iran
| | - Helia Hemasian
- Isfahan Neurosciences Research Center, Alzahra Hospital, Isfahan University of Medical SciencesIsfahan, Iran
- Department of Neurology, Isfahan University of Medical SciencesIsfahan, Iran
| | - Fariborz Khorvash
- Isfahan Neurosciences Research Center, Alzahra Hospital, Isfahan University of Medical SciencesIsfahan, Iran
- Department of Neurology, Isfahan University of Medical SciencesIsfahan, Iran
| | - Mohammad Reza Najafi
- Isfahan Neurosciences Research Center, Alzahra Hospital, Isfahan University of Medical SciencesIsfahan, Iran
- Department of Neurology, Isfahan University of Medical SciencesIsfahan, Iran
| | - Keyvan Ghadimi
- School of Medicine, Isfahan University of Medical SciencesIsfahan, Iran
| | | | - Mohammad Amin Najafi
- Isfahan Neurosciences Research Center, Alzahra Hospital, Isfahan University of Medical SciencesIsfahan, Iran
- Department of Neurology, Isfahan University of Medical SciencesIsfahan, Iran
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13
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Erfani Z, Jelodari Mamaghani H, Rawling JA, Eajazi A, Deever D, Mirmoeeni S, Azari Jafari A, Seifi A. Pneumonia in Nervous System Injuries: An Analytic Review of Literature and Recommendations. Cureus 2022; 14:e25616. [PMID: 35784955 PMCID: PMC9249029 DOI: 10.7759/cureus.25616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2022] [Indexed: 11/09/2022] Open
Abstract
Pneumonia is one of the most common complications in intensive care units and is the most common nosocomial infection in this setting. Patients with neurocritical conditions who are admitted to ICUs are no exception, and in fact, are more prone to infections such as pneumonia because of factors such as swallow dysfunction, need for mechanical ventilation, longer length of stay in hospitals, etc. Common central nervous system pathologies such as ischemic stroke, traumatic brain injury, subarachnoid hemorrhage, intracerebral hemorrhage, neuromuscular disorders, status epilepticus, and demyelinating diseases can cause long in-hospital admissions and increase the risk of pneumonia each with a mechanism of its own. Brain injury-induced immunosuppression syndrome is usually considered the common mechanism through which patients with critical central nervous system conditions become susceptible to different kinds of infection including pneumonia. Evaluating the patients and assessment of the risk factors can lead our attention toward better infection control in this population and therefore decrease the risk of infections in central nervous system injuries.
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14
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Sáez-Landete I, Gómez-Domínguez A, Estrella-León B, Díaz-Cid A, Fedirchyk O, Escribano-Muñoz M, Pedrera-Mazarro A, Martín-Palomeque G, Garcia-Ribas G, Rodríguez-Jorge F, Santos-Pérez G, Lourido-García D, Regidor-BaillyBailliere I. Retrospective Analysis of EEG in Patients With COVID-19: EEG Recording in Acute and Follow-up Phases. Clin EEG Neurosci 2022; 53:215-228. [PMID: 34319186 PMCID: PMC8958306 DOI: 10.1177/15500594211035923] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background. Interest in electroencephalographic (EEG) coronavirus disease 2019 (COVID-19) findings has been growing, especially in the search for a specific-features EEG of encephalopathy. Methods. We made a retrospective analysis of 29 EEGs recorded in 15 patients with COVID-19 and neurological symptoms. We classified the EEGs as "Acute EEG" and "follow-up EEG." We did a statistical analysis between voltage and respiratory status of the patient, stay or not in the intensive care unit (ICU), days of stay in the ICU, sedative drugs, pharmacological treatment, type of symptoms predominating, and outcome. Results. We found EEG abnormalities in all patients studied. We observed the amplitude of background <20 µV at 93% of "acute EEG," versus only 21.4% of "follow-up EEG." The average voltage went from 12.33 ± 5.09 µV in the acute EEGs to 32.8 ± 20.13 µV in the follow-up EEGs. A total of 60% of acute EEGs showed an intermittent focal rhythmic. We have not found a statistically significant association between voltage of acute EEG and nonneurological clinical status (including respiratory) that may interfere with the EEG findings. Conclusions. Nonspecific diffuse slowing EEG pattern in COVID-19 is the most common finding reported, but we found in addition to that, as a distinctive finding, low voltage EEG, that could explain the low prevalence of epileptic activity published in these patients. A metabolic/hypoxic mechanism seems unlikely on the basis of our EEG findings. This pattern in other etiologies is reminiscent of severe encephalopathy states associated with poor prognosis. However, an unreactive low voltage pattern in COVID-19 patients is not necessarily related to poor prognosis.
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Affiliation(s)
- Isabel Sáez-Landete
- 16507Department of Clinical Neurophysiology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Adriana Gómez-Domínguez
- 16507Department of Clinical Neurophysiology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Beatriz Estrella-León
- 16507Department of Clinical Neurophysiology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Alba Díaz-Cid
- 16507Department of Clinical Neurophysiology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Olga Fedirchyk
- 16507Department of Clinical Neurophysiology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Marta Escribano-Muñoz
- 16507Department of Clinical Neurophysiology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Antonio Pedrera-Mazarro
- 16507Department of Clinical Neurophysiology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | | | | | - Gloria Santos-Pérez
- 16507Departament of Anesthesiology. Hospital Universitario Ramón y Cajal, Madrid
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15
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Usta NC, Kartal S, Gunay BO, Boz C. Neurological manifestations and etiological risk factors in patients hospitalized with COVID-19 in Turkey. ASIAN BIOMED 2022; 16:23-30. [PMID: 37551396 PMCID: PMC10321161 DOI: 10.2478/abm-2022-0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Coronavirus disease 2019 (COVID-19) can affect the neurological as well as the respiratory system. Neurological manifestations may involve the central or peripheral nervous systems, or musculoskeletal system. Findings can range from mild presentations, such as headache and anosmia, to severe complications, such as stroke and seizure. Objectives To evaluate the neurological findings and to determine etiological risk factors for mortality in patients hospitalized for COVID-19. Methods Medical records of patients with COVID-19 who were hospitalized and sought neurological consultation between March 2020 and March 2021 at a reference pandemic hospital in Turkey were reviewed retrospectively in a cross-sectional study design. Result We included data from 150 (94 male) patients. Their mean age ± standard deviation was 68.56 ± 16.02 (range 21-97) years. The patients were categorized into 2 groups according to any acute neurological event or progression of neurological disease. Ischemic cerebrovascular events, seizures, and encephalopathy were the most common acute neurological events, while deterioration in consciousness, epileptic seizures, and Parkinson disease were observed in those with progression of neurological disease. Abnormal neurological findings were found at a mean of 7.8 ± 9.7 days following COVID-19 diagnosis and 50 (a third of) patients died. A logistic regression model found that advanced age, increased Modified Charlson Comorbidity Index (MCCI) score, and prolonged duration of hospitalization were factors significantly associated with increased mortality; however, sex and day of abnormal neurological findings after COVID-19 diagnosis were not. Common conditions accompanying neurological events were hypertension, coronary artery disease-heart failure, and diabetes mellitus. Conclusion COVID-19 may present with neurological symptoms in our Turkish patients and comorbidities are often present.
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Affiliation(s)
- Nuray Can Usta
- Department of Neurology, University of Health Science, Trabzon Kanuni Training and Research Hospital, Trabzon61250, Turkey
| | - Seyfi Kartal
- Department of Anaesthesiology and Reanimation, University of Health Science, Trabzon Kanuni Training and Research Hospital, Trabzon61250, Turkey
| | - Betul Onal Gunay
- Department of Ophthalmology, University of Health Science, Trabzon Kanuni Training and Research Hospital, Trabzon61250, Turkey
| | - Cavit Boz
- Department of Neurology, Karadeniz Technical University, School of Medicine, Trabzon, Turkey
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16
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Arif A, Chavarria Y, Qamar MA, Tebha SS, Butt M, Qamar K, Yosufi A. New-Onset Refractory Status Epilepticus Secondary to COVID-19 Infection in Adults: A Systematic Review. Neuropsychiatr Dis Treat 2022; 18:1951-1961. [PMID: 36065386 PMCID: PMC9440723 DOI: 10.2147/ndt.s381018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 08/20/2022] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND New-onset refractory status epilepticus (NORSE) has been reported in the scientific literature as a phenomenon associated with the COVID-19 infection. Given the resurgence of the newer variants of COVID-19 added with its multi-system manifestations, this project was conducted to study the clinical picture of NORSE secondary to COVID-19 infection. METHODS Three electronic databases were searched using an extensive search strategy from November 2019 to December 2021. Patients reporting NORSE secondary to COVID-19 were included in this review. The status epilepticus severity score (STESS) was calculated by the study authors for individual patients. Statistical analysis was performed using SPSS version 26 with a p-value <0.05 as statistically significant. RESULTS After screening, 12 patients were included in this study with a mean age of 61.6 ± 19.0-year olds. The most common type of status epilepticus reported in our study population was non-convulsive status epilepticus (NCSE) (7 out of 12 patients, 58.3%). The linear regression model revealed that STESS scores were significantly influenced by patients' age (p = 0.004) and intra-hospital occurrence (IHO) of status epilepticus (p = 0.026). Overall, 8 patients (66.7%) were discharged without complications. CONCLUSION Given the observed association of STESS with the aging population and IHO of status epilepticus, special attention is due to the caretakers of this population, while further studies are needed to further build upon this review.
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Affiliation(s)
- Aabiya Arif
- Medical School, Ziauddin University, Karachi, Sindh, Pakistan
| | - Yeny Chavarria
- Department of Neurology, University of California, Irvine, CA, USA
| | | | - Sameer Saleem Tebha
- Department of Neurosurgery and Neurology, Jinnah Medical and Dental College, Karachi, Sindh, Pakistan
| | - Mehwish Butt
- Department of Neurosurgery and Neurology, Jinnah Medical and Dental College, Karachi, Sindh, Pakistan
| | - Khulud Qamar
- Department of Medicine, Dow Medical College, Karachi, Sindh, Pakistan
| | - Abubakr Yosufi
- Medical School, Kabul University of Medical Sciences, Kabul, Afghanistan
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17
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Neurological Manifestations and Outcomes in a Retrospective Cohort of Mexican Inpatients with SARS-CoV-2 Pneumonia: Design of a Risk Profile. Healthcare (Basel) 2021; 9:healthcare9111501. [PMID: 34828547 PMCID: PMC8620259 DOI: 10.3390/healthcare9111501] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/29/2021] [Accepted: 11/01/2021] [Indexed: 01/08/2023] Open
Abstract
We analyzed the neurological manifestations in Mexican patients hospitalized with pneumonia due to COVID-19 and investigated the association between demographic, clinical, and biochemical variables and outcomes, including death. A retrospective, analytical study was conducted using the electronic records of patients hospitalized between 1 April 2020 and 30 September 2020. Records of 1040 patients were analyzed: 31.25% died and 79.42% had neurological symptoms, including headache (80.62%), anosmia (32.20%), ageusia (31.96%), myopathy (28.08%), disorientation (14.89%), encephalopathy (12.22%), neuropathy (5.4%), stroke (1.3%), seizures (1.3%), cerebral hemorrhage (1.08%), encephalitis (0.84%), central venous thrombosis (0.36%), and subarachnoid hemorrhage (0.24%). Patients also had comorbidities, such as hypertension (42.30%), diabetes mellitus (38.74%), obesity (61.34%), chronic obstructive pulmonary disease (3.17%), and asthma (2.01%). Factors associated with neurological symptoms were dyspnea, chronic obstructive pulmonary disease, advanced respiratory support, prolonged hospitalization, and worsening fibrinogen levels. Factors associated with death were older age, advanced respiratory support, amine management, chronic obstructive pulmonary disease, intensive care unit management, dyspnea, disorientation, encephalopathy, hypertension, neuropathy, diabetes, male sex, three or more neurological symptoms, and obesity grade 3. In this study we designed a profile to help predict patients at higher risk of developing neurological complications and death following COVID-19 infection.
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18
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Pauletto G, Nilo A, Deana C, Verriello L, Del Negro I, Lettieri C, Vetrugno L, Valente M, Gigli GL. Recurrent Status Epilepticus and SARS-CoV-2 infection: the "perfect storm". ACTA BIO-MEDICA : ATENEI PARMENSIS 2021; 92:e2021208. [PMID: 34738572 PMCID: PMC8689343 DOI: 10.23750/abm.v92i5.11593] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 04/09/2021] [Indexed: 11/23/2022]
Abstract
Respiratory involvement is the most common clinical manifestation of COVID-19, but neurological symptoms and complications are increasingly being recognized. Seizures and status epilepticus (SE) have been described as possible consequences of hypoxia and metabolic derangements during SARS-CoV-2 infection, direct viral invasion of the central nervous system, or as para or post-infectious complications. Single episodes of SE have been described, occurring during the acute phase of COVID-19 or once the patients have been recovered. Herein, we present the case of a patient with a positive serology test for SARS-CoV-2 (IgG+, IgM-) and recurrent SE occurring within 36 days. Diagnostic work-up ruled out other known causes of SE. A post-COVID-19 infectious inflammatory/immune response is hypothesized as the possible trigger of SE.
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Affiliation(s)
- Giada Pauletto
- Neurology Unit, Department of Neurosciences, S. Maria della Misericordia University Hospital, Udine, Italy.
| | - Annacarmen Nilo
- Clinical Neurology Unit, Department of Neurosciences, S. Maria della Misericordia University Hospital, Udine, Italy.
| | - Cristian Deana
- Anesthesia and Intensive Care Unit 1, Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy..
| | - Lorenzo Verriello
- Neurology Unit, Department of Neurosciences, S. Maria della Misericordia University Hospital, Udine, Italy.
| | - Ilaria Del Negro
- Clinical Neurology Unit, Department of Neurosciences, S. Maria della Misericordia University Hospital, Udine, Italy.
| | - Christian Lettieri
- Neurology Unit, Department of Neurosciences, S. Maria della Misericordia University Hospital, Udine, Italy.
| | - Luigi Vetrugno
- Clinical Anesthesia and Intensive Care, Department of Medicine (DAME), University of Udine Medical School, Udine, Italy.
| | - Mariarosaria Valente
- Clinical Neurology Unit, Department of Neurosciences, S. Maria della Misericordia University Hospital, Udine, Italy.
| | - Gian Luigi Gigli
- Clinical Neurology Unit, Department of Neurosciences, S. Maria della Misericordia University Hospital, Udine, Italy.
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19
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Xiong W, Lu L, Zhang B, Luo J, Li W, He L, Sander JW, Mu J, Zhu C, Zhou D. Association of consciousness impairment and mortality in people with COVID-19. Acta Neurol Scand 2021; 144:251-259. [PMID: 34028792 PMCID: PMC8222878 DOI: 10.1111/ane.13471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 04/14/2021] [Accepted: 04/20/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND To investigate the association between impairment of consciousness and risk of death in people with COVID-19. METHODS In this multicentre retrospective study, we enrolled people with confirmed COVID-19 from 44 hospitals in Wuhan and Sichuan, China, between 18 January and 30 March 2020. We extracted demographics, clinical, laboratory data and consciousness level (as measured by the Glasgow Coma Scale (GCS) score) from medical records. We used Cox proportional hazards regression, structural equation modelling and survival time analysis to compare people with different progressions of impaired consciousness. RESULTS We enrolled 1,143 people (average age 51.3 ± standard deviation 17.1-year-old; 50.3% males), of whom 76 died. Increased mortality risk was identified in people with GCS score between 9 and 14 (hazard ratio (HR) 46.76, p < .001) and below 9 (HR 65.86, p < .001). Pathway analysis suggested a significant direct association between consciousness level and death. Other factors, including age, oxygen saturation level and pH, had indirect associations with death mediated by GCS scores. People who developed impaired consciousness more rapidly either from symptoms onset (<10 days vs. 10-19 days, p = .025, <10 days vs. ≥20 days and 10-19 days vs. ≥20 days, <.001) or deterioration of oxygen saturation (≤2 days vs.>2 days, p = .028) had shorter survival times. CONCLUSION Altered consciousness and its progression had a direct link with death in COVID-19. Interactions with age, oxygen saturation level and pH suggest possible pathophysiology. Further work to confirm these findings explore prevention strategies and interventions to decrease mortality is warranted.
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Affiliation(s)
- Weixi Xiong
- Department of Neurology West China Hospital of Sichuan University Chengdu China
- Institute of Brain Science and Brain‐inspired technology of West China Hospital Sichuan University Chengdu China
| | - Lu Lu
- Department of Neurology West China Hospital of Sichuan University Chengdu China
- Institute of Brain Science and Brain‐inspired technology of West China Hospital Sichuan University Chengdu China
| | - Baiyang Zhang
- West China School of Public Health and West China Fourth Hospital Sichuan University Chengdu China
| | - Jianfei Luo
- Department of Gastrointestinal Surgery Renmin Hospital of Wuhan University Wuhan China
| | - Weimin Li
- Department of Pulmonary & Critical Care Medicine West China Hospital of Sichuan University Chengdu China
| | - Li He
- Department of Neurology West China Hospital of Sichuan University Chengdu China
- Institute of Brain Science and Brain‐inspired technology of West China Hospital Sichuan University Chengdu China
| | - Josemir W. Sander
- Department of Neurology West China Hospital of Sichuan University Chengdu China
- Institute of Brain Science and Brain‐inspired technology of West China Hospital Sichuan University Chengdu China
- UCL Queen Square Institute of Neurology NIHR University College London Hospitals Biomedical Research Centre London UK
- Chalfont Centre for Epilepsy Chalfont St Peter UK
- Stichting Epilepsie Instellingen Nederland (SEIN) Heemstede Netherlands
| | - Jie Mu
- Department of Neurology West China Hospital of Sichuan University Chengdu China
- Institute of Brain Science and Brain‐inspired technology of West China Hospital Sichuan University Chengdu China
| | - Cairong Zhu
- West China School of Public Health and West China Fourth Hospital Sichuan University Chengdu China
| | - Dong Zhou
- Department of Neurology West China Hospital of Sichuan University Chengdu China
- Institute of Brain Science and Brain‐inspired technology of West China Hospital Sichuan University Chengdu China
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20
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Khair AM, Husain S, Kaur G, Falchek S. Convulsive Status Epilepticus in a Child With Controlled Epilepsy and Concurrent COVID-19 Infection: A Case Report and a Quick Review. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2021; 13:1179547620984126. [PMID: 34456598 PMCID: PMC8388184 DOI: 10.1177/1179547620984126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 12/01/2020] [Indexed: 01/02/2023]
Abstract
The current unprecedented COVID-19 pandemic has been another step toward learning about the unique interaction between viral infections and human nervous system. Very few scientific papers explored neuroinvasive and neurotropic potentials of the SARS-CoV-2 virus in children. We report a child with convulsive status epilepticus and confirmed COVID-19 infection. Brief review of current available literature was discussed.
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Affiliation(s)
- Abdulhafeez M Khair
- Division of Neurology, Nemours/Alfred I. DuPont Hospital for Children, Wilmington, DE, USA
| | - Sumair Husain
- Division of Neurology, Nemours/Alfred I. DuPont Hospital for Children, Wilmington, DE, USA
| | - Gurcharanjeet Kaur
- Division of Neurology, Nemours/Alfred I. DuPont Hospital for Children, Wilmington, DE, USA.,Thomas Jefferson University, Philadelphia, PA, USA
| | - Stephen Falchek
- Division of Neurology, Nemours/Alfred I. DuPont Hospital for Children, Wilmington, DE, USA.,Thomas Jefferson University, Philadelphia, PA, USA
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21
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Norouzi M, Miar P, Norouzi S, Nikpour P. Nervous System Involvement in COVID-19: a Review of the Current Knowledge. Mol Neurobiol 2021; 58:3561-3574. [PMID: 33765290 DOI: 10.1007/s12035-021-02347-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 03/03/2021] [Indexed: 01/08/2023]
Abstract
The current pandemic of the new human coronavirus (CoV), i.e., severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has created an urgent global condition. The disease, termed coronavirus disease 2019 (COVID-19), is primarily known as a respiratory tract infection. Although SARS-CoV-2 directly invades the lungs, COVID-19 is a complex multi-system disease with varying degrees of severity and affects several human systems including the cardiovascular, respiratory, gastrointestinal, neurological, hematopoietic, and immune systems. From the existing data, most COVID-19 cases develop a mild disease typically presented with fever and respiratory illness. However, in some patients, clinical evidence suggests that COVID-19 might progress to acute respiratory distress syndrome (ARDS), multi-organ dysfunction, and septic shock resulting in a critical condition. Likewise, specific organ dysfunction seems to be related to the disease complication, worsens the condition, and increases the lethality of COVID-19. The neurological manifestations in association with disease severity and mortality have been reported in COVID-19 patients. Despite the continuously increasing reports of the neurological symptoms of SARS-CoV-2, our knowledge about the possible routes of nervous system involvement associated with COVID-19 is limited. Herein, we will primarily describe the critical aspects and clinical features of SARS-CoV-2 related to nervous system impairment and then discuss possible routes of SARS-CoV-2 nervous system involvement based on the current evidence.
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Affiliation(s)
- Mahnaz Norouzi
- Department of Genetics, Faculty of Sciences, Shahid Chamran University of Ahvaz, Ahvaz, Iran
| | - Paniz Miar
- Department of Genetics and Molecular Biology, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Shaghayegh Norouzi
- School of Health and Biomedical Sciences, RMIT University, Melbourne, VIC, 3083, Australia
| | - Parvaneh Nikpour
- Department of Genetics and Molecular Biology, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
- Pediatric Inherited Diseases Research Center, Research Institute for Primordial Prevention of Noncommunicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran.
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22
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Prakash A, Singh H, Sarma P, Bhattacharyya A, Dhibar DP, Balaini N, Shree R, Goyal M, Modi M, Medhi B. nCoV-2019 infection induced neurological outcome and manifestation, linking its historical ancestor SARS-CoV and MERS-CoV: a systematic review and meta-analysis. Sci Rep 2021; 11:12888. [PMID: 34145351 PMCID: PMC8213856 DOI: 10.1038/s41598-021-92188-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 01/18/2021] [Indexed: 12/23/2022] Open
Abstract
The first systematic review and meta-analysis to help clinician to identify early signs and symptoms of neurological manifestation in COVID-19 positive patients which will further help in early management of patients. Present systematic review and meta-analysis aimed to discuss the prevalence of neurological involvement of the 2019-nCoV patients and assess the symptomatic trend of events as compared to the 2002 "SARS" and 2012 "MERS" pandemics. The articles were systematically screened through several search engine and databases. The articles published or in preprint were included in the study till 15th May 2020. The systematic review done as per the published literatures which included 31 cross sectional, observational studies and case reports which revealed neurological signs and symptoms in SARS-COV-2 disease. For meta-analysis, we included 09 observational and cross-sectional studies which included COVID-19 positive patients and assessed the predominance of various neurological signs and symptoms in COVID-19 patients with relation to SARS-2002 and MERS-2012. Data was analyzed by using the "MedCalc" Statistical Software version 19.2.6 and reported as pooled prevalence. Standard I2 test was used to analyze the heterogeneity. We have collected and screened about a total 2615articles, finally we have included 31articles for the systematic review and 09 for meta-analysis as per the inclusion/exclusion criteria. The analysis was made as per the prevalence rate of neurological symptoms in COVID-19 positive patients. The cumulative neurological outcome of SARS-2002 and MERS-2012 was assessed to get the trends which was further tried to correlate the events with the current pandemic. During the analysis severity and outcome of neurological manifestations range from simple headache to vague non-focal complaints to severe neurologic impairment associated with seizure or meningitis. Central and peripheral nervous system (CNS/PNS) manifestations were seen during the SARS-2002, MERS-2012 and COVID-19. However, none of the publication had primary or secondary objectives of searching neurological manifestations in the COVID-19 patients and the pathogenic mechanism which will subsequently strengthen the importance to start more prospective clinical trials. The prevalence of neurological signs and symptoms were taken as primary objective. Thereafter, the prevalence of each CNS/PNS symptoms was categorized and their prevalence studied. The selection of Bagheri et al., 2020 may be discussed because they have done the cross-sectional study with the neurological finding and correlated the data with prevalence of the COVID-19 positive patients. The proportion of patients presenting with neurological outcome and clinical/PCR positivity were done. We had searched and followed all the possible online/web source, still the data collection process may remain a limitation of work due to addition of several publications on COVID-19 every day. Due to lack of data of SARS-CoV and MERS-CoV, we have included the case reports, MERS and COVID-19 in CNS/PNS manifestations.
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Affiliation(s)
- Ajay Prakash
- Department of Pharmacology, Research Block: B, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Harvinder Singh
- Department of Pharmacology, Research Block: B, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Phulen Sarma
- Department of Pharmacology, Research Block: B, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | | | - Deba Prasad Dhibar
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | | | - Ritu Shree
- Department of Neurology, PGIMER, Chandigarh, India
| | - Manoj Goyal
- Department of Neurology, PGIMER, Chandigarh, India
| | - Manish Modi
- Department of Neurology, PGIMER, Chandigarh, India
| | - Bikash Medhi
- Department of Pharmacology, Research Block: B, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
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Mohan N, Fayyaz MA, del Rio C, Khurana NKRS, Vaidya SS, Salazar E, Joyce J, Ali AA. Neurological manifestations and neuroimaging findings in patients with SARS-CoV2-a systematic review. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2021; 57:68. [PMID: 34093004 PMCID: PMC8170868 DOI: 10.1186/s41983-021-00322-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 05/17/2021] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic has drastically affected everyone in a hit or miss manner. Since it began, evidence of the neuro-invasive potential of the virus has been intensifying significantly. Several pathways have been hypothesized to elucidate the neurotropic nature of SARS-CoV2. It is the need of the hour to collect vital information. OBJECTIVE To evaluate and correlate the neuro-radiological and neurological manifestations in patients diagnosed with SARS-CoV2.To identify neuro-invasive pathways of COVID infection. METHODS Relevant studies were identified through four databases-the Cochrane Library, PubMed, Science Direct, and Web of Science. These were searched using relevant keywords-"COVID-19," "SARS-CoV2," "neurological manifestations," "neuroimaging," "CT," and "MRI." Relevant articles were screened according to a pre-defined inclusion and exclusion criteria from December 2019 to August 2020. RESULTS Our review included a total of 63 full text publications with 584 patients, composed mainly of observational studies, case reports, and case series. The most common neurological manifestations associated with COVID-19 were altered mental status, stroke, and paralysis. About 17.85% patients who underwent neuroimaging were found to be having ischemic changes suggestive of a stroke. This was followed by hemorrhagic changes as the second most common finding. The most commonly involved vessel was the Middle Cerebral Artery. Besides stroke, we found that SARS-CoV2 could be the cause for new-onset seizures, Guillain-Barre Syndrome, encephalitis, and many other severe neurological diseases. CONCLUSION The information that we have obtained so far will prove dynamic to healthcare providers working against the COVID-19 pandemic. It is necessary to be aware of these atypical neurological findings for the early diagnosis and treatment of COVID-19 infected patients. However, to completely understand the connection between SARS-CoV2 and the nervous system, further research is necessary.
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Affiliation(s)
- Nikita Mohan
- Jawaharlal Nehru Medical College, Belagavi, Karnataka India
| | | | - Christopher del Rio
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey Nuevo Leon, Mexico
| | | | | | - Esteban Salazar
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey Nuevo Leon, Mexico
| | - John Joyce
- M.S Ramaiah Medical College, Bangalore, Karnataka India
| | - Amrat Ayaz Ali
- Liaquat University of Medical and Health Sciences, Jamshoro, Pakistan
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24
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Delayed post-hypoxic leukoencephalopathy in an adult with COVID-19. J Neurovirol 2021; 27:514-518. [PMID: 33977501 PMCID: PMC8112471 DOI: 10.1007/s13365-021-00982-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 04/02/2021] [Accepted: 04/14/2021] [Indexed: 11/23/2022]
Abstract
As the novel coronavirus, SARS-CoV-2, has enveloped the world in a pandemic, it has become clear that the symptoms extend far beyond the respiratory system and have particularly caused a wide range of neurologic CNS complications, including diffuse leukoencephalopathy. Here, we describe a case of a 59-year-old male with severe COVID-19 infection who developed severe encephalopathy, which persisted well after his acute infection had subsided and had begun to improve from his respiratory dysfunction. He was found to have diffuse leukoencephalopathy with concomitant diffusion restriction on MR imaging. This case represents a delayed onset of leukoencephalopathy secondary to hypoxia in a small but growing cohort of COVID-related leukoencephalopathy due to similarities in imaging features and lack of superior alternate diagnosis. Patient’s clinical improvement suggests reversibility with likely pathology being demyelination rather than infarction.
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Crowley JS, Reghunathan M, Kadakia N, Barttelbort S, Gosman A. Financial Decisions and Reopening a Practice During the COVID-19 Pandemic: A Survey of California Plastic Surgeons. Ann Plast Surg 2021; 86:S354-S359. [PMID: 33833188 DOI: 10.1097/sap.0000000000002859] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND On March 11, 2020, the World Health Organization declared COVID-19 as a global pandemic. As a response, the United States shut down public gatherings and businesses in an effort to quarantine. This included the stopping of elective operations, which greatly affected plastic surgeons and their practices during the initial shutdown. OBJECTIVES We aim to study the early impact of COVID-19 on the financial implications and practice patterns of plastic surgeons in the state of California during the initial shutdown of elective surgery and provide guidelines for effective management during future crises. METHODS A 20-question survey was sent using Qualtrics XM software to 851 surgeon members of the California Society of Plastic Surgeons. The survey was open from May 13, 2020, to May 29, 2020. Standard statistical analysis was completed to compare private practice and nonprivate practice plastic surgeons. RESULTS We had a total of 140 respondents to our survey for a 16.5% response rate. The majority (77.1%) of the respondents were in a private practice setting. Private practice plastic surgeons reported a higher financial impact with a 79% reduction in financial income compared with nonprivate practice plastic surgeons at a 37% reduction (P < 0.0001). Additionally, private practice plastic surgeons demonstrated a higher reduction in case volume and were more likely to lay off or furlough staff, close their practice, and apply for loans (P < 0.001). CONCLUSIONS Our survey study showed that private practice plastic surgeons in the state of California faced the most financial hardship during the early shutdown of the COVID-19 pandemic. It serves as a valuable snapshot in our economic history and depicts the heavy financial impact of the stopping of elective surgery. Since the reopening of practices, new guidelines have been implemented to maintain safe elective surgery while the pandemic continues. Further follow-up studies on both the state and national level need to be completed to see the continued financial effects on private and nonprivate plastic surgery practices since the reopening and resumption of elective surgery.
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Affiliation(s)
- Jiwon Sarah Crowley
- From the Division of Plastic Surgery, University of California San Diego, La Jolla
| | - Meera Reghunathan
- From the Division of Plastic Surgery, University of California San Diego, La Jolla
| | - Nikita Kadakia
- School of Medicine, University of California Riverside, Riverside
| | | | - Amanda Gosman
- From the Division of Plastic Surgery, University of California San Diego, La Jolla
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26
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Lin L, Al‐Faraj A, Ayub N, Bravo P, Das S, Ferlini L, Karakis I, Lee JW, Mukerji SS, Newey CR, Pathmanathan J, Abdennadher M, Casassa C, Gaspard N, Goldenholz DM, Gilmore EJ, Jing J, Kim JA, Kimchi EY, Ladha HS, Tobochnik S, Zafar S, Hirsch LJ, Westover MB, Shafi MM. Electroencephalographic Abnormalities are Common in COVID-19 and are Associated with Outcomes. Ann Neurol 2021; 89:872-883. [PMID: 33704826 PMCID: PMC8104061 DOI: 10.1002/ana.26060] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 03/08/2021] [Accepted: 03/08/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The aim was to determine the prevalence and risk factors for electrographic seizures and other electroencephalographic (EEG) patterns in patients with Coronavirus disease 2019 (COVID-19) undergoing clinically indicated continuous electroencephalogram (cEEG) monitoring and to assess whether EEG findings are associated with outcomes. METHODS We identified 197 patients with COVID-19 referred for cEEG at 9 participating centers. Medical records and EEG reports were reviewed retrospectively to determine the incidence of and clinical risk factors for seizures and other epileptiform patterns. Multivariate Cox proportional hazards analysis assessed the relationship between EEG patterns and clinical outcomes. RESULTS Electrographic seizures were detected in 19 (9.6%) patients, including nonconvulsive status epilepticus (NCSE) in 11 (5.6%). Epileptiform abnormalities (either ictal or interictal) were present in 96 (48.7%). Preceding clinical seizures during hospitalization were associated with both electrographic seizures (36.4% in those with vs 8.1% in those without prior clinical seizures, odds ratio [OR] 6.51, p = 0.01) and NCSE (27.3% vs 4.3%, OR 8.34, p = 0.01). A pre-existing intracranial lesion on neuroimaging was associated with NCSE (14.3% vs 3.7%; OR 4.33, p = 0.02). In multivariate analysis of outcomes, electrographic seizures were an independent predictor of in-hospital mortality (hazard ratio [HR] 4.07 [1.44-11.51], p < 0.01). In competing risks analysis, hospital length of stay increased in the presence of NCSE (30 day proportion discharged with vs without NCSE: HR 0.21 [0.03-0.33] vs 0.43 [0.36-0.49]). INTERPRETATION This multicenter retrospective cohort study demonstrates that seizures and other epileptiform abnormalities are common in patients with COVID-19 undergoing clinically indicated cEEG and are associated with adverse clinical outcomes. ANN NEUROL 2021;89:872-883.
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Affiliation(s)
- Lu Lin
- Beth Israel Deaconess Medical Center, Department of NeurologyHarvard Medical SchoolBostonMA
| | | | - Neishay Ayub
- Massachusetts General Hospital, Department of NeurologyHarvard Medical SchoolBostonMA
| | - Pablo Bravo
- Department of NeurologyYale UniversityNew HavenCT
| | - Sudeshna Das
- Massachusetts General Hospital, Department of NeurologyHarvard Medical SchoolBostonMA
| | - Lorenzo Ferlini
- Hôspital Erasme, Département de NeurologieUniversité Libre de BruxellesBruxellesBelgium
| | | | - Jong Woo Lee
- Brigham and Women's Hospital, Department of NeurologyHarvard Medical SchoolBoston, MA
| | - Shibani S. Mukerji
- Massachusetts General Hospital, Department of NeurologyHarvard Medical SchoolBostonMA
| | | | | | | | - Charles Casassa
- Beth Israel Deaconess Medical Center, Department of NeurologyHarvard Medical SchoolBostonMA
| | - Nicolas Gaspard
- Department of NeurologyYale UniversityNew HavenCT
- Hôspital Erasme, Département de NeurologieUniversité Libre de BruxellesBruxellesBelgium
| | - Daniel M. Goldenholz
- Beth Israel Deaconess Medical Center, Department of NeurologyHarvard Medical SchoolBostonMA
| | | | - Jin Jing
- Massachusetts General Hospital, Department of NeurologyHarvard Medical SchoolBostonMA
| | | | - Eyal Y. Kimchi
- Massachusetts General Hospital, Department of NeurologyHarvard Medical SchoolBostonMA
| | | | - Steven Tobochnik
- Brigham and Women's Hospital, Department of NeurologyHarvard Medical SchoolBoston, MA
| | - Sahar Zafar
- Massachusetts General Hospital, Department of NeurologyHarvard Medical SchoolBostonMA
| | | | - M. Brandon Westover
- Massachusetts General Hospital, Department of NeurologyHarvard Medical SchoolBostonMA
| | - Mouhsin M. Shafi
- Beth Israel Deaconess Medical Center, Department of NeurologyHarvard Medical SchoolBostonMA
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27
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Dono F, Nucera B, Lanzone J, Evangelista G, Rinaldi F, Speranza R, Troisi S, Tinti L, Russo M, Di Pietro M, Onofrj M, Bonanni L, Assenza G, Vollono C, Anzellotti F, Brigo F. Status epilepticus and COVID-19: A systematic review. Epilepsy Behav 2021; 118:107887. [PMID: 33743344 PMCID: PMC7968345 DOI: 10.1016/j.yebeh.2021.107887] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 01/28/2021] [Accepted: 02/21/2021] [Indexed: 12/22/2022]
Abstract
PURPOSE In March 2020, the World Health Organization declared the SARS-CoV-2 infection-related coronavirus Disease (COVID-19) a pandemic. During the first and second waves of the pandemic spread, there have been several reports of COVID-19-associated neurological manifestations, including acute seizures and status epilepticus (SE). In this systematic review, we summarized the available data on clinical features, diagnosis, and therapy of COVID-19-related SE. METHODS We performed a systematic search of the literature to identify data on demographics, clinical, neurophysiological, and neuroradiological data of patients with COVID-19-related SE. We used regression models (linear or logistic) with a stepwise forward method to identify features associated with mortality or severity of SE. RESULTS Thirty-nine articles were included with a total of 47 cases of SE associated with COVID-19. Age, time between the acute respiratory phase of SARS-CoV-2 infection and SE onset, and hospitalization correlated with a higher SE severity as assessed by quantitative validated scales. CONCLUSIONS SE can be a neurological manifestation of SARS-CoV-2 infection. Although a possible association between SE and COVID-19 has been reported, the exact mechanisms are still not fully understood. Systemic inflammatory syndrome due to cytokine release could play a role in COVID-19-related SE.
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Affiliation(s)
- Fedele Dono
- Department of Neuroscience, Imaging and Clinical Science, "G. D'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Bruna Nucera
- Department of Neurology, Hospital of Merano (SABES-ASDAA), Merano, Italy
| | - Jacopo Lanzone
- Fondazione Europea per la Ricerca Biomedica Onlus, Trescore Balneario, Italy
| | - Giacomo Evangelista
- Department of Neuroscience, Imaging and Clinical Science, "G. D'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Fabrizio Rinaldi
- Department of Neurology, Hospital of Merano (SABES-ASDAA), Merano, Italy
| | - Rino Speranza
- Department of Neuroscience, Imaging and Clinical Science, "G. D'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Serena Troisi
- Pediatric Neurology, Department of Neuroscience, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Lorenzo Tinti
- Department of Neurology, San Gerardo Hospital, Monza, Italy
| | - Mirella Russo
- Department of Neuroscience, Imaging and Clinical Science, "G. D'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Martina Di Pietro
- Department of Neuroscience, Imaging and Clinical Science, "G. D'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Marco Onofrj
- Department of Neuroscience, Imaging and Clinical Science, "G. D'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Laura Bonanni
- Department of Neuroscience, Imaging and Clinical Science, "G. D'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Giovanni Assenza
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, University Campus Bio-Medico of Rome, Rome, Italy
| | - Catello Vollono
- Dipartimento Scienze dell'invecchiamento, neurologiche, ortopediche e della testa-collo, Unit of Neurophysiopathology and Sleep Medicine, Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy
| | | | - Francesco Brigo
- Department of Neurology, Hospital of Merano (SABES-ASDAA), Merano, Italy
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Post-COVID seizure: A new feature of "long-COVID". eNeurologicalSci 2021; 23:100340. [PMID: 33898792 PMCID: PMC8053221 DOI: 10.1016/j.ensci.2021.100340] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 04/05/2021] [Accepted: 04/12/2021] [Indexed: 12/19/2022] Open
Abstract
Novel coronavirus SARS-CoV-2 has created unprecedented healthcare challenges. Neurologic deficits are often an important presenting symptom. To date, the only reported post-infectious COVID-19 manifestations of neurologic disease include cognitive deficits and dysfunction of the peripheral nervous system. Here we report that seizure can also be a post-COVID-19 or “long-COVID” complication. We present a 71-year-old man with hypertension, diabetes mellitus, and COVID-19 diagnosed by RT-PCR who initially presented with posterior circulation stroke-like symptoms, which completely resolved after emergent thrombolysis. Six days later, the patient returned with seizure activity, supported by radiographic and electroencephalographic studies. Notably, he was negative for SARS-CoV-2, and no other provoking factor was uncovered after a comprehensive work-up. To our knowledge, this is the first report of post-infectious seizures after a case of COVID-19, highlighting the potential importance of monitoring for neurologic symptoms in COVID-19 patients, even after convalescence. Patients with COVID-19 can develop multiple neurologic disorders. Seizure can be a manifestation of the “Long-COVID” syndrome. Longitudinal studies of neurologic disease in COVID-19 survivors are needed.
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29
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Shehata GA, Lord KC, Grudzinski MC, Elsayed M, Abdelnaby R, Elshabrawy HA. Neurological Complications of COVID-19: Underlying Mechanisms and Management. Int J Mol Sci 2021; 22:4081. [PMID: 33920904 PMCID: PMC8071289 DOI: 10.3390/ijms22084081] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 04/10/2021] [Accepted: 04/13/2021] [Indexed: 02/06/2023] Open
Abstract
COVID-19 is a severe respiratory disease caused by the newly identified human coronavirus (HCoV) Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2). The virus was discovered in December 2019, and in March 2020, the disease was declared a global pandemic by the World Health Organization (WHO) due to a high number of cases. Although SARS-CoV-2 primarily affects the respiratory system, several studies have reported neurological complications in COVID-19 patients. Headache, dizziness, loss of taste and smell, encephalitis, encephalopathy, and cerebrovascular diseases are the most common neurological complications that are associated with COVID-19. In addition, seizures, neuromuscular junctions' disorders, and Guillain-Barré syndrome were reported as complications of COVID-19, as well as neurodegenerative and demyelinating disorders. However, the management of these conditions remains a challenge. In this review, we discuss the prevalence, pathogenesis, and mechanisms of these neurological sequelae that are secondary to SARS-CoV-2 infection. We aim to update neurologists and healthcare workers on the possible neurological complications associated with COVID-19 and the management of these disease conditions.
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Affiliation(s)
- Ghaydaa A. Shehata
- Department of Neurology and Psychiatry, Assiut University Hospitals, Assiut 71511, Egypt;
| | - Kevin C. Lord
- Department of Physiology and Pharmacology, College of Osteopathic Medicine, Sam Houston State University, Conroe, TX 77304, USA;
| | | | - Mohamed Elsayed
- Department of Psychiatry and Psychotherapy III, University of Ulm, Leimgrubenweg 12-14, 89075 Ulm, Germany;
| | - Ramy Abdelnaby
- Department of Neurology, RWTH Aachen University, Pauwelsstraße 30, 52074 Aachen, Germany;
| | - Hatem A. Elshabrawy
- Department of Molecular and Cellular Biology, College of Osteopathic Medicine, Sam Houston State University, Conroe, TX 77304, USA
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Corazza LA, Tatsch JFS, Barros MP, Queiroz APD, Batista LLR, Aidar MB, Baldocchi MA, Rocha MSG, Brucki SMD. Electroencephalographic findings among inpatients with COVID-19 in a tertiary hospital from a middle-income country. ARQUIVOS DE NEURO-PSIQUIATRIA 2021; 79:315-320. [PMID: 34133512 PMCID: PMC9231444 DOI: 10.1590/0004-282x-anp-2020-0555] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 02/06/2021] [Accepted: 02/16/2021] [Indexed: 03/25/2023]
Abstract
BACKGROUND In 2019, the world witnessed the emergence of a new type of coronavirus - the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The spectrum of coronavirus disease 2019 (COVID-19) is variable, and amongst its manifestations are neurological implications. OBJECTIVE This report aimed to describe electroencephalographic findings in COVID-19 patients from a general tertiary hospital in São Paulo, Brazil. METHODS It was a retrospective, observational, and non-interventional study. Data were collected anonymously, comprising inpatients from Mar 1 to Jun 30, 2020, either confirmed (positive RT-PCR) or probable cases (CO-RADS 4/5) who had performed EEG during hospitalization. RESULTS Twenty-eight patients were enrolled, 17 (60.7%) women and 11 men, with a median age of 58 (minimum and maximum: 18-86; IQR 23.5). COVID-19 diagnosis was confirmed in 22 (78.5%). Twenty-one patients (75%) had severe disease, requiring mechanical ventilation due to acute respiratory distress syndrome (ARDS); 16 (57.1%) patients developed adjunct sepsis throughout hospitalization. There was no specific pattern found for COVID-19 in EEG. No patients presented with status epilepticus or electrographic events; most patients developed an encephalopathic pattern, as seen in most studies, with a high prevalence of altered mental status as an indication for EEG. Adjunct sepsis was associated with higher mortality. CONCLUSIONS EEG presents as a useful tool in the context of COVID-19, as in other conditions, to differentiate nonconvulsive status epilepticus (NCSE) from encephalopathy and other causes of mental status alterations. Further studies are required to analyze whether there might be a specific EEG pattern to the disease.
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Abstract
Purpose of Review This review presents an overview of the known neurocritical care complications of severe acute respiratory virus 2 (SARS-CoV-2). We present readers with a review of the literature of severe neurologic complications of SARS-CoV-2 and cases from our institution to illustrate these conditions. Recent Findings Neurologic manifestations are being increasingly recognized in the literature. Some patients can have severe neurologic manifestations, though the true prevalence is unknown. Summary Severe neurologic complications of COVID-19 include large vessel occlusion ischemic stroke, intracranial hemorrhage, encephalitis, myelitis, Guillain-Barre syndrome, status epilepticus, posterior reversible encephalopathy syndrome, and hypoxic-ischemic encephalopathy. These conditions can manifest in COVID-19 patients even in the absence of risk factors and must be promptly identified as they can have a high mortality if left untreated.
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Affiliation(s)
- Daniella C Sisniega
- Department of Neurology, 1 Gustave L. Levy Place, Box 1136, New York, NY 10029 USA
| | - Alexandra S Reynolds
- Department of Neurology, 1 Gustave L. Levy Place, Box 1136, New York, NY 10029 USA.,Department of Neurosurgery, The Mount Sinai Hospital, 1 Gustave L. Levy Place, Box 1136, New York, NY 10029 USA
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32
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Schultz B, Krauß T, Schmidt M, Schultz M, Schneider A, Wiesner O, Schmidt JJ, Stahl K, David S, Hoeper MM, Busch M. High Incidence of Epileptiform Potentials During Continuous EEG Monitoring in Critically Ill COVID-19 Patients. Front Med (Lausanne) 2021; 8:613951. [PMID: 33842496 PMCID: PMC8032936 DOI: 10.3389/fmed.2021.613951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 02/25/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: To analyze continuous 1- or 2-channel electroencephalograms (EEGs) of mechanically ventilated patients with coronavirus disease 2019 (COVID-19) with regard to occurrence of epileptiform potentials. Design: Single-center retrospective analysis. Setting: Intensive care unit of Hannover Medical School, Hannover, Germany. Patients: Critically ill COVID-19 patients who underwent continuous routine EEG monitoring (EEG monitor: Narcotrend-Compact M) during sedation. Measurements and Main Results: Data from 15 COVID-19 patients (11 men, four women; age: 19-75 years) were evaluated. Epileptiform potentials occurred in 10 of 15 patients (66.7%). Conclusions: The results of the evaluation regarding the occurrence of epileptiform potentials show that there is an unusually high percentage of cerebral involvement in patients with severe COVID-19. EEG monitoring can be used in COVID-19 patients to detect epileptiform potentials.
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Affiliation(s)
- Barbara Schultz
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - Terence Krauß
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - Maren Schmidt
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | | | - Andrea Schneider
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Olaf Wiesner
- Department of Respiratory Medicine and German Centre of Lung Research (DZL), Hannover Medical School, Hannover, Germany
| | - Julius J Schmidt
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Klaus Stahl
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Sascha David
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany.,Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Marius M Hoeper
- Department of Respiratory Medicine and German Centre of Lung Research (DZL), Hannover Medical School, Hannover, Germany
| | - Markus Busch
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
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33
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Vellieux G, Sonneville R, Vledouts S, Jaquet P, Rouvel-Tallec A, d’Ortho MP. COVID-19-Associated Neurological Manifestations: An Emerging Electroencephalographic Literature. Front Physiol 2021; 11:622466. [PMID: 33679425 PMCID: PMC7933549 DOI: 10.3389/fphys.2020.622466] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 12/29/2020] [Indexed: 02/02/2023] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread worldwide since the end of year 2019 and is currently responsive for coronavirus infectious disease 2019 (COVID-19). The first reports considered COVID-19 as a respiratory tract disease responsible for pneumonia, but numerous studies rapidly emerged to warn the medical community of COVID-19-associated neurological manifestations, including encephalopathy at the acute phase and other postinfectious manifestations. Using standard visual analysis or spectral analysis, recent studies reported electroencephalographic (EEG) findings of COVID-19 patients with various neurological symptoms. Most EEG recordings were normal or revealed non-specific abnormalities, such as focal or generalized slowing, interictal epileptic figures, seizures, or status epilepticus. Interestingly, novel EEG abnormalities over frontal areas were also described at the acute phase. Underlying mechanisms leading to brain injury in COVID-19 are still unknown and matters of debate. These frontal EEG abnormalities could emphasize the hypothesis whereby SARS-CoV-2 enters the central nervous system (CNS) through olfactory structures and then spreads in CNS via frontal lobes. This hypothesis is reinforced by the presence of anosmia in a significant proportion of COVID-19 patients and by neuroimaging studies confirming orbitofrontal abnormalities. COVID-19 represents a new viral disease characterized by not only respiratory symptoms but also a systemic invasion associated with extra-respiratory signs. Neurological symptoms must be the focus of our attention, and functional brain evaluation with EEG is crucial, in combination with anatomical and functional brain imaging, to better understand its pathophysiology. Evolution of symptoms together with EEG patterns at the distance of the acute episode should also be scrutinized.
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Affiliation(s)
- Geoffroy Vellieux
- Université de Paris, NeuroDiderot, Inserm, Paris, France
- Neurophysiologie clinique, Service de Physiologie – Explorations Fonctionnelles, AP-HP, Hôpital Bichat-Claude Bernard, Paris, France
| | - Romain Sonneville
- Médecine Intensive-Réanimation, AP-HP, Hôpital Bichat-Claude Bernard, Paris, France
- Université de Paris, UMR 1148, LVTS, Paris, France
| | - Sérafima Vledouts
- Université de Paris, NeuroDiderot, Inserm, Paris, France
- Neurophysiologie clinique, Service de Physiologie – Explorations Fonctionnelles, AP-HP, Hôpital Bichat-Claude Bernard, Paris, France
| | - Pierre Jaquet
- Médecine Intensive-Réanimation, AP-HP, Hôpital Bichat-Claude Bernard, Paris, France
- Université de Paris, UMR 1148, LVTS, Paris, France
| | - Anny Rouvel-Tallec
- Université de Paris, NeuroDiderot, Inserm, Paris, France
- Neurophysiologie clinique, Service de Physiologie – Explorations Fonctionnelles, AP-HP, Hôpital Bichat-Claude Bernard, Paris, France
| | - Marie-Pia d’Ortho
- Université de Paris, NeuroDiderot, Inserm, Paris, France
- Neurophysiologie clinique, Service de Physiologie – Explorations Fonctionnelles, AP-HP, Hôpital Bichat-Claude Bernard, Paris, France
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Borah P, Deb PK, Chandrasekaran B, Goyal M, Bansal M, Hussain S, Shinu P, Venugopala KN, Al-Shar’i NA, Deka S, Singh V. Neurological Consequences of SARS-CoV-2 Infection and Concurrence of Treatment-Induced Neuropsychiatric Adverse Events in COVID-19 Patients: Navigating the Uncharted. Front Mol Biosci 2021; 8:627723. [PMID: 33681293 PMCID: PMC7930836 DOI: 10.3389/fmolb.2021.627723] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 01/12/2021] [Indexed: 01/08/2023] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) binds to the angiotensin-converting enzyme 2 (ACE2) receptor and invade the human cells to cause COVID-19-related pneumonia. Despite an emphasis on respiratory complications, the evidence of neurological manifestations of SARS-CoV-2 infection is rapidly growing, which is substantially contributing to morbidity and mortality. The neurological disorders associated with COVID-19 may have several pathophysiological underpinnings, which are yet to be explored. Hypothetically, SARS-CoV-2 may affect the central nervous system (CNS) either by direct mechanisms like neuronal retrograde dissemination and hematogenous dissemination, or via indirect pathways. CNS complications associated with COVID-19 include encephalitis, acute necrotizing encephalopathy, diffuse leukoencephalopathy, stroke (both ischemic and hemorrhagic), venous sinus thrombosis, meningitis, and neuroleptic malignant syndrome. These may result from different mechanisms, including direct virus infection of the CNS, virus-induced hyper-inflammatory states, and post-infection immune responses. On the other hand, the Guillain-Barre syndrome, hyposmia, hypogeusia, and myopathy are the outcomes of peripheral nervous system injury. Although the therapeutic potential of certain repurposed drugs has led to their off-label use against COVID-19, such as anti-retroviral drugs (remdesivir, favipiravir, and lopinavir-ritonavir combination), biologics (tocilizumab), antibiotics (azithromycin), antiparasitics (chloroquine and hydroxychloroquine), and corticosteroids (dexamethasone), unfortunately, the associated clinical neuropsychiatric adverse events remains a critical issue. Therefore, COVID-19 represents a major threat to the field of neuropsychiatry, as both the virus and the potential therapies may induce neurologic as well as psychiatric disorders. Notably, potential COVID-19 medications may also interact with the medications of pre-existing neuropsychiatric diseases, thereby further complicating the condition. From this perspective, this review will discuss the possible neurological manifestations and sequelae of SARS-CoV-2 infection with emphasis on the probable underlying neurotropic mechanisms. Additionally, we will highlight the concurrence of COVID-19 treatment-associated neuropsychiatric events and possible clinically relevant drug interactions, to provide a useful framework and help researchers, especially the neurologists in understanding the neurologic facets of the ongoing pandemic to control the morbidity and mortality.
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Affiliation(s)
- Pobitra Borah
- School of Pharmacy, Graphic Era Hill University, Dehradun, India
| | - Pran Kishore Deb
- Department of Pharmaceutical Sciences, Faculty of Pharmacy, Philadelphia University, Amman, Jordan
| | - Balakumar Chandrasekaran
- Department of Pharmaceutical Sciences, Faculty of Pharmacy, Philadelphia University, Amman, Jordan
| | - Manoj Goyal
- Department of Anesthesia Technology, College of Applied Medical Sciences in Jubail, Imam Abdulrahman bin Faisal University, Dammam, Saudi Arabia
| | - Monika Bansal
- Department of Neuroscience Technology College of Applied Medical Sciences in Jubail, Imam Abdulrahman bin Faisal University, Dammam, Saudi Arabia
| | - Snawar Hussain
- Department of Biomedical Sciences, College of Clinical Pharmacy, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Pottathil Shinu
- Department of Biomedical Sciences, College of Clinical Pharmacy, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Katharigatta N. Venugopala
- Department of Pharmaceutical Sciences, College of Clinical Pharmacy, King Faisal University, Al-Ahsa, Kingdom of Saudi Arabia
- Department of Biotechnology and Food Technology, Durban University of Technology, Durban, South Africa
| | - Nizar A. Al-Shar’i
- Department of Medicinal Chemistry and Pharmacognosy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Satyendra Deka
- Pratiksha Institute of Pharmaceutical Sciences, Chandrapur Road, Panikhaiti, Guwahati, India
| | - Vinayak Singh
- Drug Discovery and Development Centre (H3D), University of Cape Town, Rondebosch, South Africa
- South African Medical Research Council Drug Discovery and Development Research Unit, Department of Chemistry and Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Rondebosch, South Africa
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Waters BL, Michalak AJ, Brigham D, Thakur KT, Boehme A, Claassen J, Bell M. Incidence of Electrographic Seizures in Patients With COVID-19. Front Neurol 2021; 12:614719. [PMID: 33613431 PMCID: PMC7890122 DOI: 10.3389/fneur.2021.614719] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 01/12/2021] [Indexed: 11/23/2022] Open
Abstract
Critical illness and sepsis are commonly associated with subclinical seizures. COVID-19 frequently causes severe critical illness, but the incidence of electrographic seizures in patients with COVID-19 has been reported to be low. This retrospective case series assessed the incidence of and risks for electrographic seizures in patients hospitalized with COVID-19 who underwent continuous video electroencephalography monitoring (cvEEG) between March 1st, 2020 and June 30th, 2020. One hundred and twenty-two patients were initially identified who resulted SARS-CoV-2 nasopharyngeal RT-PCR swab positivity with any electroencephalography order placed in the EMR. Seventy-nine patients met study inclusion criteria: age ≥18 years, >1 h of cvEEG monitoring, and positive SARS-CoV-2 nasopharyngeal swab PCR. Six (8%) of the 79 patients suffered electrographic seizures (ES), three of whom suffered non-convulsive status epilepticus. Acute hyperkinetic movements were the most common reason for cvEEG in patients with ES (84%). None of the patients undergoing cvEEG for persistent coma (29% of all patients) had ES. Focal slowing (67 vs. 10%), sporadic interictal epileptiform discharges (EDs; 33 vs. 6%), and periodic/rhythmic EDs (67 vs. 1%) were proportionally more frequent among patients with electrographic seizures than those without these seizures. While 15% of patients without ES had generalized periodic discharges (GPDs) with triphasic morphology on EEG, none of the patients with ES had this pattern. Further study is required to assess the predictive values of these risk factors on electrographic seizure incidence and subsequent outcomes.
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Affiliation(s)
- Brandon L Waters
- Department of Neurology, Columbia University Irving Medical Center, Neurological Institute, New York Presbyterian Hospital, New York, NY, United States
| | - Andrew J Michalak
- Department of Neurology, Columbia University Irving Medical Center, Neurological Institute, New York Presbyterian Hospital, New York, NY, United States
| | - Danielle Brigham
- Department of Neurology, Columbia University Irving Medical Center, Neurological Institute, New York Presbyterian Hospital, New York, NY, United States
| | - Kiran T Thakur
- Department of Neurology, Columbia University Irving Medical Center, Neurological Institute, New York Presbyterian Hospital, New York, NY, United States
| | - Amelia Boehme
- Department of Neurology and Epidemiology, Sergievsky Center, Columbia University Irving Medical Center, New York, NY, United States
| | - Jan Claassen
- Department of Neurology, Columbia University Irving Medical Center, Neurological Institute, New York Presbyterian Hospital, New York, NY, United States
| | - Michelle Bell
- Department of Neurology, Columbia University Irving Medical Center, Neurological Institute, New York Presbyterian Hospital, New York, NY, United States
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36
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Neurological symptoms, manifestations, and complications associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease 19 (COVID-19). J Neurol 2021; 268:3059-3071. [PMID: 33486564 PMCID: PMC7826147 DOI: 10.1007/s00415-021-10406-y] [Citation(s) in RCA: 172] [Impact Index Per Article: 57.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 01/09/2021] [Accepted: 01/12/2021] [Indexed: 12/16/2022]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a novel coronavirus, is responsible for the outbreak of coronavirus disease 19 (COVID-19) and was first identified in Wuhan, China in December 2019. It is evident that the COVID-19 pandemic has become a challenging world issue. Although most COVID-19 patients primarily develop respiratory symptoms, an increasing number of neurological symptoms and manifestations associated with COVID-19 have been observed. In this narrative review, we elaborate on proposed neurotropic mechanisms and various neurological symptoms, manifestations, and complications of COVID-19 reported in the present literature. For this purpose, a review of all current published literature (studies, case reports, case series, reviews, editorials, and other articles) was conducted and neurological sequelae of COVID-19 were summarized. Essential and common neurological symptoms including gustatory and olfactory dysfunctions, myalgia, headache, altered mental status, confusion, delirium, and dizziness are presented separately in sections. Moreover, neurological manifestations and complications that are of great concern such as stroke, cerebral (sinus) venous thrombosis, seizures, meningoencephalitis, Guillain-Barré syndrome, Miller Fisher syndrome, acute myelitis, and posterior reversible encephalopathy syndrome (PRES) are also addressed systematically. Future studies that examine the impact of neurological symptoms and manifestations on the course of the disease are needed to further clarify and assess the link between neurological complications and the clinical outcome of patients with COVID-19. To limit long-term consequences, it is crucial that healthcare professionals can early detect possible neurological symptoms and are well versed in the increasingly common neurological manifestations and complications of COVID-19.
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Ibañez Valdés LDF, Geroge J, Joseph S, Alshmandi M, Makaleni W, Foyaca Sibat H. Case Report and Literature Review: COVID-19 and status epilepticus in Dyke-Davidoff-Masson syndrome. F1000Res 2021; 10:9. [PMID: 35814634 PMCID: PMC9214268 DOI: 10.12688/f1000research.27971.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/22/2020] [Indexed: 11/20/2022] Open
Abstract
Dyke-Davidoff-Masson syndrome (DMMS) is a non-inherited rare condition with a clinical constellation of hemiparesis/hemiplegia, facial asymmetry, intellectual disability, and epilepsy. The radiological features can be including unilateral cerebral atrophy, calvarial thickening, and hyper pneumatization of the paranasal sinuses. The condition can either be congenital or acquired. The presentation usually occurs during childhood or early adolescents, but there have been adult cases reported. Here we report a 48-year-old male who was a known poorly controlled epileptic that contracted SARS-CoV-2 with subsequently developed status epilepticus and, when worked up, was shown to have features of DDMS. This case is unique as the patient had hemiatrophy and epilepsy but managed to lead a normal, physically demanding, and high functioning academic career and presented late in life. Perhaps only due to coronavirus disease 2019 (COVID-19) was this diagnosis picked up. This report contains a case presenting atypical DDMS in status epilepticus and COVID -19 plus other complications. From our knowledge, this is the first case presenting these comorbidities reported to the medical literature.
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Affiliation(s)
| | - Jerry Geroge
- Neurology Department, Walter Sisulu University/ Nelson Mandela Academic Hospital, Mthatha, Eastern Cape, 5100, South Africa
| | - Sibi Joseph
- Neurology Department, Walter Sisulu University/ Nelson Mandela Academic Hospital, Mthatha, Eastern Cape, 5100, South Africa
| | - Mohamed Alshmandi
- Internal Medicine Department, Walter Sisulu University/Nelson Mandela Academic Hospital, Mthatha, Eastern Cape, 5100, South Africa
| | - Wendy Makaleni
- Internal Medicine Department, Walter Sisulu University/Nelson Mandela Academic Hospital, Mthatha, Eastern Cape, 5100, South Africa
| | - Humberto Foyaca Sibat
- Neurology Department, Walter Sisulu University/ Nelson Mandela Academic Hospital, Mthatha, Eastern Cape, 5100, South Africa
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DeKosky ST, Kochanek PM, Valadka AB, Clark RS, Chou SHY, Au AK, Horvat C, Jha RM, Mannix R, Wisniewski SR, Wintermark M, Rowell SE, Welch RD, Lewis L, House S, Tanzi RE, Smith DR, Vittor AY, Denslow ND, Davis MD, Glushakova OY, Hayes RL. Blood Biomarkers for Detection of Brain Injury in COVID-19 Patients. J Neurotrauma 2021; 38:1-43. [PMID: 33115334 PMCID: PMC7757533 DOI: 10.1089/neu.2020.7332] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus attacks multiple organs of coronavirus disease 2019 (COVID-19) patients, including the brain. There are worldwide descriptions of neurological deficits in COVID-19 patients. Central nervous system (CNS) symptoms can be present early in the course of the disease. As many as 55% of hospitalized COVID-19 patients have been reported to have neurological disturbances three months after infection by SARS-CoV-2. The mutability of the SARS-COV-2 virus and its potential to directly affect the CNS highlight the urgency of developing technology to diagnose, manage, and treat brain injury in COVID-19 patients. The pathobiology of CNS infection by SARS-CoV-2 and the associated neurological sequelae of this infection remain poorly understood. In this review, we outline the rationale for the use of blood biomarkers (BBs) for diagnosis of brain injury in COVID-19 patients, the research needed to incorporate their use into clinical practice, and the improvements in patient management and outcomes that can result. BBs of brain injury could potentially provide tools for detection of brain injury in COVID-19 patients. Elevations of BBs have been reported in cerebrospinal fluid (CSF) and blood of COVID-19 patients. BB proteins have been analyzed in CSF to detect CNS involvement in patients with infectious diseases, including human immunodeficiency virus and tuberculous meningitis. BBs are approved by the U.S. Food and Drug Administration for diagnosis of mild versus moderate traumatic brain injury and have identified brain injury after stroke, cardiac arrest, hypoxia, and epilepsy. BBs, integrated with other diagnostic tools, could enhance understanding of viral mechanisms of brain injury, predict severity of neurological deficits, guide triage of patients and assignment to appropriate medical pathways, and assess efficacy of therapeutic interventions in COVID-19 patients.
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Affiliation(s)
- Steven T. DeKosky
- McKnight Brain Institute, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Patrick M. Kochanek
- Department of Critical Care Medicine, Department of Anesthesiology, Pediatrics, Bioengineering, and Clinical and Translational Science, Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Alex B. Valadka
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Robert S.B. Clark
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Sherry H.-Y. Chou
- Department of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Alicia K. Au
- University of Pittsburgh, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Christopher Horvat
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Division of Pediatric Critical Care, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ruchira M. Jha
- Departments of Critical Care Medicine, Neurology, Neurological Surgery, Clinical and Translational Science Institute, Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Rebekah Mannix
- Department of Pediatrics and Emergency Medicine, Harvard Medical School, Department of Medicine, Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | | | - Max Wintermark
- Department of Neuroradiology, Stanford University, Stanford, California, USA
| | - Susan E. Rowell
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Robert D. Welch
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit Receiving Hospital/University Health Center, Detroit, Michigan, USA
| | - Lawrence Lewis
- Department of Emergency Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Stacey House
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Rudolph E. Tanzi
- Genetics and Aging Research Unit, Massachusetts General Hospital, McCance Center for Brain Health, Massachusetts General Hospital, MassGeneral Institute for Neurodegenerative Diseases, Massachusetts General Hospital, Department of Neurology (Research), Massachusetts General Hospital, Department of Neurology, Harvard Medical School, Charlestown, Massachusetts, USA
| | - Darci R. Smith
- Immunodiagnostics Department, Naval Medical Research Center, Biological Defense Research Directorate, Fort Detrick, Maryland, USA
| | - Amy Y. Vittor
- Division of Infectious Disease and Global Medicine, University of Florida, Emerging Pathogens Institute, Gainesville, Florida, USA
| | - Nancy D. Denslow
- Departments of Physiological Sciences and Biochemistry and Molecular Biology, University of Florida, Center for Environmental and Human Toxicology, Gainesville, Florida
| | - Michael D. Davis
- Department of Pediatrics, Wells Center for Pediatric Research/Pulmonology, Allergy, and Sleep Medicine, Riley Hospital for Children at Indiana University, Indianapolis, Indiana, USA
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Koutroumanidis M, Gratwicke J, Sharma S, Whelan A, Tan SV, Glover G. Alpha coma EEG pattern in patients with severe COVID-19 related encephalopathy. Clin Neurophysiol 2021; 132:218-225. [PMID: 33060058 PMCID: PMC7527310 DOI: 10.1016/j.clinph.2020.09.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 09/03/2020] [Accepted: 09/18/2020] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Encephalopathy is a major neurological complication of severe Coronavirus Disease 2019 (COVID-19), but has not been fully defined yet. Further, it remains unclear whether neurological manifestations are primarily due to neurotropism of the virus, or indirect effects, like cerebral hypoxia. METHODS We analysed the electroencephalograms (EEGs) of 19 consecutive patients with laboratory-confirmed COVID-19, performed at peak disease severity as part of their clinical management. Disease severity, respiratory failure, immune and metabolic dysfunction, sedation status, and neurological examination on the day of the EEG were noted. RESULTS Severe encephalopathy was confirmed in 13 patients, all with severe COVID-19; 10 remained comatose off sedation, and five of them had alpha coma (AC). Disease severity, sedation, immune and metabolic dysfunction were not different between those with AC and those without. CONCLUSIONS Severe COVID-19 encephalopathy is a principal cause of persisting coma after sedation withdrawal. The relatively high incidence of the rare AC pattern may reflect direct SARS-CoV-2 neurotropism with a predilection for the brainstem ascending reticular system. SIGNIFICANCE Systematic early EEG detection of encephalopathy related to severe COVID-19 is important for the acute care and the management of long-term neurological and cognitive sequelae, and may help our better understanding of its pathophysiology.
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Affiliation(s)
| | - James Gratwicke
- Department of Neurology and Clinical Neurophysiology, St. Thomas' Hospital, London, UK
| | - Simeran Sharma
- Department of Neurology and Clinical Neurophysiology, St. Thomas' Hospital, London, UK
| | - Aoife Whelan
- Department of Neurology and Clinical Neurophysiology, St. Thomas' Hospital, London, UK
| | - S Veronica Tan
- Department of Neurology and Clinical Neurophysiology, St. Thomas' Hospital, London, UK
| | - Guy Glover
- Intensive Care Unit, St Thomas' Hospital, London, UK
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Favas TT, Dev P, Chaurasia RN, Chakravarty K, Mishra R, Joshi D, Mishra VN, Kumar A, Singh VK, Pandey M, Pathak A. Neurological manifestations of COVID-19: a systematic review and meta-analysis of proportions. Neurol Sci 2020; 41:3437-3470. [PMID: 33089477 PMCID: PMC7577367 DOI: 10.1007/s10072-020-04801-y] [Citation(s) in RCA: 124] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 10/05/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Coronaviruses mainly affect the respiratory system; however, there are reports of SARS-CoV and MERS-CoV causing neurological manifestations. We aimed at discussing the various neurological manifestations of SARS-CoV-2 infection and to estimate the prevalence of each of them. METHODS We searched the following electronic databases; PubMed, MEDLINE, Scopus, EMBASE, Google Scholar, EBSCO, Web of Science, Cochrane Library, WHO database, and ClinicalTrials.gov . Relevant MeSH terms for COVID-19 and neurological manifestations were used. Randomized controlled trials, non-randomized controlled trials, case-control studies, cohort studies, cross-sectional studies, case series, and case reports were included in the study. To estimate the overall proportion of each neurological manifestations, the study employed meta-analysis of proportions using a random-effects model. RESULTS Pooled prevalence of each neurological manifestations are, smell disturbances (35.8%; 95% CI 21.4-50.2), taste disturbances (38.5%; 95%CI 24.0-53.0), myalgia (19.3%; 95% CI 15.1-23.6), headache (14.7%; 95% CI 10.4-18.9), dizziness (6.1%; 95% CI 3.1-9.2), and syncope (1.8%; 95% CI 0.9-4.6). Pooled prevalence of acute cerebrovascular disease was (2.3%; 95%CI 1.0-3.6), of which majority were ischaemic stroke (2.1%; 95% CI 0.9-3.3), followed by haemorrhagic stroke (0.4%; 95% CI 0.2-0.6), and cerebral venous thrombosis (0.3%; 95% CI 0.1-0.6). CONCLUSIONS Neurological symptoms are common in SARS-CoV-2 infection, and from the large number of cases reported from all over the world daily, the prevalence of neurological features might increase again. Identifying some neurological manifestations like smell and taste disturbances can be used to screen patients with COVID-19 so that early identification and isolation is possible.
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Affiliation(s)
- T T Favas
- Department of Neurology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Priya Dev
- Department of Neurology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Rameshwar Nath Chaurasia
- Department of Neurology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | | | - Rahul Mishra
- Department of Statistics, Institute of science, Banaras Hindu University, Varanasi, India
| | - Deepika Joshi
- Department of Neurology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Vijay Nath Mishra
- Department of Neurology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Anand Kumar
- Department of Neurology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Varun Kumar Singh
- Department of Neurology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Manoj Pandey
- Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Abhishek Pathak
- Department of Neurology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India.
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Asadi-Pooya AA, Simani L, Shahisavandi M, Barzegar Z. COVID-19, de novo seizures, and epilepsy: a systematic review. Neurol Sci 2020; 42:415-431. [PMID: 33237493 PMCID: PMC7686454 DOI: 10.1007/s10072-020-04932-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 11/20/2020] [Indexed: 12/15/2022]
Abstract
Objective We discuss the evidence on the occurrence of de novo seizures in patients with COVID-19, the consequences of this catastrophic disease in people with epilepsy (PWE), and the electroencephalographic (EEG) findings in patients with COVID-19. Methods This systematic review was prepared according to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. MEDLINE, Scopus, and Embase from inception to August 15, 2020 were systematically searched. These key words were used: “COVID” AND “seizure” OR “epilepsy” OR “EEG” OR “status epilepticus” OR “electroencephalography”. Results We could identify 62 related manuscripts. Many studies were case reports or case series of patients with COVID-19 and seizures. PWE showed more psychological distress than healthy controls. Many cases with new-onset focal seizures, serial seizures, and status epilepticus have been reported in the literature. EEG studies have been significantly ignored and underused globally. Conclusion Many PWE perceived significant disruption in the quality of care to them, and some people reported increase in their seizure frequency since the onset of the pandemic. Telemedicine is a helpful technology that may improve access to the needed care for PWE in these difficult times. De novo seizures may occur in people with COVID-19 and they may happen in a variety of forms. In addition to prolonged EEG monitoring, performing a through metabolic investigation, electrocardiogram, brain imaging, and a careful review of all medications are necessary steps. The susceptibility of PWE to contracting COVID-19 should be investigated further.
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Affiliation(s)
- Ali A Asadi-Pooya
- Epilepsy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran. .,Jefferson Comprehensive Epilepsy Center, Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Leila Simani
- Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mina Shahisavandi
- Epilepsy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Zohreh Barzegar
- Epilepsy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Hwang ST, Ballout AA, Mirza U, Sonti AN, Husain A, Kirsch C, Kuzniecky R, Najjar S. Acute Seizures Occurring in Association With SARS-CoV-2. Front Neurol 2020; 11:576329. [PMID: 33224090 PMCID: PMC7674622 DOI: 10.3389/fneur.2020.576329] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 09/29/2020] [Indexed: 12/13/2022] Open
Abstract
Seizures are an infrequent and serious neurological complication of SARS-CoV-2 infection, with limited data describing the etiology and the clinical context in which these occur or the associated electrographic and imaging findings. This series details four cases of seizures occurring in patients with COVID-19 with distinct time points, underlying pathology, and proposed physiological mechanisms. An enhanced understanding of seizure manifestations in COVID-19 and their clinical course may allow for earlier detection and improved patient management.
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Affiliation(s)
- Sean T Hwang
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, NY, United States
| | - Ahmad A Ballout
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, NY, United States
| | - Usman Mirza
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, NY, United States
| | - Anup N Sonti
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, NY, United States
| | - Arif Husain
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, NY, United States
| | - Claudia Kirsch
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, NY, United States
| | - Ruben Kuzniecky
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, NY, United States
| | - Souhel Najjar
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, NY, United States
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Leitinger M, Poppert KN, Mauritz M, Rossini F, Zimmermann G, Rohracher A, Kalss G, Kuchukhidze G, Höfler J, Bosque Varela P, Kreidenhuber R, Volna K, Neuray C, Kobulashvili T, Granbichler CA, Siebert U, Trinka E. Status epilepticus admissions during the COVID-19 pandemic in Salzburg-A population-based study. Epilepsia 2020; 61:e198-e203. [PMID: 33140437 PMCID: PMC7756208 DOI: 10.1111/epi.16737] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 09/30/2020] [Accepted: 09/30/2020] [Indexed: 12/15/2022]
Abstract
Several emergencies were admitted less frequently to the hospital during the coronavirus disease 2019 (COVID‐19) pandemic. To investigate whether this also occurred with status epilepticus (SE) we compared admissions due to first SE from March to April 2020 (“Time of COVID,” TOC) with January to February 2020 (“pre‐COVID,” preCOV). We also compared admission numbers in TOC and preCOV with the respective 2‐month periods in 2018 and 2019 in a retrospective cohort analysis. Two investigators independently searched the hospital patient database for various forms of SE. There was no significant change in the 2‐month incidences of first SE in the city of Salzburg from preCOV of 6.1 (95% confidence interval [CI] 2.9‐12.3) to TOC of 6.9/100 000 adults (95% CI 3.4‐13.3). Admission numbers did not differ significantly from previous years. Estimated adjusted incidence was in line with a recent 5‐year epidemiological study in Salzburg. However, a trend toward less‐frequent nonconvulsive SE (NCSE) and loss of female predominance were indirect hints of underdiagnosing SE. In contrast to other medical conditions, SE most often presents clinically with impaired consciousness, which may promote admission to emergency departments even in times of lock‐down. Further research of medical support of women and patients with NCSE during pandemic‐related restrictions is warranted.
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Affiliation(s)
- Markus Leitinger
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, Affiliated partner of the ERN EpiCARE, Salzburg, Austria.,Centre of Neuroscience, Christian Doppler University Hospital Salzburg, Salzburg, Austria
| | - Kai-Nicolas Poppert
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, Affiliated partner of the ERN EpiCARE, Salzburg, Austria.,Centre of Neuroscience, Christian Doppler University Hospital Salzburg, Salzburg, Austria
| | - Matthias Mauritz
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, Affiliated partner of the ERN EpiCARE, Salzburg, Austria.,Centre of Neuroscience, Christian Doppler University Hospital Salzburg, Salzburg, Austria
| | - Fabio Rossini
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, Affiliated partner of the ERN EpiCARE, Salzburg, Austria.,Centre of Neuroscience, Christian Doppler University Hospital Salzburg, Salzburg, Austria
| | - Georg Zimmermann
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, Affiliated partner of the ERN EpiCARE, Salzburg, Austria.,Team Biostatistics and Big Medical Data, IDA Lab Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Alexandra Rohracher
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, Affiliated partner of the ERN EpiCARE, Salzburg, Austria.,Centre of Neuroscience, Christian Doppler University Hospital Salzburg, Salzburg, Austria
| | - Gudrun Kalss
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, Affiliated partner of the ERN EpiCARE, Salzburg, Austria.,Centre of Neuroscience, Christian Doppler University Hospital Salzburg, Salzburg, Austria
| | - Giorgi Kuchukhidze
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, Affiliated partner of the ERN EpiCARE, Salzburg, Austria.,Centre of Neuroscience, Christian Doppler University Hospital Salzburg, Salzburg, Austria
| | - Julia Höfler
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, Affiliated partner of the ERN EpiCARE, Salzburg, Austria.,Centre of Neuroscience, Christian Doppler University Hospital Salzburg, Salzburg, Austria
| | - Pilar Bosque Varela
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, Affiliated partner of the ERN EpiCARE, Salzburg, Austria
| | - Rudolf Kreidenhuber
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, Affiliated partner of the ERN EpiCARE, Salzburg, Austria.,Centre of Neuroscience, Christian Doppler University Hospital Salzburg, Salzburg, Austria
| | - Kamila Volna
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, Affiliated partner of the ERN EpiCARE, Salzburg, Austria.,Centre of Neuroscience, Christian Doppler University Hospital Salzburg, Salzburg, Austria
| | - Caroline Neuray
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, Affiliated partner of the ERN EpiCARE, Salzburg, Austria.,Queen Square Institute of Neurology, University College London (UCL), London, UK
| | - Teia Kobulashvili
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, Affiliated partner of the ERN EpiCARE, Salzburg, Austria.,Centre of Neuroscience, Christian Doppler University Hospital Salzburg, Salzburg, Austria
| | - Claudia A Granbichler
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, Affiliated partner of the ERN EpiCARE, Salzburg, Austria.,Centre of Neuroscience, Christian Doppler University Hospital Salzburg, Salzburg, Austria.,Department of Neurology, Sheba Medical Center, Tel Hashomer, Israel
| | - Uwe Siebert
- Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria.,Center for Health Decision Science, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Institute for Technology Assessment and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Eugen Trinka
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, Affiliated partner of the ERN EpiCARE, Salzburg, Austria.,Centre of Neuroscience, Christian Doppler University Hospital Salzburg, Salzburg, Austria.,Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
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Sanchez-Larsen A, Gonzalez-Villar E, Díaz-Maroto I, Layos-Romero A, Martínez-Martín Á, Alcahut-Rodriguez C, Grande-Martin A, Sopelana-Garay D. Influence of the COVID-19 outbreak in people with epilepsy: Analysis of a Spanish population (EPICOVID registry). Epilepsy Behav 2020; 112:107396. [PMID: 32911299 PMCID: PMC7476448 DOI: 10.1016/j.yebeh.2020.107396] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 08/03/2020] [Accepted: 08/06/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND The aim of this study was to have a better understanding of the influence of the coronavirus disease 2019 (COVID-19) pandemic in people with epilepsy (PWE) and to assess whether there have been changes in seizure control during the current COVID-19 outbreak, exploring the possible causes thereof. METHODS This is an observational, retrospective study based on prospective data collection of 100 successive patients who attended an epilepsy outpatient clinic either face-to-face or telephonically during the months of the COVID-19 outbreak and national state of emergency. RESULTS One hundred patients were included, 52% women, mean age 42.4 years. During the COVID-19 period, 27% of the patients presented an increase of >50% of seizure frequency. An increase of stress/anxiety (odds ratios (OR): 5.78; p = 0.008) and a prior higher seizure frequency (OR: 12.4; p = 0.001) were associated with worsening of seizures. Other risk factors were exacerbation of depression, sleep deprivation, less physical activity, and history of epilepsy surgery. Three patients had status epilepticus (SE) and one a cluster of seizures. Likewise, 9% of patients improved their seizure control. Reduction in stress/anxiety (OR: 0.05; p = 0.03) and recent adjustment of antiepileptics (OR: 0.07; p = 0.01) acted as protecting factors. CONCLUSIONS A high proportion of PWE suffered a significant worsening of their seizure control during the months of the COVID-19 pandemic. Emotional distress due to home confinement was the main factor for the change in seizure control. Promoting physical activity and adequate sleep may minimize the potential impact of the pandemic in PWE. Ensuring correct follow-up can prevent decompensation in those PWE at high risk.
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Affiliation(s)
- Alvaro Sanchez-Larsen
- Department of Neurology, Complejo Hospitalario Universitario de Albacete, Albacete, Castilla-La Mancha, Spain.
| | - Esther Gonzalez-Villar
- Department of Neurology, Complejo Hospitalario Universitario de Albacete, Albacete, Castilla-La Mancha, Spain
| | - Inmaculada Díaz-Maroto
- Department of Neurology, Complejo Hospitalario Universitario de Albacete, Albacete, Castilla-La Mancha, Spain
| | - Almudena Layos-Romero
- Department of Neurology, Complejo Hospitalario Universitario de Albacete, Albacete, Castilla-La Mancha, Spain
| | - Álvaro Martínez-Martín
- Department of Neurology, Complejo Hospitalario Universitario de Albacete, Albacete, Castilla-La Mancha, Spain
| | - Cristian Alcahut-Rodriguez
- Department of Neurology, Complejo Hospitalario Universitario de Albacete, Albacete, Castilla-La Mancha, Spain
| | - Alberto Grande-Martin
- Department of Clinical Neurophysiology Complejo, Hospitalario Universitario de Albacete, Albacete, Castilla-La Mancha, Spain
| | - David Sopelana-Garay
- Department of Neurology, Complejo Hospitalario Universitario de Albacete, Albacete, Castilla-La Mancha, Spain
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Salahuddin H, Afreen E, Sheikh IS, Lateef S, Dawod G, Daboul J, Karim N, Gharaibeh K, Al-Chalabi M, Park S, Castonguay AC, Assaly R, Safi F, Matal M, Sheikh A, Tietjen G, Malaiyandi D, James E, Ali I, Zaidi SF, Abdelwahed A, Kung V, Burgess R, Jumaa MA. Neurological Predictors of Clinical Outcomes in Hospitalized Patients With COVID-19. Front Neurol 2020; 11:585944. [PMID: 33193048 PMCID: PMC7662675 DOI: 10.3389/fneur.2020.585944] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 10/05/2020] [Indexed: 01/08/2023] Open
Abstract
Introduction: Multiple risk factors of mortality have been identified in patients with COVID-19. Here, we sought to determine the effect of a history of neurological disorder and development of neurological manifestations on mortality in hospitalized patients with COVID-19. Methods: From March 20 to May 20, 2020, hospitalized patients with laboratory confirmed or highly suspected COVID-19 were identified at four hospitals in Ohio. Previous history of neurological disease was classified by severity (major or minor). Neurological manifestations during disease course were also grouped into major and minor manifestations. Encephalopathy, ischemic or hemorrhagic stroke, and seizures were defined as major manifestations, whereas minor neurological manifestations included headache, anosmia, dysgeusia, dizziness or vertigo, and myalgias. Multivariate logistic regression models were used to determine significant predictors of mortality in patients with COVID-19 infection. Results: 574/626 hospitalized patients were eligible for inclusion. Mean age of the 574 patients included in the analysis was 62.8 (SD 17.6), with 298 (51.9%) women. Of the cohort, 240(41.8%) patients had a prior history of neurological disease (HND), of which 204 (35.5%) had a major history of neurological disease (HND). Mortality rates were higher in patients with a major HND (30.9 vs. 15.4%; p = 0.00002), although this was not a significant predictor of death. Major neurological manifestations were recorded in 203/574 (35.4%) patients during disease course. The mortality rate in patients who had major neurological manifestations was 37.4% compared to 11.9% (p = 2 × 10-12) in those who did not. In multivariate analysis, major neurological manifestation (OR 2.1, CI 1.3-3.4; p = 0.002) was a predictor of death. Conclusions: In this retrospective study, history of pre-existing neurological disease in hospitalized COVID-19 patients did not impact mortality; however, development of major neurological manifestations during disease course was found to be an independent predictor of death. Larger studies are needed to validate our findings.
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Affiliation(s)
- Hisham Salahuddin
- ProMedica Neurosciences Center, Toledo, OH, United States
- Department of Neurology, College of Medicine and Life Sciences University of Toledo, Toledo, OH, United States
| | - Ehad Afreen
- Department of Neurology, College of Medicine and Life Sciences University of Toledo, Toledo, OH, United States
| | - Irfan S. Sheikh
- Department of Neurology, College of Medicine and Life Sciences University of Toledo, Toledo, OH, United States
| | - Sohaib Lateef
- Department of Neurology, College of Medicine and Life Sciences University of Toledo, Toledo, OH, United States
| | - Giana Dawod
- Department of Neurology, College of Medicine and Life Sciences University of Toledo, Toledo, OH, United States
| | - Judy Daboul
- Department of Neurology, College of Medicine and Life Sciences University of Toledo, Toledo, OH, United States
- St. Luke's Hospital, Maumee, OH, United States
| | - Nurose Karim
- Department of Neurology, College of Medicine and Life Sciences University of Toledo, Toledo, OH, United States
| | - Khaled Gharaibeh
- Department of Neurology, College of Medicine and Life Sciences University of Toledo, Toledo, OH, United States
| | - Mustafa Al-Chalabi
- Department of Neurology, College of Medicine and Life Sciences University of Toledo, Toledo, OH, United States
| | - Sihyeong Park
- Department of Neurology, College of Medicine and Life Sciences University of Toledo, Toledo, OH, United States
| | - Alicia C. Castonguay
- Department of Neurology, College of Medicine and Life Sciences University of Toledo, Toledo, OH, United States
| | - Ragheb Assaly
- Department of Internal Medicine, College of Medicine and Life Sciences, University of Toledo, Toledo, OH, United States
| | - Fadi Safi
- Department of Internal Medicine, College of Medicine and Life Sciences, University of Toledo, Toledo, OH, United States
| | - Marla Matal
- Anesthesiology and Critical Medicine, ProMedica Physicians, Toledo, OH, United States
| | - Ajaz Sheikh
- Department of Neurology, College of Medicine and Life Sciences University of Toledo, Toledo, OH, United States
| | - Gretchen Tietjen
- Department of Neurology, College of Medicine and Life Sciences University of Toledo, Toledo, OH, United States
| | - Deepa Malaiyandi
- Department of Neurology, College of Medicine and Life Sciences University of Toledo, Toledo, OH, United States
| | - Elysia James
- Department of Neurology, College of Medicine and Life Sciences University of Toledo, Toledo, OH, United States
| | - Imran Ali
- Department of Neurology, College of Medicine and Life Sciences University of Toledo, Toledo, OH, United States
| | - Syed F. Zaidi
- ProMedica Neurosciences Center, Toledo, OH, United States
- Department of Neurology, College of Medicine and Life Sciences University of Toledo, Toledo, OH, United States
| | - Ahmad Abdelwahed
- Pulmonary Medicine, Critical Care Medicine, Sleep Medicine, ProMedica Physicians, Toledo, OH, United States
| | - Vieh Kung
- Department of Neurology, College of Medicine and Life Sciences University of Toledo, Toledo, OH, United States
| | - Richard Burgess
- Department of Neurology, College of Medicine and Life Sciences University of Toledo, Toledo, OH, United States
| | - Mouhammad A. Jumaa
- ProMedica Neurosciences Center, Toledo, OH, United States
- Department of Neurology, College of Medicine and Life Sciences University of Toledo, Toledo, OH, United States
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Abstract
Purpose of Review Coronavirus disease 2019 (COVID-19) has become a global health crisis of our time. The disease arises from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that binds to angiotensin-converting enzyme 2 (ACE2) receptors on host cells for its internalization. COVID-19 has a wide range of respiratory symptoms from mild to severe and affects several other organs, increasing the complexity of the treatment. There is accumulating evidence to suggest that SARS-CoV-2 can target the nervous system. In this review, we provide an account of the COVID-19 central nervous system (CNS) manifestations. Recent Findings A broad spectrum of the CNS manifestations including headache, impaired consciousness, delirium, loss of smell and taste, encephalitis, seizures, strokes, myelitis, acute disseminated encephalomyelitis, neurogenic respiratory failure, encephalopathy, silent hypoxemia, generalized myoclonus, neuroleptic malignant syndrome and Kawasaki syndrome has been reported in patients with COVID-19. Summary CNS manifestations associated with COVID-19 should be considered in clinical practice. There is a need for modification of current protocols and standing orders to provide better care for COVID-19 patients presenting with neurological symptoms.
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47
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Sharifian-Dorche M, Huot P, Osherov M, Wen D, Saveriano A, Giacomini PS, Antel JP, Mowla A. Neurological complications of coronavirus infection; a comparative review and lessons learned during the COVID-19 pandemic. J Neurol Sci 2020; 417:117085. [PMID: 32871412 PMCID: PMC7413162 DOI: 10.1016/j.jns.2020.117085] [Citation(s) in RCA: 130] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 08/05/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Coronavirus disease-19 (COVID-19) pandemic continues to grow all over the world. Several studies have been performed, focusing on understanding the acute respiratory syndrome and treatment strategies. However, there is growing evidence indicating neurological manifestations occur in patients with COVID-19. Similarly, the other coronaviruses (CoV) epidemics; severe acute respiratory syndrome (SARS-CoV-1) and Middle East respiratory syndrome (MERS-CoV) have been associated with neurological complications. METHODS This systematic review serves to summarize available information regarding the potential effects of different types of CoV on the nervous system and describes the range of clinical neurological complications that have been reported thus far in COVID-19. RESULTS Two hundred and twenty-five studies on CoV infections associated neurological manifestations in human were reviewed. Of those, 208 articles were pertinent to COVID-19. The most common neurological complaints in COVID-19 were anosmia, ageusia, and headache, but more serious complications, such as stroke, impairment of consciousness, seizures, and encephalopathy, have also been reported. CONCLUSION There are several similarities between neurological complications after SARS-CoV-1, MERS-CoV and COVID-19, however, the scope of the epidemics and number of patients are very different. Reports on the neurological complications after and during COVID-19 are growing on a daily basis. Accordingly, comprehensive knowledge of these complications will help health care providers to be attentive to these complications and diagnose and treat them timely.
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Affiliation(s)
- Maryam Sharifian-Dorche
- Department of Neurology and Neurosurgery, Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada; Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Philippe Huot
- Department of Neurology and Neurosurgery, Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
| | - Michael Osherov
- Department of Neurology and Neurosurgery, Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
| | - Dingke Wen
- Department of Neurology and Neurosurgery, Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada; Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Alexander Saveriano
- Department of Neurology and Neurosurgery, Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
| | - Paul S Giacomini
- Department of Neurology and Neurosurgery, Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
| | - Jack P Antel
- Department of Neurology and Neurosurgery, Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
| | - Ashkan Mowla
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, USA.
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48
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Valiuddin HM, Kalajdzic A, Rosati J, Boehm K, Hill D. Update on Neurological Manifestations of SARS-CoV-2. West J Emerg Med 2020; 21:45-51. [PMID: 33052822 PMCID: PMC7673884 DOI: 10.5811/westjem.2020.8.48839] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 08/02/2020] [Accepted: 08/10/2020] [Indexed: 12/16/2022] Open
Abstract
Severe acute respiratory syndrome coronavirus 2, the source of COVID-19, causes numerous clinical findings including respiratory and gastrointestinal findings. Evidence is now growing for increasing neurological symptoms. This is thought to be from direct in-situ effects in the olfactory bulb caused by the virus. Angiotensin-converting enzyme 2 receptors likely serve as a key receptor for cell entry for most coronaviridae as they are present in multiple organ tissues in the body, notably neurons, and in type 2 alveolar cells in the lung. Hematogenous spread to the nervous system has been described, with viral transmission along neuronal synapses in a retrograde fashion. The penetration of the virus to the central nervous system (CNS) allows for the resulting intracranial cytokine storm, which can result in a myriad of CNS complications. There have been reported cases of associated cerebrovascular accidents with large vessel occlusions, cerebral venous sinus thrombosis, posterior reversible encephalopathy syndrome, meningoencephalitis, acute necrotizing encephalopathy, epilepsy, and myasthenia gravis. Peripheral nervous system effects such as hyposmia, hypogeusia, ophthalmoparesis, Guillain-Barré syndrome, and motor peripheral neuropathy have also been reported. In this review, we update the clinical manifestations of COVID-19 concentrating on the neurological associations that have been described, including broad ranges in both central and peripheral nervous systems.
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Affiliation(s)
- Hisham M. Valiuddin
- University of Pennsylvania, Department of Emergency Medicine, Philadelphia, Pennsylvania
| | - Almir Kalajdzic
- St. Mary Mercy Hospital, Department of Emergency Medicine, Livonia, Michigan
| | - James Rosati
- St. Mary Mercy Hospital, Department of Emergency Medicine, Livonia, Michigan
| | - Kevin Boehm
- Broward Health Medical Center, Department of Emergency Medicine, Fort Lauderdale, Florida
| | - Dominique Hill
- St. Mary Mercy Hospital, Department of Emergency Medicine, Livonia, Michigan
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49
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Abdulsalam MA, Abdulsalam AJ, Shehab D. Generalized status epilepticus as a possible manifestation of COVID-19. Acta Neurol Scand 2020; 142:297-298. [PMID: 32779768 PMCID: PMC7405327 DOI: 10.1111/ane.13321] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 07/03/2020] [Accepted: 07/15/2020] [Indexed: 12/31/2022]
Affiliation(s)
| | - Ahmad J. Abdulsalam
- Department of Physical Medicine and Rehabilitation Physical Medicine and Rehabilitation Hospital Andalous Kuwait
| | - Diaa Shehab
- Health Science Center Faculty of Medicine Kuwait University Jabriya Kuwait
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50
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Carroll E, Neumann H, Aguero-Rosenfeld ME, Lighter J, Czeisler BM, Melmed K, Lewis A. Post-COVID-19 inflammatory syndrome manifesting as refractory status epilepticus. Epilepsia 2020; 61:e135-e139. [PMID: 32944946 PMCID: PMC7537028 DOI: 10.1111/epi.16683] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 08/13/2020] [Accepted: 08/14/2020] [Indexed: 01/21/2023]
Abstract
There have been multiple descriptions of seizures during the acute infectious period in patients with COVID‐19. However, there have been no reports of status epilepticus after recovery from COVID‐19 infection. Herein, we discuss a patient with refractory status epilepticus 6 weeks after initial infection with COVID‐19. Extensive workup demonstrated elevated inflammatory markers, recurrence of a positive nasopharyngeal SARS‐CoV‐2 polymerase chain reaction, and hippocampal atrophy. Postinfectious inflammation may have triggered refractory status epilepticus in a manner similar to the multisystemic inflammatory syndrome observed in children after COVID‐19.
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Affiliation(s)
- Elizabeth Carroll
- Department of Neurology, NYU Langone Medical Center, New York, New York
| | - Henry Neumann
- Department of Medicine, NYU Langone Medical Center, New York, New York
| | | | - Jennifer Lighter
- Department of Pediatrics, NYU Langone Medical Center, New York, New York
| | - Barry M Czeisler
- Department of Neurology, NYU Langone Medical Center, New York, New York.,Department of Neurosurgery, NYU Langone Medical Center, New York, New York
| | - Kara Melmed
- Department of Neurology, NYU Langone Medical Center, New York, New York.,Department of Neurosurgery, NYU Langone Medical Center, New York, New York
| | - Ariane Lewis
- Department of Neurology, NYU Langone Medical Center, New York, New York.,Department of Neurosurgery, NYU Langone Medical Center, New York, New York
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