Acute symptomatic seizures and COVID-19: Hospital-based study

New-onset refractory status epilepticus after SARS-CoV-2 infection: a review of literature

Although severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) primarily affects the respiratory system, neurological symptoms were reported both during acute and post-acute COVID-19. Notably, patients with no history of epilepsy or other neurological conditions developed new-onset refractory status epilepticus (NORSE) weeks, months, or even up to a year following the viral infection. While NORSE is uncommon, it carries a high mortality rate and can result in permanent epilepsy. Therefore, clinicians should consider the possibility of death or epilepsy development when treating individuals with NORSE who have recently contracted SARS-CoV-2. This article compiles comprehensive information on the mechanisms of epileptogenesis linked to SARS-CoV-2, the diagnosis of NORSE syndrome, its treatment options, and associated outcomes. Our aim was to enhance physicians' understanding of the virus's pathogenesis and increase the awareness of NORSE.

Late-Onset Idiopathic Generalized Epilepsy Manifesting With De Novo Late-Onset Absence Status Epilepticus After COVID-19 Infection: A Case Report

Herein, we present a case of idiopathic generalized epilepsy (IGE) manifesting as de novo late-onset absence status epilepticus (ASE) following mild coronavirus disease 2019 (COVID-19). A woman in her 40s presented with persistent 3-5.5 Hz generalized spike-wave complexes (SWCs) on electroencephalography (EEG). She experienced a generalized tonic-clonic seizure (GTCS) 10 days after the COVID-19 infection. She was diagnosed with epilepsy at 40 years of age, after which she was started on levetiracetam (LEV) 1,000 mg/day. After the medication was started, she experienced three other GTCSs. We performed a long-term video EEG of the patient, leading to a diagnosis of late-onset IGE with de novo late-onset ASE. She achieved seizure freedom for over a year with a combination of valproic acid (VPA) and lamotrigine (LTG), although her EEG continued to demonstrate persistent generalized SWCs. This case suggests that late-onset IGE accompanied by de novo late-onset status epilepticus may have been triggered by COVID-19. Persistent neuroinflammation may be reflected in persistent EEG abnormalities, even after epileptic seizures are well controlled with medications. LTG and VPA are believed to be effective for clinical management, and EEG is an essential modality for recording epileptic activity in outpatient settings.

Innovative drug discovery strategies in epilepsy: integrating next-generation syndrome-specific mouse models to address pharmacoresistance and epileptogenesis

INTRODUCTION

Although there are numerous treatment options already available for epilepsy, over 30% of patients remain resistant to these antiseizure medications (ASMs). Historically, ASM discovery has relied on the demonstration of efficacy through the use of 'traditional' acute in vivo seizure models (e.g. maximal electroshock, subcutaneous pentylenetetrazol, and kindling). However, advances in genetic sequencing technologies and remaining medical needs for people with treatment-resistant epilepsy or special patient populations have encouraged recent efforts to identify novel compounds in syndrome-specific models of epilepsy. Syndrome-specific models, including Scn1a variant models of Dravet syndrome and APP/PS1 mice associated with familial early-onset Alzheimer's disease, have already led to the discovery of two mechanistically novel treatments for developmental and epileptic encephalopathies (DEEs), namely cannabidiol and soticlestat, respectively.

AREAS COVERED

In this review, the authors discuss how it is likely that next-generation drug discovery efforts for epilepsy will more comprehensively integrate syndrome-specific epilepsy models into early drug discovery providing the reader with their expert perspectives.

EXPERT OPINION

The percentage of patients with pharmacoresistant epilepsy has remained unchanged despite over 30 marketed ASMs. Consequently, there is a high unmet need to reinvent and revise discovery strategies to more effectively address the remaining needs of patients with specific epilepsy syndromes, including drug-resistant epilepsy and DEEs.

Clinical outcomes of patients with seizure admitted for COVID-19: Findings from the Philippine CORONA study

Objective

Seizure is one of the neurologic manifestations of coronavirus disease 2019 (COVID-19) infection. There are few studies focused on the outcome of hospitalized patients with COVID-19 and seizure.

Methods

This was a subgroup analysis of patients with seizure based on a nationwide, multicenter, retrospective study of COVID-19 patients admitted in 37 hospitals in the Philippines.

Results

A total of 10,881 patients with COVID-19 infection were included. Among these, 27 (0.2 %) patients had pre-existing seizure/epilepsy and 125 (1.1 %) had new-onset seizure. The patients with pre-existing seizure/epilepsy had a mean age of 49 years and majority were males (63.0 %). The patients with new-onset seizure had a mean age of 57 years and majority were males (60.5 %). Among patients with pre-existing seizure/epilepsy, there were no significant differences in the proportion of severe/critical COVID-19 (p = 0.131), all-cause mortality (p = 0.177), full/partial neurologic recovery (p = 0.190), ventilator use (p = 0.106), length of intensive care unit stay (p = 0.276), and length of hospitalization (p = 0.591). Patients with new-onset seizure were 2.65 times more likely to have severe/critical COVID-19 infection (p < 0.001), 3.12 times more likely to die (p < 0.001), and 3.51 times more likely to require a ventilator (p < 0.001) than those without new-onset seizure. New-onset seizure, however, was not significantly associated with full/partial neurologic recovery (p = 0.184) and prolonged length of hospitalization (p = 0.050).

Conclusion

Severe/critical COVID-19 infection, higher mortality rate, and use of a ventilator were significantly higher among patients with new-onset seizure but not among patients with pre-existing seizure/epilepsy.

Diet composition and sterilization modifies intestinal microbiome diversity and burden of Theiler's virus infection-induced acute seizures

OBJECTIVE

Brain infection with Theiler's murine encephalomyelitis virus (TMEV) in C57BL/6J mice can induce acquired epileptogenesis. Diet alters acute seizure incidence in TMEV-infected mice; yet it is unclear whether intestinal dysbiosis may also impact acute or chronic behavioral comorbidities. This study thus assessed the impact of diet formulation and sterilization on acute seizure presentation, gut microbiome composition, and epilepsy-related chronic behavioral comorbidities.

METHODS

Baseline fecal samples were collected from male C57BL/6J mice (4- to 5-weeks-old; Jackson Labs) upon facility arrival. Mice were randomized to either autoclaved (AC) or irradiated diet (IR) (Prolab RMH 3000) or IR (Picolab 5053). Three days later, mice underwent intracerebral TMEV or phosphate-buffered saline (PBS) injection. Fecal samples were collected from a subset of mice at infection (Day 0) and Day 7 post-infection. Epilepsy-related working memory deficits and seizure threshold were assessed 6 weeks post-infection. Gut microbiome diversity was determined by 16S rRNA amplicon sequencing of fecal samples.

RESULTS

TMEV-infected mice displayed acute handling-induced seizures, regardless of diet: 28 of 57 IR Picolab 5053 (49.1%), 30 of 41 IR Prolab RMH 3000 (73.2%), and 47 of 77 AC Prolab RMH 3000 (61%) mice displayed seizures. The number of observed seizures differed significantly by diet: IR Picolab 5053 diet-fed mice had 2.2 ± 2.8 seizures (mean ± standard deviation), IR Prolab RMH 3000 diet-fed mice had 3.5 ± 2.9 seizures, and AC Prolab RMH 3000 diet-fed mice had 4.4 ± 3.8 seizures during the 7-day monitoring period. Gut microbiome composition differed significantly in TMEV-infected mice fed the AC Prolab RMH 3000 diet, with measured differences in gram-positive bacteria. These mice also displayed worsened long-term working memory deficits.

SIGNIFICANCE

Diet-induced differences in intestinal dysbiosis in the TMEV model are associated with marked changes in acute seizure presentation, symptomatic recovery, and onset of chronic behavioral comorbidities of epilepsy. Our study reveals a novel disease-modifying impact of dietary manipulation on intestinal bacterial species after TMEV-induced acute seizures.

Diet composition and sterilization modifies intestinal microbiome diversity and burden of Theiler's virus infection-induced acute seizures

Objective

Central nervous system infection with Theiler's murine encephalomyelitis virus (TMEV) in C57BL/6J mice can model acquired epileptogenesis. Diet alters the acute seizure incidence in TMEV-infected mice; yet it is unclear whether intestinal dysbiosis may also impact acute or chronic behavioral comorbidities. This study thus assessed the impact of diet sterilization in a specific pathogen-free vivarium on acute seizure presentation, the composition of the gut microbiome, and chronic behavioral comorbidities of epilepsy.

Methods

Baseline fecal samples were collected from male C57BL/6J mice (4-5 weeks-old; Jackson Labs) upon arrival. Mice were randomized to either autoclaved (AC) or irradiated (IR) diet (Prolab RMH 3000 - UU diets) or IR (Picolab 5053 - UW IR diet). Mice then underwent intracerebral TMEV or PBS injection three days later. Fecal samples were collected from a subset of mice at infection (Day 0) and Day 7 post-infection. Epilepsy-related working memory deficits and seizure threshold were assessed 6 weeks post-infection. Gut microbiome diversity was determined by 16S rRNA amplicon sequencing of fecal samples.

Results

TMEV-infected mice displayed acute handling-induced seizures, regardless of diet: 28/57 UW IR (49.1%), 30/41 UU IR (73.2%), and 47/77 UU AC (61%) mice displayed seizures. The number of observed seizures significantly differed: UW IR mice had 2.2±2.8 seizures (mean±standard deviation), UU IR mice had 3.5±2.9 seizures, and UU AC mice had 4.4±3.8 seizures during the 7-day monitoring period. The composition of the gut microbiome significantly differed in TMEV-infected mice fed the UU AC diet, with most measured differences occurring in Gram-positive bacteria. TMEV-infected mice fed the UU AC diet displayed worsened chronic working memory.

Significance

Intestinal dysbiosis evokes stark differences in acute seizure presentation in the TMEV model and vastly influences the trajectory of post-TMEV infection-induced behavioral comorbidities of epilepsy. Our study reveals a novel disease-modifying contribution of intestinal bacterial species after TMEV-induced acute seizures.

Neurological manifestation in COVID-19 disease with neuroimaging studies

OBJECTIVE

Magnetic resonance imaging (MRI) of the brain or spine examines the findings as well as the time interval between the onset of symptoms and other adverse effects in coronavirus disease that first appeared in 2019 (COVID-19) patients. The goal of this study is to look at studies that use neuroimaging to look at neurological and neuroradiological symptoms in COVID-19 patients.

METHODS

We try to put together all of the research on how severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes neurological symptoms and cognitive-behavioral changes and give a full picture.

RESULTS

We have categorized neuroimaging findings into subtitles such as: headache and dizziness; cerebrovascular complications after stroke; Intracerebral Hemorrhage (ICH); Cerebral Microbleeds (CMBs); encephalopathy; meningitis; encephalitis and myelitis; altered mental status (AMS) and delirium; seizure; neuropsychiatric symptoms; Guillain-Barre Syndrome (GBS) and its variants; smell and taste disorders; peripheral neuropathy; Mild Cognitive Impairment (MCI); and myopathy and myositis.

CONCLUSION

In this review study, we talked about some MRI findings that show how COVID-19 affects the nervous system based on what we found.

Imaging Markers of Neurologic Damage in COVID-19: A Systematic Review

BACKGROUND AND OBJECTIVES

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection commonly leads to neurologic manifestations. In the present review, we aimed to investigate potential neuroimaging markers of early diagnosis and prognosis of neurologic manifestations in COVID-19.

METHODS

Our study was registered in the Prospective Register of Systematic Reviews (PROSPERO) under the protocol CDR42021265443. Based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we selected 51 studies for whole-manuscript analysis.

RESULTS

Magnetic resonance imaging (MRI) was the most common imaging method. The pattern, sites of lesion, signs, and symptoms of neurologic injury varied. Such manifestations possibly resulted from a direct viral infection or, most likely, from indirect mechanisms including coagulation disturbances, hypoxemia, and immunological responses.

CONCLUSION

The heterogeneity of the studies precludes any generalization of the findings. Brain MRI is the most informative imaging exam. Population studies, including the entire spectrum of COVID-19 are missing. There is still a need for future population studies evaluating neurologic manifestations of all COVID-19 severities acutely and chronically.

Neurological manifestations in SARS-CoV-2 infection: A single-center cross-sectional study in Malaysia

Background

Neurological involvement associated with SARS-CoV-2 infection has been reported from different regions of the world. However, data from South East Asia are scarce. We described the neurological manifestations and their associated factors among the hospitalized COVID-19 patients from an academic tertiary hospital in Malaysia.

Methods

A cross-sectional observational study of hospitalized COVID-19 patients was conducted. The neurological manifestations were divided into the self-reported central nervous system (CNS) symptoms, stroke associated symptoms, symptoms of encephalitis or encephalopathy and specific neurological complications. Multiple logistic regression was performed using demographic and clinical variables to determine the factors associated with outcome.

Results

Of 156 hospitalized COVID-19 patients with mean age of 55.88 ± 6.11 (SD) years, 23.7% developed neurological complications, which included stroke, encephalitis and encephalopathy. Patients with neurological complications were more likely to have diabetes mellitus (p = 0.033), symptoms of stroke [limb weakness (p < 0.001), slurred speech (p < 0.001)]; and encephalitis or encephalopathy [confusion (p < 0.001), forgetfulness (p = 0.006) and seizure (p = 0.019)]. Unvaccinated patients had a 4.25-fold increased risk of having neurological complications (adjusted OR = 4.25; 95% CI: 1.02, 17.71, p = 0.047). Anosmia and dysgeusia were less associated with neurological complications (adjusted OR = 0.22; 95% CI: 0.05, 0.96, p = 0.044). The odds of neurological complications were increased by 18% in patients with leukocytosis (adjusted OR = 1.18, 95% CI: 1.003, p = 0.0460).

Conclusions

Stroke, encephalitis and encephalopathy were the common neurological complications from our study. Diabetes mellitus, presence of symptoms of stroke, symptoms of encephalitis or encephalopathy, leukocytosis, and being unvaccinated against COVID-19 were the associated risk factors of developing neurological complications.

A companion to the preclinical common data elements for phenotyping seizures and epilepsy in rodent models. A report of the TASK3-WG1C: Phenotyping working group of the ILAE/AES joint translational task force

Epilepsy is a heterogeneous disorder characterized by spontaneous seizures and behavioral comorbidities. The underlying mechanisms of seizures and epilepsy across various syndromes lead to diverse clinical presentation and features. Similarly, animal models of epilepsy arise from numerous dissimilar inciting events. Preclinical seizure and epilepsy models can be evoked through many different protocols, leaving the phenotypic reporting subject to diverse interpretations. Serendipity can also play an outsized role in uncovering novel drivers of seizures or epilepsy, with some investigators even stumbling into epilepsy research because of a new genetic cross or unintentional drug effect. The heightened emphasis on rigor and reproducibility in preclinical research, including that which is conducted for epilepsy, underscores the need for standardized phenotyping strategies. To address this goal as part of the TASK3-WG1C Working Group of the International League Against Epilepsy (ILAE)/American Epilepsy Society (AES) Joint Translational Task Force, we developed a case report form (CRF) to describe the common data elements (CDEs) necessary for the phenotyping of seizure-like behaviors in rodents. This companion manuscript describes the use of the proposed CDEs and CRF for the visual, behavioral phenotyping of seizure-like behaviors. These phenotyping CDEs and accompanying CRF can be used in parallel with video-electroencephalography (EEG) studies or as a first visual screen to determine whether a model manifests seizure-like behaviors before utilizing more specialized diagnostic tests, like video-EEG. Systematic logging of seizure-like behaviors may help identify models that could benefit from more specialized diagnostic tests to determine whether these are epileptic seizures, such as video-EEG.

Poststroke Seizure and Epilepsy: A Review of Incidence, Risk Factors, Diagnosis, Pathophysiology, and Pharmacological Therapies

Stroke is the most common cause of epilepsy and ultimately leads to a decrease in the quality of life of those affected. Ischemic and hemorrhagic strokes can both lead to poststroke epilepsy (PSE). Significant risk factors for PSE include age < 65age less than 65 years, stroke severity measured by the National Institutes of Health Stroke Scale (NIHSS), cortical involvement, and genetic factors such as TRPM6 polymorphism. The diagnosis of PSE is made by using imaging modalities, blood biomarkers, and prognostic criteria. Electroencephalography (EEG) is currently the gold standard to diagnose PSE, while new combinations of modalities are being tested to increase diagnostic specificity. This literature review uncovers a newly found mechanism for the pathology of poststroke epilepsy. The pathogenesis of early-onset and late-onset is characterized by sequelae of neuronal cellular hypoxia and disruption of the blood-brain barrier, respectively. Interleukin-6 is responsible for increasing the activity of glial cells, causing gliosis and hyperexcitability of neurons. Epinephrine, high-mobility group protein B1, downregulation of CD32, and upregulation of HLA-DR impact the pathology of poststroke epilepsy by inhibiting the normal neuronal immune response. Decreased levels of neuropeptide Y, a neurotransmitter, act through multiple unique mechanisms, such as inhibiting intracellular Ca²⁺ accumulation and acting as an anti-inflammatory, also implemented in the worsening progression of poststroke epilepsy. Additionally, CA1 hippocampal resonant neurons that increase theta oscillation are associated with poststroke epilepsy. Hypertensive small vessel disease may also have an implication in the temporal lobe epilepsy by causing occult microinfarctions. Furthermore, this review highlights the potential use of statins as primary prophylaxis against PSE, with multiple studies demonstrating a reduction in incidence using statins alone, statins in combination with antiepileptic drugs (AEDs), and statins with aspirin. The evidence strongly suggests that the second generation AEDs are a superior treatment method for PSE. Data from numerous studies demonstrate their relative lack of significant drug interactions, increased tolerability, and potential superiority in maintaining seizure-free status.

Post COVID-19 complications, adjunct therapy explored, and steroidal after effects

For COVID-19 survivors, defeating the virus is just the beginning of a long road to recovery. The inducibility and catastrophic effects of the virus are distributed across multiple organs. The induction of cytokine storms in COVID-19 patients is due to the interaction of the SARS-CoV-2 virus and the host receptor, leading to various immunopathological consequences that may eventually lead to death. So far, COVID-19 has affected tons of people across the world, but there is still no effective treatment. Patients facing complications of COVID-19 after recovery have shown extensive clinical symptoms similar to that of patients recovering from previously circulating coronaviruses. Previous knowledge and literature have opened up ways to treat this disease and manage post-COVID-19 complications, which pose a severe challenge to the health system globally and may exacerbate the fragmentation of diseases. The use of steroids as a treatment has resulted in various health problems and side-effects in COVID-19 patients. This review discusses various post-COVID-19 complications observed and adjunctive therapies used along with common COVID-19 treatment and spotlights their side effects and consequences. This review provides the latest literature on COVID-19, which emphasizes the subsequent complications in various organs, side effects of drugs, and alternative regimens used to treat COVID-19.

Acute to Chronic Electro-Clinical Manifestations of Neuro-COVID and the Long-Haul Consequences in People With Epilepsy: A Review

Severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) infection can involve the central nervous system (CNS). Acute symptomatic seizures or epileptiform discharges have not been commonly reported in patients with altered mental status related to coronavirus disease 2019 (COVID-19) infection. However, long-term neurological symptoms have been reported after COVID-19 infection (i.e., brain fog, cognitive complaints, and confusion), suggesting chronic encephalopathy. People with epilepsy (PWE) have been specifically affected by the COVID-19 pandemic, with changes in their seizure frequency, quality of life, health care accessibility, and medication interactions. This narrative review highlights possible pathophysiological mechanisms of COVID-19 on the brain, related to short- and long-term epileptiform activity and the impact of this infection on PWE.

COVID-19 Presenting as a Seizure: A Kenyan Case Report

The new coronavirus quickly spread throughout the world in late 2019 and became a pandemic in early 2020. The most common symptoms observed are fever, dry cough, loss of taste and smell, and respiratory distress. Other rarer complications can involve the cardiovascular, gastrointestinal, or neurological systems. Of the neurological complications, epileptic seizures are a subject of particular interest due to their relatively unknown and widespread etiologies. It is understood that the entry or production of pro-inflammatory cytokines during a COVID-19 infection can result in neurotransmitter modulation and ion channel dysfunction, leading to neuronal hyperexcitability, presenting as seizures. To the best of our knowledge, we present the first case in sub-Saharan Africa of a COVID-19 positive patient presenting to our institution with a reported seizure followed by confusion. Our case highlights the need to broaden our differential diagnosis to include COVID-19 infections in patients presenting with seizures.