Inpatient Neurology Consultations During the Onset of the SARS-CoV-2 New York City Pandemic: A Single Center Case Series

Acute Encephalitis During a SARS-CoV-2 Infection: A Case Report

It was in December 2019 that the coronavirus causing COVID-19 was first detected in Wuhan, China. Although the primary clinical presentation is respiratory disease, an increasing number of reports worldwide have noted various neurological manifestations, such as acute encephalitis. We present a case of a 49-year-old female admitted with afebrile impaired consciousness, diagnosed with acute encephalitis and a severe infection of COVID-19. Clinical and radiological improvement was observed following treatment with corticosteroids.

Implementation of a Real-Time Documentation Assistance Tool: Automated Diagnosis (AutoDx)

BACKGROUND

 Clinical documentation improvement programs are utilized by most health care systems to enhance provider documentation. Suggestions are sent to providers in a variety of ways, and are commonly referred to as coding queries. Responding to these coding queries can require significant provider time and do not often align with workflows. To enhance provider documentation in a more consistent manner without creating undue burden, alternative strategies are required.

OBJECTIVES

 The aim of this study is to evaluate the impact of a real-time documentation assistance tool, named AutoDx, on the volume of coding queries and encounter-level outcome metrics, including case-mix index (CMI).

METHODS

 The AutoDx tool was developed utilizing tools existing within the electronic health record, and is based on the generation of messages when clinical conditions are met. These messages appear within provider notes and required little to no interaction. Initial diagnoses included in the tool were electrolyte deficiencies, obesity, and malnutrition. The tool was piloted in a cohort of Hospital Medicine providers, then expanded to the Neuro Intensive Care Unit (NICU), with addition diagnoses being added.

RESULTS

 The initial Hospital Medicine implementation evaluation included 590 encounters pre- and 531 post-implementation. The volume of coding queries decreased 57% (p < 0.0001) for the targeted diagnoses compared with 6% (p = 0.77) in other high-volume diagnoses. In the NICU cohort, 829 encounters pre-implementation were compared with 680 post. The proportion of AutoDx coding queries compared with all other coding queries decreased from 54.9 to 37.1% (p < 0.0001). During the same period, CMI demonstrated a significant increase post-implementation (4.00 vs. 4.55, p = 0.02).

CONCLUSION

 The real-time documentation assistance tool led to a significant decrease in coding queries for targeted diagnoses in two unique provider cohorts. This improvement was also associated with a significant increase in CMI during the implementation time period.

The Neurological Implications of COVID-19: A Comprehensive Narrative Review

The COVID-19 pandemic caused by the coronavirus SARS-CoV-2 revealed a huge number of problems as well as discoveries in medicine, notably, regarding the effects of the virus on the central nervous system (CNS) and peripheral nervous system (PNS). This paper is a narrative review that takes a deep dive into the complex interactions between COVID-19 and the NS. Therefore, this paper explains the broad range of neurological manifestations and neurodegenerative diseases caused by the virus. It carefully considers the routes through which SARS-CoV-2 reaches the NS, including the olfactory system and of course, the hematogenous route, which are also covered when discussing the virus's direct and indirect mechanisms of neuropathogenesis. Besides neurological pathologies such as stroke, encephalitis, Guillain-Barré syndrome, Parkinson's disease, and multiple sclerosis, the focus area is also given to the challenges of making diagnosis, treatment, and management of these conditions during the pandemic. The review also examines the strategic and interventional approaches utilized to prevent these disorders, as well as the ACE2 receptors implicated in the mediation of neurological effects caused by COVID-19. This detailed overview, which combines research outputs with case data, is directed at tackling this pandemic challenge, with a view toward better patient care and outcomes in the future.

Seizures in COVID-19: the relationship between biomarkers and prognosis

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.

High-dose steroid-responsive COVID-19-related encephalopathy with a sudden onset of dysarthria mimicking stroke: a case report

There has been limited research on encephalitis/encephalopathy, which is a less common coronavirus disease 2019 (COVID-19) neurological complication. The differentiation between stroke and encephalopathy with stroke mimickers is challenging in patients with COVID-19. Here, we describe a case of COVID-19-related encephalopathy mimicking stroke that was successfully treated with high-dose steroid pulse therapy. The patient suddenly experienced language disturbance with a left facial droop and symmetric numbness in his upper limbs. Magnetic resonance imaging (MRI) scans revealed hyperintensities in both the white matter and splenium. No pneumonia was observed. MRI abnormalities and neurological symptoms resolved after steroid pulse therapy and administration of remdesivir. High-dose steroid pulse treatment (for 3 days) might alleviate COVID-19-related encephalopathy.

Neurological Complications of SARS-CoV-2 Infection and COVID-19 Vaccines: From Molecular Mechanisms to Clinical Manifestations

Coronavirus Disease 2019 (COVID-19) is an infectious disease, caused by the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), that reached pandemic proportions in 2020. Despite the fact that it was initially characterized by pneumonia and acute respiratory distress syndrome, it is now clear that the nervous system is also compromised in one third of these patients. Indeed, a significant proportion of COVID-19 patients suffer nervous system damage via a plethora of mechanisms including hypoxia, coagulopathy, immune response to the virus, and the direct effect of SARS-CoV-2 on endothelial cells, neurons, astrocytes, pericytes and microglia. Additionally, a low number of previously healthy individuals develop a variety of neurological complications after receiving COVID-19 vaccines and a large proportion of COVID-19 survivors experience longlasting neuropsychiatric symptoms. In conclusion, COVID-19 is also a neurological disease, and the direct and indirect effects of the virus on the nervous system have a significant impact on the morbidity and mortality of these patients. Here we will use the concept of the neurovascular unit, assembled by endothelial cells, basement membrane, perivascular astrocytes, neurons and microglia, to review the effects of SARS-CoV-2 in the nervous system. We will then use this information to review data published to this date on the neurological manifestations of COVID-19, the post- COVID syndrome and COVID-19 vaccines.

COVID-19-Induced Seizures: A Meta-Analysis of Case Series and Retrospective Cohorts

The adverse events and complications of coronavirus disease 2019 (COVID-19) continue to challenge the medical profession despite the worldwide vaccination against the severe acute respiratory coronavirus 2 (SARS-CoV-2), the causative agent of COVID-19. Other than typical respiratory manifestations, COVID-19 also presents a wide range of neurological manifestations. This article underlines the pooled incidence of COVID-19-induced seizures in patients with epilepsy and without epilepsy. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocols, we conducted a bibliographical search, and an initial search revealed 1,375 articles. In total, 21 articles were included in the final analysis by following the inclusion criteria. A total of 11,526 patients from 21 published articles that met the predetermined search criteria were included. The median age of the patients was 61.9 years, of whom 51.5% were males. A total of 255 patients presented with seizures as the first manifestation of COVID-19 with a prevalence of 2.2% (95% confidence interval = 0.05-0.24, p < 0.01) (I² = 97%), of which 71 patients had previously been diagnosed with epilepsy. Among patients with epilepsy, 49 patients had seizures as an initial presentation of SARA-CoV-2 with an incidence of 72% (0.54-0.85, p = 0.1) (I² = 34). Although the incidence of COVID-19-induced seizures is not high compared to other neurological manifestations, seizure incidence in epileptic patients with COVID-19 is remarkably high. New-onset seizures in any patient should be considered a presentation of COVID-19 in the absence of other causative factors.

Cerebral microvascular complications associated with SARS-CoV-2 infection: How did it occur and how should it be treated?

Cerebral microvascular disease has been reported as a central feature of the neurological disorders in patients with SARS-CoV-2 infection that may be associated with an increased risk of ischemic stroke. The main pathomechanism in the development of cerebrovascular injury due to SARS-CoV-2 infection can be a consequence of endothelial cell dysfunction as a structural part of the blood-brain barrier (BBB), which may be accompanied by increased inflammatory response and thrombocytopenia along with blood coagulation disorders. In this review, we described the properties of the BBB, the neurotropism behavior of SARS-CoV-2, and the possible mechanisms of damage to the CNS microvascular upon SARS-CoV-2 infection.

Clinical symptoms, diagnosis, treatment, and outcome of COVID-19-associated encephalitis: A systematic review of case reports and case series

Introduction

Since COVID‐19 outbreak, various studies mentioned the occurrence of neurological disorders. Of these, encephalitis is known as a critical neurological complication in COVID‐19 patients. Numerous case reports and case series have found encephalitis in relation to COVID‐19, which have not been systematically reviewed. This study aims to evaluate the clinical symptoms, diagnosis, treatment, and outcome of COVID‐19‐associated encephalitis.

Methods

We used the Pubmed/Medline, Embase, and Web of Science databases to search for reports on COVID‐19‐associated encephalitis from January 1, 2019, to March 7, 2021. The irrelevant studies were excluded based on screening and further evaluation. Then, the information relating diagnosis, treatment, clinical manifestations, comorbidities, and outcome was extracted and evaluated.

Results

From 4455 initial studies, 45 articles met our criteria and were selected for further evaluation. Included publications reported an overall number of 53 COVID‐19‐related encephalitis cases. MRI showed hyperintensity of brain regions including white matter (44.68%), temporal lobe (17.02%), and thalamus (12.76%). Also, brain CT scan revealed the hypodensity of the white matter (17.14%) and cerebral hemorrhages/hemorrhagic foci (11.42%) as the most frequent findings. The IV methylprednisolone/oral prednisone (36.11%), IV immunoglobulin (27.77%), and acyclovir (16.66%) were more preferred for COVID‐19 patients with encephalitis. From the 46 patients, 13 (28.26%) patients were died in the hospital.

Conclusion

In this systematic review, characteristics of COVID‐19‐associated encephalitis including clinical symptoms, diagnosis, treatment, and outcome were described. COVID‐19‐associated encephalitis can accompany with other neurological symptoms and involve different brain. Although majority of encephalitis condition are reversible, but it can lead to life‐threatening status. Therefore, further investigation of COVID‐19‐associated encephalitis is required.

Citicoline and COVID-19-Related Cognitive and Other Neurologic Complications

With growing concerns about COVID-19’s hyperinflammatory condition and its potentially damaging impact on the neurovascular system, there is a need to consider potential treatment options for managing short- and long-term effects on neurological complications, especially cognitive function. While maintaining adequate structure and function of phospholipid in brain cells, citicoline, identical to the natural metabolite phospholipid phosphatidylcholine precursor, can contribute to a variety of neurological diseases and hypothetically toward post-COVID-19 cognitive effects. In this review, we comprehensively describe in detail the potential citicoline mechanisms as adjunctive therapy and prevention of COVID-19-related cognitive decline and other neurologic complications through citicoline properties of anti-inflammation, anti-viral, neuroprotection, neurorestorative, and acetylcholine neurotransmitter synthesis, and provide a recommendation for future clinical trials.

Encephalitis as a neurological complication of COVID-19: A systematic review and meta-analysis of incidence, outcomes, and predictors

BACKGROUND AND PURPOSE

Although COVID-19 predominantly affects the respiratory system, recent studies have reported the occurrence of neurological disorders such as stroke in relation to COVID-19 infection. Encephalitis is an inflammatory condition of the brain that has been described as a severe neurological complication of COVID-19. Despite a growing number of reported cases, encephalitis related to COVID-19 infection has not been adequately characterised. To address this gap, this systematic review and meta-analysis aims to describe the incidence, clinical course, and outcomes of patients who suffer from encephalitis as a complication of COVID-19.

METHODS

All studies published between 1 November 2019 and 24 October 2020 that reported on patients who developed encephalitis as a complication of COVID-19 were included. Only cases with radiological and/or biochemical evidence of encephalitis were included.

RESULTS

In this study, 610 studies were screened and 23 studies reporting findings from 129,008 patients, including 138 with encephalitis, were included. The average time from diagnosis of COVID-19 to onset of encephalitis was 14.5 days (range = 10.8-18.2 days). The average incidence of encephalitis as a complication of COVID-19 was 0.215% (95% confidence interval [CI] = 0.056%-0.441%). The average mortality rate of encephalitis in COVID-19 patients was 13.4% (95% CI = 3.8%-25.9%). These patients also had deranged clinical parameters, including raised serum inflammatory markers and cerebrospinal fluid pleocytosis.

CONCLUSIONS

Although encephalitis is an uncommon complication of COVID-19, when present, it results in significant morbidity and mortality. Severely ill COVID-19 patients are at higher risk of suffering from encephalitis as a complication of the infection.

Neurohospitalist Practice and Well-Being During the COVID-19 Pandemic

Background and Purpose

Neurohospitalists play an important role in, and have been variably affected by, the ongoing COVID-19 pandemic. In this study, we survey neurohospitalists to characterize practice changes and the impact of the pandemic on their well-being.

Methods

A 22-item survey was distributed to neurohospitalists through the Neurohospitalist Society and the American Academy of Neurology Neurohospitalist, Stroke & Vascular Neurology, and Critical Care & Emergency Neurology Sections.

Results

After 2 weeks of collection, 123 responses were received, with 57% of respondents practicing in academic settings, 23% in private practice, and 7% in community hospitals. A minority of neurohospitalists (8%) were redeployed to care for COVID-19 or non-COVID-19 medicine patients. The most common neurologic diagnoses they reported in COVID-19 patients were delirium (85%), cerebrovascular events (75%), and seizure (35%); however, most neurohospitalists (59%) had evaluated fewer than 10 patients with COVID-19. Respondents observed that fewer patients with unrelated neurological diseases were admitted to the hospital compared to before the pandemic. Neurohospitalists experienced changes in administrative (27%), educational (15%), and research duties (11%), and had overall worse well-being and work-life balance (77%).

Conclusions

The most common neurologic diagnoses seen in COVID-19 patients by neurohospitalists in this sample are delirium, cerebrovascular disease, and seizure. Though the majority of survey respondents reported not being primary frontline providers, they report key clinical and operational roles during the pandemic, and report worse well-being as compared to before the pandemic. Our data suggests that there are opportunities to improve neurohospitalists' experience through flexible work practices and providing family care support.

Mononeuropathy Multiplex After COVID-19

OBJECTIVES

COVID-19 is a novel coronavirus that emerged in 2019 and is responsible for a global pandemic. Numerous neurologic manifestations have been described in the literature regarding COVID-19, but most studies are focused on the central nervous system. The authors have noted an association between prior COVID-19 infection and the development of a systemic neuropathy that manifests with asymmetric sensorimotor loss in the peripheral nervous system. We describe 4 cases of mononeuropathy multiplex that were diagnosed after COVID-19 infection.

METHODS

All patients included were treated for severe COVID-19 infection at New York Presbyterian Hospital and subsequently referred to the Columbia Peripheral Neuropathy Center for persistent neuropathy.

RESULTS

Patient history, COVID-19 disease course, and mononeuropathy multiplex diagnostic evaluation of the 4 patients are recounted.

CONCLUSIONS

We postulate a connection between COVID-19 and the development of mononeuropathy multiplex with implications in prognostication, rehabilitation strategies, and future treatments.

What can the neurological manifestations of COVID-19 tell us: a meta-analysis

Background

Covid-19 became a global pandemic in 2019. Studies have shown that coronavirus can cause neurological symptoms, but clinical studies on its neurological symptoms are limited. In this meta-analysis, we aimed to summarize the various neurological manifestations that occurred in COVID-19 patients and calculate the incidence of various neurological manifestations. At the same time, we further explored the mechanism of nervous system injury and prognosis in COVID-19 patients in combination with their nervous system manifestations. This study provides a reference for early clinical identification of COVID-19 nervous system injury in the future, so as to achieve early treatment and reduce neurological sequelae.

Methods

We systematically searched all published English literature related to the neurological manifestations of COVID-19 from January 1, 2020, to April 30, 2021, in Pubmed, Embase, and Cochrane Library. The keywords used were COVID-19 and terminology related to the nervous system performance. All included studies were selected by two independent reviewers using EndNote and NoteExpress software, any disagreement was resolved by consensus or by a third reviewer, and the selected data were then collected for meta-analysis using a random-effects model.

Results

A total of 168 articles (n = 292,693) were included in the study, and the meta-analysis showed that the most common neurological manifestations of COVID-19 were myalgia(33%; 95%CI 0.30–0.37; I² = 99.17%), smell impairment(33%; 95%CI 0.28–0.38; I² = 99.40%), taste dysfunction(33%; 95%CI 0.27–0.39; I² = 99.09%), altered mental status(32%; 95%CI 0.22–0.43; I² = 99.06%), headache(29%; 95%CI 0.25–0.33; I² = 99.42%), encephalopathy(26%; 95%CI 0.16–0.38; I² = 99.31%), alteration of consciousness(13%; 95%CI 0.08–0.19; I² = 98.10%), stroke(12%; 95%CI 0.08–0.16; I² = 98.95%), dizziness(10%; 95%CI 0.08–0.13; I² = 96.45%), vision impairment(6%; 95%CI 0.03–0.09; I² = 86.82%), intracerebral haemorrhage(5%; 95%CI 0.03–0.09; I² = 95.60%), seizure(4%; 95%CI 0.02 -0.05; I² = 98.15%), encephalitis(2%; 95%CI 0.01–0.03; I² = 90.36%), Guillan-Barré Syndrome (GBS) (1%; 95%CI 0.00–0.03; I² = 89.48%).

Conclusions

Neurological symptoms are common and varied in Covid-19 infections, and a growing number of reports suggest that the prevalence of neurological symptoms may be increasing. In the future, the role of COVID-19 neurological symptoms in the progression of COVID-19 should be further studied, and its pathogenesis and assessment methods should be explored, to detect and treat early neurological complications of COVID-19 and reduce mortality.

ATTR amyloidosis during the COVID-19 pandemic: insights from a global medical roundtable

BACKGROUND

The global spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection causing the ongoing coronavirus disease 2019 (COVID-19) pandemic has raised serious concern for patients with chronic disease. A correlation has been identified between the severity of COVID-19 and a patient's preexisting comorbidities. Although COVID-19 primarily involves the respiratory system, dysfunction in multiple organ systems is common, particularly in the cardiovascular, gastrointestinal, immune, renal, and nervous systems. Patients with amyloid transthyretin (ATTR) amyloidosis represent a population particularly vulnerable to COVID-19 morbidity due to the multisystem nature of ATTR amyloidosis.

MAIN BODY

ATTR amyloidosis is a clinically heterogeneous progressive disease, resulting from the accumulation of amyloid fibrils in various organs and tissues. Amyloid deposition causes multisystem clinical manifestations, including cardiomyopathy and polyneuropathy, along with gastrointestinal symptoms and renal dysfunction. Given the potential for exacerbation of organ dysfunction, physicians note possible unique challenges in the management of patients with ATTR amyloidosis who develop multiorgan complications from COVID-19. While the interplay between COVID-19 and ATTR amyloidosis is still being evaluated, physicians should consider that the heightened susceptibility of patients with ATTR amyloidosis to multiorgan complications might increase their risk for poor outcomes with COVID-19.

CONCLUSION

Patients with ATTR amyloidosis are suspected to have a higher risk of morbidity and mortality due to age and underlying ATTR amyloidosis-related organ dysfunction. While further research is needed to characterize this risk and management implications, ATTR amyloidosis patients might require specialized management if they develop COVID-19. The risks of delaying diagnosis or interrupting treatment for patients with ATTR amyloidosis should be balanced with the risk of exposure in the health care setting. Both physicians and patients must adapt to a new construct for care during and possibly after the pandemic to ensure optimal health for patients with ATTR amyloidosis, minimizing treatment interruptions.

[Neuromuscular complications of SARS-CoV-2 infections-Part 1: peripheral nerves]

In recent months various disorders and diseases of the peripheral nerves (including cranial nerves) and the musculature have been described in association with the pulmonary disease coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In the first part of our review the current knowledge about a potential association of a SARS-CoV‑2 infection with dysfunction and diseases of cranial and peripheral nerves is discussed. Anosmia, ageusia, motor cranial nerve involvement and Guillain-Barré syndrome (GBS) were described in a temporal association with a SARS-CoV‑2 infection. Several studies could show that anosmia and ageusia were frequent symptoms of a SARS-CoV‑2 infection. In contrast the failure of other cranial nerves has so far only been sporadically described. A number of case reports and case series indicate a causal association between a SARS-CoV‑2 infection and GBS but epidemiological evidence is still lacking.

Case report and systematic review suggest that children may experience similar long-term effects to adults after clinical COVID-19

Aim

Persistent symptoms in adults after COVID‐19 are emerging and the term long COVID is increasingly appearing in the literature. However, paediatric data are scarce.

Methods

This paper contains a case report of five Swedish children and the long‐term symptoms reported by their parents. It also includes a systematic literature review of the MEDLINE, EMBASE and Web of Science databases and the medRxiv/bioRxiv pre‐print servers up to 2 November 2020.

Results

The five children with potential long COVID had a median age of 12 years (range 9–15) and four were girls. They had symptoms for 6–8 months after their clinical diagnoses of COVID‐19. None were hospitalised at diagnosis, but one was later admitted for peri‐myocarditis. All five children had fatigue, dyspnoea, heart palpitations or chest pain, and four had headaches, difficulties concentrating, muscle weakness, dizziness and sore throats. Some had improved after 6–8 months, but they all suffered from fatigue and none had fully returned to school. The systematic review identified 179 publications and 19 of these were deemed relevant and read in detail. None contained any information on long COVID in children.

Conclusion

Children may experience similar long COVID symptoms to adults and females may be more affected.

COVID-19-Associated Neurological Manifestations: An Emerging Electroencephalographic Literature

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.

A rapid review of the pathoetiology, presentation, and management of delirium in adults with COVID-19

Background COVID-19 causes significant morbidity and mortality. Despite the high prevalence of delirium and delirium-related symptoms in COVID-19 patients, data and evidence-based recommendations on the pathophysiology and management of delirium are limited. Objective We conducted a rapid review of COVID-19-related delirium literature to provide a synthesis of literature on the prevalence, pathoetiology, and management of delirium in these patients. Methods Systematic searches of Medline, Embase, PsycInfo, LitCovid, WHO-COVID-19, and Web of Science electronic databases were conducted. Grey literature was also reviewed, including preprint servers, archives, and websites of relevant organizations. Search results were limited to the English language. We included literature focused on adults with COVID-19 and delirium. Papers were excluded if they did not mention signs or symptoms of delirium. Results 229 studies described prevalence, pathoetiology, and/or management of delirium in adults with COVID-19. Delirium was rarely assessed with validated tools. Delirium affected >50% of all patients with COVID-19 admitted to the ICU. The etiology of COVID-19 delirium is likely multifactorial, with some evidence of direct brain effect. Prevention remains the cornerstone of management in these patients. To date, there is no evidence to suggest specific pharmacological strategies. Discussion Delirium is common in COVID-19 and may manifest from both indirect and direct effects on the central nervous system. Further research is required to investigate contributing mechanisms. As there is limited empirical literature on delirium management in COVID-19, management with non-pharmacological measures and judicious use of pharmacotherapy is suggested.

COVID-19, de novo seizures, and epilepsy: a systematic review

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.

Neuroprotective versus Neuroinflammatory Roles of Complement: From Development to Disease

Complement proteins are ancient components of innate immunity that have emerged as crucial regulators of neural networks. We discuss these roles in the context of the CNS development, acute CNS viral infections, and post-infectious and noninfectious CNS disorders, with an emphasis on microglia-mediated loss of synapses. Despite extensive examples that implicate classical complement proteins and their receptors in CNS dysfunction, recent data suggest that they exert neuroprotective roles in CNS homeostasis through continued refinement of synaptic connections. Thorough understanding of the mechanisms involved in these processes may lead to novel targets for the treatment of CNS diseases involving aberrant complement-mediated synapse loss.