Clinical Electroencephalography Findings and Considerations in Hospitalized Patients with Coronavirus SARS-CoV-2

Abstract

Background and Purpose Reports have suggested that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes neurologic manifestations including encephalopathy and seizures. However, there has been relatively limited electrophysiology data to contextualize these specific concerns and to understand their associated clinical factors. Our objective was to identify EEG abnormalities present in patients with SARS-CoV-2, and to determine whether they reflect new or preexisting brain pathology. Methods We studied a consecutive series of hospitalized patients with SARS-CoV-2 who received an EEG, obtained using tailored safety protocols. Data from EEG reports and clinical records were analyzed to identify EEG abnormalities and possible clinical associations, including neurologic symptoms, new or preexisting brain pathology, and sedation practices. Results We identified 37 patients with SARS-CoV-2 who underwent EEG, of whom 14 had epileptiform findings (38%). Patients with epileptiform findings were more likely to have preexisting brain pathology (6/14, 43%) than patients without epileptiform findings (2/23, 9%; p=0.042). There were no clear differences in rates of acute brain pathology. One case of nonconvulsive status epilepticus was captured, but was not clearly a direct consequence of SARS-CoV-2. Abnormalities of background rhythms were common, and patients recently sedated were more likely to lack a posterior dominant rhythm (p=0.022). Conclusions Epileptiform abnormalities were common in patients with SARS-CoV-2 referred for EEG, but particularly in the context of preexisting brain pathology and sedation. These findings suggest that neurologic manifestations during SARS-CoV-2 infection may not solely relate to the infection itself, but rather may also reflect patients' broader, preexisting neurologic vulnerabilities.

Meta-analysis of EEG findings in patients with COVID-19

“…The full-text screening of these studies led to the exclusion of 216 studies that did not meet the inclusion criteria. A total of 12 studies with 308 patients fulfilled the eligibility criteria for inclusion in the meta-analysis [6] , [7] , [8] , [17] , [18] , [19] , [20] , [21] , [22] , [23] , [24] , [25] . We referred to a case report [26] of patients who were included in a case series [19] to obtain more detailed EEG findings.…”

Response: Epileptic discharges in acutely ill patients investigated for SARS‐CoV‐2/COVID‐19 and the absence of evidence

“…Subsequent to our report, case series of COVID-19-positive patients with EEG studies (n = 13-111 each) have been published by independent groups; yet, none has incorporated COVID-19-negative patient populations exhibiting similar presentations. Among COVID-19-positive patients, the reported rates of EDs in these recently published studies varied between 0% and 38% [3][4][5][6][7][8][9][10] ; our reported 40.9% rate falls at the higher end of the spectrum. Such a spread of rates of epileptiform EEGs among small-or moderate-scale case series from different institutions exemplifies how differences in inclusion criteria, study design, patient enrollment and demographics, and clinical history may alter outcomes.…”

Severe Neurologic Complications of SARS-CoV-2

“…At least 0.5% of patients have seizures as a neurological manifestation of COVID-19 infection [21]. Critical illness, acute neurologic insult, hypoxia, metabolic derangements, or organ failure can provoke seizures in patients with COVID-19 [64][65][66][67]. Seizures may also occur as a result of cortical irritation due to the interaction of SARS-CoV-2 with endothelial receptors and glial tissue receptors [68].…”

“…Use of EEG, however, is limited by the need to minimize contact to protect healthcare workers, prone-positioning, and contamination risk to equipment [66]. Thirty-eight to 40.9% of COVID-19 positive patients who had an EEG for concern of encephalopathy or seizure-like event had epileptiform discharges with frontal spikes as the predominant pattern [66,67]. The presence of epileptiform discharges was not associated with the presence of renal or hepatic failure [66].…”

“…When available, some institutions opt for a rapid response 8-channel EEG instead of routing or continuous EEG to reduce the time of patient contact [73]. As one considers anti-epileptic therapy in these patients, special consideration must be given to concomitant circumstances that may affect antiseizure medication pharmacokinetics, such as renal or hepatic failure or extra corporeal membrane oxygenation [67]. While there currently is no data on the optimal duration of anti-epileptic therapy in COVID-19 patients with new onset seizures or status epilepticus, one may consider continuing anti-epileptic therapy throughout the course of the hospitalization with possible discontinuation as an outpatient depending on the clinical course.…”