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2.
J Stroke Cerebrovasc Dis ; 30(12): 106118, 2021 Dec.
Article in English | MEDLINE | ID: covidwho-1415616

ABSTRACT

BACKGROUND AND OBJECTIVES: RCVS (Reversible Cerebral Vasoconstrictive Syndrome) is a condition associated with vasoactive agents that alter endothelial function. There is growing evidence that endothelial inflammation contributes to cerebrovascular disease in patients with coronavirus disease 2019 (COVID-19). In our study, we describe the clinical features, risk factors, and outcomes of RCVS in a multicenter case series of patients with COVID-19. MATERIALS AND METHODS: Multicenter retrospective case series. We collected clinical characteristics, imaging, and outcomes of patients with RCVS and COVID-19 identified at each participating site. RESULTS: Ten patients were identified, 7 women, ages 21 - 62 years. Risk factors included use of vasoconstrictive agents in 7 and history of migraine in 2. Presenting symptoms included thunderclap headache in 5 patients with recurrent headaches in 4. Eight were hypertensive on arrival to the hospital. Symptoms of COVID-19 included fever in 2, respiratory symptoms in 8, and gastrointestinal symptoms in 1. One patient did not have systemic COVID-19 symptoms. MRI showed subarachnoid hemorrhage in 3 cases, intraparenchymal hemorrhage in 2, acute ischemic stroke in 4, FLAIR hyperintensities in 2, and no abnormalities in 1 case. Neurovascular imaging showed focal segment irregularity and narrowing concerning for vasospasm of the left MCA in 4 cases and diffuse, multifocal narrowing of the intracranial vasculature in 6 cases. Outcomes varied, with 2 deaths, 2 remaining in the ICU, and 6 surviving to discharge with modified Rankin scale (mRS) scores of 0 (n=3), 2 (n=2), and 3 (n=1). CONCLUSIONS: Our series suggests that patients with COVID-19 may be at risk for RCVS, particularly in the setting of additional risk factors such as exposure to vasoactive agents. There was variability in the symptoms and severity of COVID-19, clinical characteristics, abnormalities on imaging, and mRS scores. However, a larger study is needed to validate a causal relationship between RCVS and COVID-19.


Subject(s)
COVID-19/complications , Cerebral Arteries/physiopathology , Cerebrovascular Circulation , Vasoconstriction , Vasospasm, Intracranial/etiology , Adult , COVID-19/diagnosis , COVID-19/therapy , Cerebral Arteries/diagnostic imaging , Female , Humans , Male , Middle Aged , Neuroimaging , Retrospective Studies , Risk Factors , Severity of Illness Index , Syndrome , Time Factors , Treatment Outcome , United States , Vasospasm, Intracranial/diagnostic imaging , Vasospasm, Intracranial/physiopathology , Vasospasm, Intracranial/therapy , Young Adult
3.
Neurol Clin Pract ; 11(3): e337-e343, 2021 Jun.
Article in English | MEDLINE | ID: covidwho-1394505

ABSTRACT

The coronavirus disease 2019 (COVID-19) pandemic has led to an acceleration of clinical information dissemination to unprecedented speeds, a phenomenon only partially explained by formal efforts of the scientific community. These have ranged from the establishment of open-source platforms for review of article preprints to the elimination of journal paywalls for COVID-19-related publications. In addition, informal efforts that rely on various modern media platforms that promote, repackage, and synthesize information have played substantial adjunctive roles, many of which did not exist during the severe acute respiratory syndrome pandemic of 2003. Although these latter efforts have greatly bolstered the speed of knowledge dissemination, their unregulated nature subjects them to risk for facilitating the spread of misinformation. In our opinion, the role of modern media in influencing clinical knowledge dissemination was not adequately examined even before the pandemic and therefore remains largely unchecked. In this article, we examine the spread of information in the field of COVID-19 and neurologic disorders, develop a simple model that maps various modern media tools on to the dissemination pipeline, and critically examine its components. Through this exercise, we identify opportunities for the scientific community to regulate and safeguard the clinical knowledge dissemination process, with implications both for the pandemic and beyond.

4.
Neurol Neuroimmunol Neuroinflamm ; 8(5)2021 09.
Article in English | MEDLINE | ID: covidwho-1339394

ABSTRACT

BACKGROUND AND OBJECTIVES: We sought to define the risk of severe coronavirus disease 2019 (COVID-19) infection requiring hospitalization in patients with CNS demyelinating diseases such as MS and the factors that increase the risk for severe infection to guide decisions regarding patient care during the COVID-19 pandemic. METHODS: A pilot cohort of 91 patients with confirmed or suspected COVID-19 infection from the Northeastern United States was analyzed to characterize patient risk factors and factors associated with an increased severity of COVID-19 infection. Univariate analysis of variance was performed using the Mann-Whitney U test or analysis of variance for continuous variables and the χ2 or Fisher exact test for nominal variables. Univariate and stepwise multivariate logistic regression identified clinical characteristics or symptoms associated with hospitalization. RESULTS: Our cohort demonstrated a 27.5% hospitalization rate and a 4.4% case fatality rate. Performance on Timed 25-Foot Walk before COVID-19 infection, age, number of comorbidities, and presenting symptoms of nausea/vomiting and neurologic symptoms (e.g., paresthesia or weakness) were independent risk factors for hospitalization, whereas headache predicted a milder course without hospitalization. An absolute lymphocyte count was lower in hospitalized patients during COVID-19 infection. Use of disease-modifying therapy did not increase the risk of hospitalization but was associated with an increased need for respiratory support. DISCUSSION: The case fatality and hospitalization rates in our cohort were similar to those found in MS and general population COVID-19 cohorts within the region. Hospitalization was associated with increased disability, age, and comorbidities but not disease-modifying therapy use.


Subject(s)
COVID-19 , Demyelinating Autoimmune Diseases, CNS , Hospitalization/statistics & numerical data , Immunologic Factors/therapeutic use , Registries/statistics & numerical data , Respiration, Artificial/statistics & numerical data , Adult , COVID-19/diagnosis , COVID-19/epidemiology , COVID-19/therapy , Cohort Studies , Comorbidity , Demyelinating Autoimmune Diseases, CNS/drug therapy , Demyelinating Autoimmune Diseases, CNS/epidemiology , Female , Humans , Immunologic Factors/adverse effects , Male , Middle Aged , Mortality , New England/epidemiology , Pilot Projects , Risk Factors , Severity of Illness Index
6.
J Stroke Cerebrovasc Dis ; 29(12): 105412, 2020 Dec.
Article in English | MEDLINE | ID: covidwho-907409

ABSTRACT

INTRODUCTION: Early studies suggest that acute cerebrovascular events may be common in patients with coronavirus disease 2019 (COVID-19) and may be associated with a high mortality rate. Most cerebrovascular events described have been ischemic strokes, but both intracerebral hemorrhage and rarely cerebral venous sinus thrombosis (CVST) have also been reported. The diagnosis of CVST can be elusive, with wide-ranging and nonspecific presenting symptoms that can include headache or altered sensorium alone. OBJECTIVE: To describe the presentation, barriers to diagnosis, treatment, and outcome of CVST in patients with COVID-19. METHODS: We abstracted data on all patients diagnosed with CVST and COVID-19 from March 1 to August 9, 2020 at Boston Medical Center. Subsequently, we reviewed the literature and extracted all published cases of CVST in patients with COVID-19 from January 1, 2020 through August 9, 2020 and included all studies with case descriptions. RESULTS: We describe the clinical features and management of CVST in 3 women with COVID-19 who developed CVST days to months after initial COVID-19 symptoms. Two patients presented with encephalopathy and without focal neurologic deficits, while one presented with visual symptoms. All patients were treated with intravenous hydration and anticoagulation. None suffered hemorrhagic complications, and all were discharged home. We identified 12 other patients with CVST in the setting of COVID-19 via literature search. There was a female predominance (54.5%), most patients presented with altered sensorium (54.5%), and there was a high mortality rate (36.4%). CONCLUSIONS: During this pandemic, clinicians should maintain a high index of suspicion for CVST in patients with a recent history of COVID-19 presenting with non-specific neurological symptoms such as headache to provide expedient management and prevent complications. The limited data suggests that CVST in COVID-19 is more prevalent in females and may be associated with high mortality.


Subject(s)
COVID-19/complications , Sinus Thrombosis, Intracranial/etiology , Venous Thrombosis/etiology , Adult , Aged , Anticoagulants/therapeutic use , COVID-19/diagnosis , COVID-19/therapy , Female , Fluid Therapy , Humans , Male , Middle Aged , Risk Factors , Sinus Thrombosis, Intracranial/diagnostic imaging , Sinus Thrombosis, Intracranial/therapy , Treatment Outcome , Venous Thrombosis/diagnostic imaging , Venous Thrombosis/therapy
7.
Neurohospitalist ; 11(2): 125-130, 2021 Apr.
Article in English | MEDLINE | ID: covidwho-788575

ABSTRACT

The COVID-19 pandemic has led to shifts in healthcare utilization for patients both with and without COVID-19. We aimed to determine how trends in neurology service admissions during the pandemic may aid in departmental planning by predicting future clinician staffing and other needs. We examined all admissions to the general neurology, stroke, and neurocritical care services from January 31 to May 16, 2020 at our tertiary-care hospital using an electronic health record query, comparing these to analogous data in 2019. We trended admission rates and projected future censuses using logarithmic regression, tracked changes in length of stay (LOS), and quantified shifts in presentations of specific diagnoses. Daily rates of admissions declined sharply during the week of March 13, 2020 (the week after pandemic status was declared by the World Health Organization). On the censoring date, we projected a return to pre-pandemic censuses in the week of June 21 and used this information to make decisions regarding neurology resident schedules. There was a trend toward increased LOS for general neurology and stroke patients between March 27 and April 9, 2020 compared to in 2019, with subsequent decline coinciding with early hospital initiatives. Since March 13, 2020, there has been a trend toward reduced presentations of ischemic stroke, suggesting a need for community education on stroke awareness. Characterizing early trends in neurology admissions may allow physician administrators to plan local and community-level responses to the pandemic.

9.
Crit Care Med ; 48(11): 1664-1669, 2020 11.
Article in English | MEDLINE | ID: covidwho-720986

ABSTRACT

OBJECTIVES: To describe the risk factors for and outcomes after myoclonus in a cohort of patients with coronavirus disease 2019. DESIGN: Multicenter case series. SETTING: Three tertiary care hospitals in Massachusetts, Georgia, and Virginia. PATIENTS: Eight patients with clinical myoclonus in the setting of coronavirus disease 2019. INTERVENTIONS & MEASUREMENTS AND MAIN RESULTS: Outcomes in patients with myoclonus were variable, with one patient who died during the study period and five who were successfully extubated cognitively intact and without focal neurologic deficits. In five cases, the myoclonus completely resolved within 2 days of onset, while in three cases, it persisted for 10 days or longer. Seven patients experienced significant metabolic derangements, hypoxemia, or exposure to sedating medications that may have contributed to the development of myoclonus. One patient presented with encephalopathy and developed prolonged myoclonus in the absence of clear systemic provoking factors. CONCLUSIONS: Our findings suggest that myoclonus may be observed in severe acute respiratory syndrome coronavirus 2 infected patients, even in the absence of hypoxia. This association warrants further evaluation in larger cohorts to determine whether the presence of myoclonus may aid in the assessment of disease severity, neurologic involvement, or prognostication.


Subject(s)
Betacoronavirus , Coronavirus Infections/complications , Coronavirus Infections/therapy , Myoclonus/etiology , Pneumonia, Viral/complications , Pneumonia, Viral/therapy , Adult , Aged , COVID-19 , Female , Follow-Up Studies , Georgia , Humans , Hypoxia , Male , Massachusetts , Middle Aged , Myoclonus/diagnosis , Myoclonus/therapy , Pandemics , SARS-CoV-2 , Virginia
10.
J Stroke Cerebrovasc Dis ; 29(11): 105212, 2020 Nov.
Article in English | MEDLINE | ID: covidwho-688668

ABSTRACT

INTRODUCTION: Encephalopathy is a common complication of coronavirus disease 2019. Although the encephalopathy is idiopathic in many cases, there are several published reports of patients with posterior reversible encephalopathy syndrome in the setting of coronavirus disease 2019. OBJECTIVE: To describe the diverse presentations, risk factors, and outcomes of posterior reversible encephalopathy syndrome in patients with coronavirus disease 2019. METHODS: We assessed patients with coronavirus disease 2019 and a diagnosis of posterior reversible encephalopathy syndrome at our institution from April 1 to June 24, 2020. We performed a literature search to capture all known published cases of posterior reversible encephalopathy syndrome in patients with coronavirus disease 2019. RESULTS: There were 2 cases of posterior reversible encephalopathy syndrome in the setting of coronavirus 2019 at our institution during a 3-month period. One patient was treated with anakinra, an interleukin-1 inhibitor that may disrupt endothelial function. The second patient had an underlying human immunodeficiency virus infection. We found 13 total cases in our literature search, which reported modest blood pressure fluctuations and a range of risk factors for posterior reversible encephalopathy syndrome. One patient was treated with tocilizumab, an interleukin-6 inhibitor that may have effects on endothelial function. All patients had an improvement in their neurological symptoms. Interval imaging, when available, showed radiographic improvement of brain lesions. CONCLUSIONS: Risk factors for posterior reversible encephalopathy syndrome in patients with coronavirus disease 2019 may include underlying infection or immunomodulatory agents with endothelial effects in conjunction with modest blood pressure fluctuations. We found that the neurological prognosis for posterior reversible encephalopathy syndrome in the setting of coronavirus disease 2019 infection is favorable. Recognition of posterior reversible encephalopathy syndrome in this patient population is critical for prognostication and initiation of treatment, which may include cessation of potential offending agents and tight blood pressure control.


Subject(s)
Betacoronavirus/pathogenicity , Coronavirus Infections/virology , Endothelium, Vascular/virology , Pneumonia, Viral/virology , Posterior Leukoencephalopathy Syndrome/virology , Blood Pressure , COVID-19 , Coinfection , Coronavirus Infections/diagnosis , Coronavirus Infections/immunology , Coronavirus Infections/physiopathology , Endothelium, Vascular/physiopathology , Female , HIV Infections/immunology , HIV Infections/physiopathology , HIV Infections/virology , Host-Pathogen Interactions , Humans , Immunosuppressive Agents/adverse effects , Middle Aged , Pandemics , Pneumonia, Viral/diagnosis , Pneumonia, Viral/immunology , Pneumonia, Viral/physiopathology , Posterior Leukoencephalopathy Syndrome/diagnosis , Posterior Leukoencephalopathy Syndrome/immunology , Posterior Leukoencephalopathy Syndrome/physiopathology , Prognosis , Risk Factors , SARS-CoV-2
11.
Epilepsy Behav ; 112: 107335, 2020 11.
Article in English | MEDLINE | ID: covidwho-662646

ABSTRACT

BACKGROUND: Coronavirus Disease 2019 (COVID-19) has rapidly become a global pandemic, with over 1.8 million confirmed cases worldwide to date. Preliminary reports suggest that the disease may present in diverse ways, including with neurological symptoms, but few published reports in the literature describe seizures in patients with COVID-19. OBJECTIVE: The objective of the study was to characterize the risk factors, clinical features, and outcomes of seizures in patients with COVID-19. METHODS: This is a retrospective case series. Cases were identified through a review of admissions and consultations to the neurology and neurocritical care services between April 1, 2020 and May 15, 2020. SETTING: The study setting was in a tertiary care, safety-net hospital in Boston, MA. PARTICIPANTS: Patients presenting with seizures and COVID-19 during the study period were included in the study. RESULTS: Seven patients met inclusion criteria (5 females, 71%). Patients ranged in age from 37 to 88 years (median: 75 years). Three patients had a prior history of well-controlled epilepsy (43%), while 4 patients had new-onset seizures, including 2 patients with prior history of remote stroke. Three patients had no preceding symptoms of COVID-19 prior to presentation (57%), and in all cases, seizures were the symptom that prompted presentation to the emergency department, regardless of prior symptoms of COVID-19. CONCLUSIONS: Provoking factors for seizures in patients with COVID-19 may include metabolic factors, systemic illness, and possibly direct effects of the virus. In endemic areas with community spread of COVID-19, clinicians should be vigilant for the infection in patients who present with seizures, which may precede respiratory symptoms or prompt presentation to medical care. Early testing, isolation, and contact tracking of these patients can prevent further transmission of the virus.


Subject(s)
Coronavirus Infections/physiopathology , Pneumonia, Viral/physiopathology , Seizures/physiopathology , Adult , Aged , Aged, 80 and over , Anticonvulsants/therapeutic use , Betacoronavirus , Boston , COVID-19 , Coronavirus Infections/complications , Coronavirus Infections/diagnosis , Coronavirus Infections/therapy , Emergency Service, Hospital , Epilepsy/complications , Epilepsy/drug therapy , Female , Humans , Male , Middle Aged , Pandemics , Pneumonia, Viral/complications , Pneumonia, Viral/diagnosis , Pneumonia, Viral/therapy , Retrospective Studies , Risk Factors , SARS-CoV-2 , Seizures/drug therapy , Seizures/etiology
13.
Muscle Nerve ; 62(2): 254-258, 2020 08.
Article in English | MEDLINE | ID: covidwho-232707

ABSTRACT

INTRODUCTION: Coronavirus disease 2019 (COVID-19) has rapidly become a global pandemic, but little is known about its potential impact on patients with myasthenia gravis (MG). METHODS: We studied the clinical course of COVID-19 in five hospitalized patients with autoimmune MG (four with acetylcholine receptor antibodies, one with muscle-specific tyrosine kinase antibodies) between April 1, 2020-April 30-2020. RESULTS: Two patients required intubation for hypoxemic respiratory failure, whereas one required significant supplemental oxygen. One patient with previously stable MG had myasthenic exacerbation. One patient treated with tocilizumab for COVID-19 was successfully extubated. Two patients were treated for MG with intravenous immunoglobulin without thromboembolic complications. DISCUSSION: Our findings suggest that the clinical course and outcomes in patients with MG and COVID-19 are highly variable. Further large studies are needed to define best practices and determinants of outcomes in this unique population.


Subject(s)
Antibodies, Monoclonal, Humanized/therapeutic use , Coronavirus Infections/therapy , Hypoxia/therapy , Immunoglobulins, Intravenous/therapeutic use , Immunologic Factors/therapeutic use , Myasthenia Gravis/therapy , Pneumonia, Viral/therapy , Respiratory Insufficiency/therapy , Adult , Aged, 80 and over , Betacoronavirus , COVID-19 , Coronavirus Infections/complications , Coronavirus Infections/drug therapy , Disease Progression , Female , Humans , Hypoxia/etiology , Immunosuppressive Agents/therapeutic use , Intubation, Intratracheal , Male , Middle Aged , Myasthenia Gravis/complications , Myasthenia Gravis/immunology , Oxygen Inhalation Therapy , Pandemics , Pneumonia, Viral/complications , Receptor Protein-Tyrosine Kinases/immunology , Receptors, Cholinergic/immunology , Respiration, Artificial , Respiratory Insufficiency/etiology , SARS-CoV-2
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