Risk Estimation of SUDEP During COVID-19 Pandemic Era in a Tertiary Referral Center

Abstract, originally published in Epilepsy Research

Objective: No data exist regarding the impact of the lockdown due to the COVID-19 pandemic on the risk factors of sudden unexpected death in epilepsy (SUDEP). This study aimed to stratify risk factors of SUDEP in relation to COVID-19 lockdown, among patients with epilepsy (PWE) in Cairo University epilepsy unit (CUEU). Therefore, we can detect risk factors and mitigate such factors in the second wave of the virus.

Methods: an observational, cross-sectional study carried on 340 Egyptian patients with active epilepsy. Individual risk identification and stratification was done by using The SUDEP and seizure Safety Checklist, after which sharing risk knowledge to PWE and their caregivers was undertaken.

Results: The mean age of patients was 29.72 ± 12.12. The median of the static factors was 4 (IQR 3-5) whereas, the median of the modifiable factors was 2 (IQR 1-3). Epilepsy emergencies (serial seizures or status epilepticus) were reported in 24.1 % of patients, for which non-compliance was the commonest cause, followed by deferral of epilepsy surgery for patients with drug resistant epilepsy (DRE). Stepwise logistic regression analysis showed that use of anxiolytic medications, non-compliance, keeping patients with DRE on dual anti-seizure medications (ASMs), or adding third medication increased the odds of increased seizure frequency by 2.7, 3.5, 16.6 and 6.1 times, respectively.

Conclusion: Some COVID-19 related issues had influenced the risk of seizure worsening including postponing epilepsy surgery for patients with DRE, non-compliance, and psychiatric comorbidities. Special attention should be paid to these issues to mitigate the risk of SUDEP.

a graphic of the COVID-19 virus

Epilepsy During the COVID-19 Pandemic Lockdown: A US Population Survey

Abstract, originally published in Epileptic Disorders

Objective: This study sought to understand issues facing people with epilepsy (PWE) during the lockdown period of the COVID-19 pandemic in the United States.

Methods: We conducted a cross-sectional study using a 20-question survey that used SeziureTracker.com, sent to eligible PWE and their caregivers on May 6th, 2020. Questions about demographics and medical history were used to calculate COVID mortality risk odds ratios (OR) compared to a low baseline risk group.

Results: In total, 505 responses were collected. Of these, 71% reported no change in seizure rates and 25% reported an increase in seizures, which they attributed primarily to disrupted sleep (63%) and decreased exercise (42%). Mortality risks from COVID-19 had median OR of 1.67, ranging 1.00-906.98. Fear about hospitalization (53%) and concern for loved ones (52%) were prominent concerns. Of the respondents, 5% reported stopping or reducing anti-seizure medications due to problems communicating with doctors, access or cost. Lower-risk COVID patients reported more fear of hospitalization (55% versus 38%, p<0.001) and anxiety about medication access (43% versus 28%, p=0.03) compared with higher-risk COVID patients. Increased anxiety was reported in 47%, and increased depression in 28%. Ten percent without generalized convulsions and 8% with did not know anything about epilepsy devices (VNS, RNS, DBS).

Significance: The COVID-19 pandemic presents unique challenges to PWE, including increased seizure rates, problems with access and cost of life-saving medications. Those with lower COVID-19 risk may have been marginalized more than those with higher risk. Efforts to protect PWE during major public health emergencies should take these findings into account.

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COVID-19-Associated Seizures May Be Common, Linked to Higher Risk of Death

Study Featuring Former CURE Epilepsy Grantee Dr. Moushin Shafi

COVID-19 can have damaging effects on multiple organs in the body, including the brain. A new study led by investigators at Massachusetts General Hospital (MGH) and Beth Israel Deaconess Medical Center (BIDMC) indicates that some hospitalized patients with COVID-19 experience non-convulsive seizures, which may put them at a higher risk of dying. The findings are published in the Annals of Neurology.

“Seizures are a very common complication of severe critical illness. Most of these seizures are not obvious: Unlike seizures that make a person fall down and shake, or convulse, seizures in critically ill patients are usually nonconvulsive,” explains co-senior author M. Brandon Westover, MD, PhD, an investigator in the Department of Neurology at MGH and director of Data Science at the MGH McCance Center for Brain Health. “There is increasing evidence that non-convulsive seizures can damage the brain and make outcomes worse, similar to convulsions.”

Westover notes that there have been only a few small reports of seizures in patients with severe COVID-19 illness, and it was previously unclear whether such seizures primarily occur in patients who already have a seizure disorder or whether they can arise for the first time because of COVID-19. The effects of such seizures on patients’ health was also unknown.

“We found that seizures indeed can happen in patients with COVID-19 critical illness, even those without any prior neurologic history, and that they are associated with worse outcomes: higher rates of death and longer hospital stay, even after adjusting for other factors,” says co-senior author Mouhsin Shafi, MD, PhD, an investigator in the Department of Neurology at BIDMC, medical director of the BIDMC EEG laboratory, and director of the Berenson-Allen Center for Noninvasive Brain Stimulation. “Our results suggest that patients with COVID-19 should be monitored closely for nonconvulsive seizures. Treatments are available and warranted in patients at high risk; however, further research is needed to clarify how aggressively to treat seizures in COVID-19.”

Status Epilepticus and COVID-19: A Systematic Review

Abstract, originally published in Epilepsy & Behavior

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.

The Impact of the Coronavirus Disease (COVID-19) Pandemic on Outpatient Epilepsy Care: An Analysis of Physician Practices in Germany

Abstract, originally published in Epilepsy & Behavior

Objective: To gain insight into epilepsy care during coronavirus disease (COVID-19) pandemic, we analyzed prescription data of a large cohort of persons with epilepsy (PWE) during lockdown in Germany.

Methods: Information was obtained from the Disease Analyzer database, which collects anonymous demographic and medical data from practice computer systems of general practitioners (GP) and neurologists (NL) throughout Germany. We retrospectively compared prescription data for anti-seizure medication (ASM) and physicians’ notes of “known” and “new” PWE from January 2020 until May 2020 with the corresponding months in the three preceding years 2017-2019. Adherence was estimated by calculating the proportion of patients with follow-up prescriptions within 90 days after initial prescriptions in January or February. We additionally analyzed hospital referrals of PWE. The significance level was set to 0.01 to adjust for multiple comparisons.

Results: A total of 52,844 PWE were included. Anti-seizure medication prescriptions for known PWE increased in March 2020 (GP + 36%, NL + 29%; P < 0.01). By contrast, a decrease in prescriptions to known and new PWE was observed in April and significantly in May 2020 ranging from -16% to -29% (P < 0.01). The proportion of PWE receiving follow-up prescriptions was slightly higher in 2020 (73.5%) than in 2017-2019 (70.7%, P = 0.001). General practitioners and NL referred fewer PWE to hospitals in March 2020 (GP: -30%, P < 0.01; NL: -12%), April 2020 (GP: -29%, P < 0.01; NL: -37%), and May 2020 (GP: -24%, P < 0.01; NL: -16%).

Conclusion: Adherence of known people with epilepsy to anti-seizure medication treatment appeared to remain stable during lockdown in Germany. However, this study revealed findings which point to reduced care for newly diagnosed PWE as well as fewer hospital admissions. These elements may warrant consideration during future lockdown situations.

COVID-19 Presentations and Outcome in Patients With Epilepsy

Abstract, originally published in Acta Neurologica Scandinavica

Objective: To determine whether patients with epilepsy (PWE) are particularly over-represented in a very large cohort of patients with COVID-19. We also investigated whether COVID-19 is associated with a different clinical picture or a more severe course of illness in PWE (compared with others).

Methods: All consecutive patients who referred to and admitted at healthcare facilities anywhere in Fars province (located in the south of Iran with a population of 4,851,000 people) from February 19, 2020 until November 20, 2020 were included.

Results: A total of 37,968 patients were studied. Eighty-two patients (0.2%) had pre-existing epilepsy. Seizures were significantly more frequent among PWE as a presenting manifestation of COVID-19 compared with that in people without epilepsy (Odds Ratio = 27; p = 0.0001). Furthermore, PWE less often reported cough (significantly) and more often had gastrointestinal symptoms (vomiting and anorexia; as trends) compared with those in people without epilepsy. Patients with epilepsy were not differently likely to be intubated or admitted at ICUs. Case fatality rates were not different between the two groups [9.8% in PWE and 8.5% in people without epilepsy; p = 0.690].

Conclusion: Patients with epilepsy are not susceptible to contracting COVID-19 more than other individuals. Furthermore, COVID-19 in PWE is not associated with a more severe illness or a poorer prognosis. However, PWE and COVID-19 may present somewhat differently than others with such an illness. Why PWE less often present with cough and more often present with gastrointestinal symptoms is not clear yet and should be investigated and clarified in the future studies.

The Initial Impact of the SARS-COV2 Pandemic on Epilepsy Research

Abstract, originally published in Epilepsia Open

The COVID-19 pandemic has changed the face of many practices throughout the world. Through necessary to minimize spread and provide clinical care to those with severe disease, focus has been on limiting face-to face-contact. Research in many areas has been put on hold. We sought to determine the impact of the COVID-19 pandemic on epilepsy research from international basic science and clinical researchers.

Responses to five questions were solicited through a convenience sample by direct email and through postings on the ILAE social media accounts and an ILAE online platform (utilizing Slack). Information was collected from 15 respondents in 11 countries by email or via Zoom interviews between May 19, 2020 and June 4, 2020.

Several themes emerged including a move to virtual working, project delays with laboratory work halted and clinical work reduced, funding concerns, a worry about false data with regard to COVID research and concern about research time lost. However, a number of positive outcomes were highlighted, not least the efficiency of online working and other adaptations that could be sustained in the future.

Seizure is a Rare Presenting Manifestation of COVID-19

Abstract, originally published in Seizure

Objective: The aim of the current study was to investigate whether seizure is among the presenting manifestations of COVID-19.

Methods: All patients referred to emergency rooms anywhere in Iran between 12 and 25 April 2020 and who were sufficiently ill to require hospital admission with COVID-19, confirmed by a positive COVID-19 test, were studied. Data on the presenting manifestations were collected.

Results: Of 5872 people, who were admitted to hospitals in Iran with COVID-19 during the study period, 45 came to the emergency room with seizures. This makes seizure as the presenting manifestation of COVID-19 in 0.8 % of all patients with a severe illness. 93 % of the patients were 15 years of age and older. Four of the individuals presenting with seizures (9%) had a past history of epilepsy. Fifteen of these individuals (33 %) had other chronic medical conditions (e.g., cancer, diabetes mellitus, heart disease, etc.).

Conclusion: This case series provides evidence that seizures are among the presenting manifestations of COVID-19 in 0.8 % of the patients who are admitted to hospital due to a severe illness.

The Perceived Impact of COVID-19 and Associated Restrictions on Young People with Epilepsy in the UK: Young People and Caregiver Survey

Abstract, originally published in Seizure

Purpose: To garner the views of young people with epilepsy and caregivers regarding the impact of COVID-19 and subsequent restrictions in the UK.

Methods: An online survey was used to explore the views of young people with epilepsy (n = 71) and caregivers (n = 130) in June 2020. It included questions on the impact of the pandemic and associated restrictions on the child’s epilepsy and on child and parental wellbeing.

Results: One in three young people and 29% of caregivers reported that the young person’s seizures had increased during the pandemic (only 10% of young people and 8% of caregivers reported a decrease). Half of young people reported that they were more reluctant to go to hospital. Thirty-one percent of young people and 20% of parents reported difficulties getting epilepsy medication whilst a significant minority of young people (18%) and caregivers (25%) reported that the young person had investigations/assessments cancelled by their hospital. The majority of young people reported their sleep (72%), mood (64%) and levels of physical activity (53%) had deteriorated. Caregivers experienced increases in stress (55%) and anxiety (52%). Epilepsy nurses were seen as the most helpful support

Conclusions: Results indicate that the pandemic and associated restrictions have had a negative impact on young people with epilepsy. Perceived increases in seizures, reluctance to go to hospital and cancelled investigations are likely to impact on epilepsy management. The wider psychosocial impact is also likely to be significant with increases in child and caregiver mental health problems in an already vulnerable group.

Is the Risk of COVID-19 Contraction Increased in Patients with Epilepsy?

Abstract, originally published in Epilepsy & Behavior

Objective: The aim of the current study was to investigate the rates of contracting COVID-19 in various populations to provide evidence on the susceptibility of patients with epilepsy (PWE) to contracting symptomatic COVID-19.

Methods: We surveyed a random sample of three groups of people: patients with epilepsy, people with psychiatric problems, and a group of the general population. The survey included four general questions (age, sex, education, and medical/psychiatric problem) and four COVID-19 specific questions (contracting COVID-19, relatives with COVID-19, wearing a face mask, and frequent hand washings).

Results: Three hundred and fifty-eight people were surveyed (108 healthy individuals, 154 patients with epilepsy, and 96 patients with psychiatric problems). Thirty-eight (11%) people had a history of COVID-19 contraction. The only factor that had a significant association with COVID-19 contraction was a relative with COVID-19 (Odds Ratio: 5.82; 95% Confidence Interval: 2.85-11.86; p = 0.0001). Having epilepsy did not increase the risk of COVID-19 contraction.

Conclusion: Symptomatic COVID-19 does not seem to be more likely in PWE. The single most important factor associated with contracting COVID-19 is a close relative with this infection. Isolation of people with SARS-CoV-2 infection and observation of their close contacts may reduce the risk of secondary infections.