New Neurological Syndromes with COVID-19 Infection: Is Immune System Hyperactivity to Blame?

Objective: NA Background: We present 3 clinically important, treatment-responsive COVID-19 related neurological cases. Diagnosis and treatment can be challenging but neurological sequelae may be treatable, and recovery can occur. Design/Methods: NA Case 1: An 81-year-old gentleman was admitted with a one-week history of incoherent speech, deteriorating mobility, and poor appetite. While admitted, he developed cyclical apnoeic spells during sleep. Neurological examination revealed profound spasticity, hyper-reflexia, myoclonus and startle response to loud noise. Clinically, he was treated as a case of progressive encephalopathy rigidity and myoclonus (PERM) and responded well to intravenous immunoglobulin with improvement in his cognition and mobility. To our knowledge, this is the first case report of post-Covid PERM. Case 2: A 76-year-old lady, recovered from COVID-19 infection, continued to deteriorate neurologically with cognitive slowing, aphasia, and dyskinesia. Cranial MRI was unremarkable and CSF was sterile. Encephalopathic changes were noted on scalp EEG. Autoimmune encephalitis was suspected, a 3-day course of methyl prednisolone yielded significant improvement and complete recovery ensued over 3 months. Case 3: A 44-year-old man admitted with COVID-19 pneumonitis developed sudden onset left arm weakness and sensory loss, treated as COVID-related ischemic stroke. Extensive white and grey matter hyper-intensity with punctate hemorrhage on MRI raised radiological suspicion of hemorrhagic encephalitis or vasculitis. There was no beading on a subsequent MR angiogram. He was treated with a course of intravenous methyl prednisolone and a weaning regime of oral prednisolone. At 4-month follow up, he had made a good functional recovery. Conclusions: We report three cases of neurological complications temporally associated with COVID-19 infection. Improvement occurred following immunosuppression, which supports hypotheses of virus-induced autoimmunity.

The international European Academy of Neurology survey on neurological symptoms in patients with COVID-19 infection.

BACKGROUND AND PURPOSE: Although the main clinical features of COVID-19 infection are pulmonary, several associated neurological signs, symptoms and diseases are emerging. The incidence and characteristics of neurological complications are unclear. For this reason, the European Academy of Neurology (EAN) core COVID-19 Task Force initiated a survey on neurological symptoms observed in patients with COVID-19 infection. METHODS: A 17-question online survey was made available on the EAN website and distributed to EAN members and other worldwide physicians starting on 9 April 2020. RESULTS: By 27 April 2020, proper data were collected from 2343 responders (out of 4199), of whom 82.0% were neurologists, mostly from Europe. Most responders (74.7%) consulted patients with COVID-19 mainly in emergency rooms and in COVID-19 units. The majority (67.0%) had evaluated fewer than 10 patients with neurological manifestations of COVID-19 (neuro COVID-19). The most frequently reported neurological findings were headache (61.9%), myalgia (50.4%), anosmia (49.2%), ageusia (39.8%), impaired consciousness (29.3%) and psychomotor agitation (26.7%). Encephalopathy and acute cerebrovascular disorders were reported at 21.0%. Neurological manifestations were generally interpreted as being possibly related to COVID-19; they were most commonly recognized in patients with multiple general symptoms and occurred at any time during infection. CONCLUSION: Neurologists are currently and actively involved in the management of neurological issues related to the COVID-19 pandemic. This survey justifies setting up a prospective registry to better capture the prevalence of patients with neuro COVID-19, neurological disease characteristics and the contribution of neurological manifestations to outcome.

EAN consensus statement for management of patients with neurological diseases during the COVID-19 pandemic.

BACKGROUND AND PURPOSE: The recent SARS-CoV-2 pandemic has posed multiple challenges to the practice of clinical neurology including recognition of emerging neurological complications and management of coexistent neurological diseases. In a fast-evolving pandemic, evidence-based studies are lacking in many areas. This paper presents European Academy of Neurology (EAN) expert consensus statements to guide neurologists caring for patients with COVID-19. METHODS: A refined Delphi methodology was applied. In round 1, statements were provided by EAN scientific panels (SPs). In round 2, these statements were circulated to SP members not involved in writing them, asking for agreement/disagreement. Items with agreement >70% were retained for round 3, in which SP co-chairs rated importance on a five-point Likert scale. Results were graded by importance and reported as consensus statements. RESULTS: In round one, 70 statements were provided by 23 SPs. In round two, 259/1061 SP member responses were received. Fifty-nine statements obtained >70% agreement and were retained. In round three, responses were received from 55 co-chairs of 29 SPs. Whilst general recommendations related to prevention of COVID-19 transmission had high levels of agreement and importance, opinion was more varied concerning statements related to therapy. CONCLUSION: This is the first structured consensus statement on good clinical practice in patients with neurological disease during the COVID-19 pandemic that provides immediate guidance for neurologists. In this fast-evolving pandemic, a rapid response using refined Delphi methodology is possible, but guidance may be subject to change as further evidence emerges.