Case Series of New-Onset CNS Immunological Disorders Temporally Associated with mRNAbased COVID-19 Vaccines

Objective: To present a single-health system retrospective analysis of post-mRNA-based COVID-19 vaccination CNS autoimmunity conducted in the greater New York City area. Background: There have been rare reports associating mRNA-based COVID-19 vaccines with central nervous system (CNS) inflammation. We report a case series of five patients with newonset neurological disorders of immunological origin temporally associated with these vaccines. Design/Methods: Case-series. Results: Five cases of post-vaccination CNS disorders of immune origin were observed within two weeks of inoculation with either the first or second dose of mRNA-based COVID-19 vaccines (Moderna = 3, Pfizer = 2). This includes: Fatal ADEM (n = 1), new-onset NMO (n = 2), new-onset fulminant MS (n = 1), and meningoencephalitis (n = 1). The age of our patients ranged from 27 to 81, and three were female. None of the patients had pre-existing neurological illnesses and one had a pre-existing autoimmune condition (immune thrombocytopenia purpura). New-onset focal neurological symptoms were present in all five patients, including quadriparesis, numbness, diplopia, and encephalopathy. CSF pleocytosis was present in all patients, and three had elevated protein. All but one patient (meningoencephalitis) had contrastenhancing lesions involving either the cerebrum or spinal cord. Both NMO patients had longitudinally extensive transverse lesions involving the central thoracic cord. Aquaporin-4 serum antibody was present in one NMO patients and aquaporin-4 CSF antibody present in the other. All but one patient (fatal ADEM) clinically improved with pulse steroids or plasmapheresis. Conclusions: These are among the emerging cases of CNS immunological events temporally associated with mRNA-based COVID-19 vaccines. These findings should be interpreted with great caution as they neither prove a link nor imply a potential long-term increased risk in postvaccination CNS autoimmunity. Larger prospective studies are needed. The mRNA-based SARS-CoV-2 vaccines should continue to be strongly encouraged given their high efficacy in overcoming this pandemic.

Characterization of electroencephalographic abnormalities and their radiographic correlates associated with COVID-19

Objective: To identify the prevalence of electroencephalographic (EEG) and neuroimaging abnormalities in patients with COVID-19 and neurologic changes. Background: Neurological complications associated with COVID-19 are increasingly being recognized, though the incidence of epileptiform abnormalities and prognosis remains uncertain. Design/Methods: Retrospective case series of 192 adult COVID-19 inpatients with EEG performed between March and June 2020 in four hospitals in the Northwell Health system in the New York City area, including 159 patients undergoing continuous EEG, 24 undergoing routine EEG, and nine with reduced montage EEG. Associated patient characteristics were analyzed including EEG indication, epilepsy history, and in-hospital mortality. Cases with epileptiform abnormalities were reviewed for acute and chronic neuroimaging abnormalities. Results: EEG indications included encephalopathy (57.3%), coma (16.7%), seizure (15.6%), abnormal movements (5.2%), and focal neurological deficit (5.2%). Eight of the 30 patients with clinical seizures had known epilepsy. Generalized slowing was seen in 88.5% of patients, while epileptiform abnormalities, including periodic patterns, occurred in 38.0%. Focal intermittent epileptiform discharges were in 24.0%, lateralized periodic discharges in 5.7%, and generalized periodic discharges in 18.8%. Seizures were recorded in 3.6%, including three patients with status epilepticus. Intracranial abnormalities were seen on neuroimaging of 68.4% of patients with epileptiform abnormalities, two-thirds of which were acute. In-hospital mortality rate was 37.5% for all patients studied: 41.1% in patients with epileptiform abnormalities on EEG and 35.8% in patients without epileptiform abnormalities on EEG. Mortality rates were highest for those with periodic patterns on EEG. Conclusions: There is a high correlation between patients with COVID-19 with neurologic symptoms, and abnormalities on EEG. Many patients with EEG abnormalities, especially epileptiform abnormalities, have associated intracranial lesions on neuroimaging, most acute Mortality rates were elevated in patients with epileptiform abnormalities on EEG, particularly those with periodic patterns. These findings may guide the prognosis and management of patients with COVID-19 and neurologic changes.