COVID-19-associated seizure: Difference between revisions

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__NOTOC__
__NOTOC__
{{COVID-19}}
{{SI}}


{{CMG}}; {{AE}} {{Mandana.Sa}} [[User:Tayebah Chaudhry|Tayebah Chaudhry]][mailto:dr.thch@yahoo.com] {{sali}}
{{CMG}}; {{AE}} {{Mandana.Sa}} [[User:Tayebah Chaudhry|Tayebah Chaudhry]][mailto:dr.thch@yahoo.com], {{Fs}}, {{sali}}


{{SK}}  
{{SK}}  
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==Overview==
==Overview==


Coronaviruses impacts are not always restricted to respiratory system and they have potential for neuroinvasion under specific circumstances.  
[[Seizure]] refers to an episode of [[symptom]]s due to abnormally excessive or synchronous [[neuronal]] activity in the [[brain]] followed by return to normal state. [[Seizures]] manifest as abnormal uncontrolled shaking movements that involve much of the [[body]] with loss of [[consciousness]], shaking movements of part of the [[body]] with variable level of [[consciousness]] or a subtle momentary loss of [[consciousness]]. As [[COVID-19]] (caused by [[SARS-CoV-2|SARS-Cov2]]) is now known to have several [[neurological]] [[complications]], [[seizure]] is one of the [[complications]] seen in a few cases so far. [[Brain]] waive activity can be seen on [[EEG]] to confirm diagnosis since structural changes are very rarely seen on [[brain]] [[imaging]]. Anti-[[seizure]] [[medications]] are used for symptomatic treatment of [[seizure]] along with [[treatment]] of [[COVID-19]].
Neurological manifestations such as [[dizziness]],[[headache]] ,[[anosmia]] as well as case reports with [[encephalitis]] ,[[stroke]],[[epileptic seizures]] associated with covid-19, have been reported.


==Historical Perspective==
==Historical Perspective==
* two male patients, non-epileptic  were hospitalised  with covid-19 signs and symptoms, March 2020 ,Ohio, U.S.A. During their hospital stay they developed [[encephalopathy]] and [[seizures]], controlled by [[levetiracetam]] <ref name="HepburnMullaguri2020">{{cite journal|last1=Hepburn|first1=Madihah|last2=Mullaguri|first2=Naresh|last3=George|first3=Pravin|last4=Hantus|first4=Stephen|last5=Punia|first5=Vineet|last6=Bhimraj|first6=Adarsh|last7=Newey|first7=Christopher R.|title=Acute Symptomatic Seizures in Critically Ill Patients with COVID-19: Is There an Association?|journal=Neurocritical Care|year=2020|issn=1541-6933|doi=10.1007/s12028-020-01006-1}}</ref>


*First case of seizure in [[COVID-19]] patient was a result of [[meningitis]]/[[encephalitis]] caused by [[SARS-CoV-2|SARS-CoV2]] and documented by Moriguchi et al in late February 2020 <ref name="pmid32251791">{{cite journal |vauthors=Moriguchi T, Harii N, Goto J, Harada D, Sugawara H, Takamino J, Ueno M, Sakata H, Kondo K, Myose N, Nakao A, Takeda M, Haro H, Inoue O, Suzuki-Inoue K, Kubokawa K, Ogihara S, Sasaki T, Kinouchi H, Kojin H, Ito M, Onishi H, Shimizu T, Sasaki Y, Enomoto N, Ishihara H, Furuya S, Yamamoto T, Shimada S |title=A first case of meningitis/encephalitis associated with SARS-Coronavirus-2 |journal=Int. J. Infect. Dis. |volume=94 |issue= |pages=55–58 |date=May 2020 |pmid=32251791 |pmc=7195378 |doi=10.1016/j.ijid.2020.03.062 |url=}}</ref>.
*After that, more cases were reported with acute [[Seizure|seizures]] as a complication of COVID-19.<ref name="HepburnMullaguri2020">{{citejournal|last1=Hepburn|first1=Madihah|last2=Mullaguri|first2=Naresh|last3=George|first3=Pravin|last4=Hantus|first4=Stephen|last5=Punia|first5=Vineet|last6=Bhimraj|first6=Adarsh|last7=Newey|first7=Christopher R.|title=Acute Symptomatic Seizures in Critically Ill Patients with COVID-19: Is There an Association?|journal=Neurocritical Care|year=2020|issn=1541-6933|doi=10.1007/s12028-020-01006-1}}</ref><ref><nowiki>{{</nowiki>https://www.sciencedirect.com/science/article/pii/S1059131120301151<nowiki>}}</nowiki></ref>
*In early February 2020, seizurelike activity was reported in two COVID-19 patients but the cause was acute [[anxiety]] disorder and [[electrolyte imbalance]] instead of viral damage by [[SARS-Cov-2]]<ref><nowiki>{{</nowiki>https://onlinelibrary.wiley.com/doi/full/10.1111/epi.16524<nowiki>}}</nowiki></ref>
*To view the historical perspective of COVID-19, [[COVID-19 historical perspective|click here]].


*A women with the past medical history of seizure following [[herpetic encephalitis]] ,presented with a sudden focal [[myoclonus]] and positive test for covid 19 in Italy, 23rd of april 2020.<ref><nowiki>{{</nowiki>https://www.sciencedirect.com/science/article/pii/S1059131120301151<nowiki>}}</nowiki></ref>
==Classification==


*Also, a cohort multicentre study was done in China, April 2020, demonstrating that COVID 19 doesn't increase the risk of symptomatic seizure in patients hospitalized with the acute respiratory phase of COVID 19.Although some seizure-like reactions are seen because of acute reaction to stress or hypocalcemia .<ref><nowiki>{{</nowiki>https://onlinelibrary.wiley.com/doi/full/10.1111/epi.16524<nowiki>}}</nowiki></ref>
*There is no established classification for [[COVID-19]] associated [[seizure]].


==Classification==
There isn't any established classification for covid-19 associated seizure.
==Pathophysiology==
==Pathophysiology==
* Neurological complications caused by [[COVID-19]] are through direct or indirect pathways. This includes [[hematogenous]] pathway, neuronal retrograde dissemination through [[olfactory bulb]], entry into to glial cells and neurons via ACE2 receptor and impairment of gas exchange in lungs leading to [[anemia]], hence increasing anaerobic metabolites in brain resulting in cellular and interstitial edema <ref><nowiki>{{</nowiki>https://pubmed.ncbi.nlm.nih.gov/32458193/<nowiki>}}</nowiki></ref>
* Seizures in a patient with [[COVID-19]] may be due to primary virus infection or due to reactivation of the latent virus.
* Infiltration of the brain tissue by the virus and subsequent production of toxins by the virus is one of the several mechanisms that can cause seizures in a COVID-19 patient. <ref name="KarimiSharifi Razavi2020">{{cite journal|last1=Karimi|first1=Narges|last2=Sharifi Razavi|first2=Athena|last3=Rouhani|first3=Nima|title=Frequent Convulsive Seizures in an Adult Patient with COVID-19: A Case Report|journal=Iranian Red Crescent Medical Journal|volume=22|issue=3|year=2020|issn=2074-1804|doi=10.5812/ircmj.102828}}</ref>
* Production of [[inflammatory mediators]] by the brain may also trigger seizures.
* Inflammatory [[cytokines]] that are released as a result of [[inflammatory cascade]] provoked by COVID-19 include [[interleukin]] 2,6,7, and 10, [[TNF-α]] and [[granulocyte colony-stimulating factor]]. Consequently, activation of [[glutamate receptors]] by the cytokines causes neuronal hyperexcitability and development of seizures. <ref name="KarimiSharifi Razavi2020">{{cite journal|last1=Karimi|first1=Narges|last2=Sharifi Razavi|first2=Athena|last3=Rouhani|first3=Nima|title=Frequent Convulsive Seizures in an Adult Patient with COVID-19: A Case Report|journal=Iranian Red Crescent Medical Journal|volume=22|issue=3|year=2020|issn=2074-1804|doi=10.5812/ircmj.102828}}</ref>


[[Image:covid 19 seizure.jpeg|500px|thumb|center|Pathophysiology]]
*[[Neurological]] complications caused by [[COVID-19]] are through direct or indirect pathways.
*This includes [[hematogenous]] pathway, [[neuronal]] [[retrograde]] dissemination through [[olfactory bulb]], entry into to [[glial]] cells and [[neurons]] via [[ACE2]] receptor and impairment of [[gas]] exchange in [[lung]]s leading to [[anemia]], hence increasing [[anaerobic]] metabolites in [[brain]] resulting in [[cellular]] and interstitial [[edema]] <ref><nowiki>{{</nowiki>https://pubmed.ncbi.nlm.nih.gov/32458193/<nowiki>}}</nowiki></ref>
*[[Seizures]] in a patient with [[COVID-19]] may be due to primary [[virus]] [[infection]] or due to reactivation of the latent [[virus]].
*Infiltration of the [[brain]] [[tissue]] by the [[virus]] and subsequent production of [[toxins]] by the [[virus]] is one of the several mechanisms that can cause [[seizures]] in a [[COVID-19]] [[patient]]. <ref name="KarimiSharifi Razavi2020">{{cite journal|last1=Karimi|first1=Narges|last2=Sharifi Razavi|first2=Athena|last3=Rouhani|first3=Nima|title=Frequent Convulsive Seizures in an Adult Patient with COVID-19: A Case Report|journal=Iranian Red Crescent Medical Journal|volume=22|issue=3|year=2020|issn=2074-1804|doi=10.5812/ircmj.102828}}</ref>
*Production of [[inflammatory]] mediators by the brain may also trigger [[seizures]].
*[[Inflammatory]] [[cytokines]] that are released as a result of [[inflammatory cascade]] provoked by [[COVID-19]] include [[interleukin]] 2,6,7, and 10, [[TNF-α]] and [[granulocyte colony-stimulating factor]]. Consequently, activation of [[glutamate receptors]] by the cytokines causes [[neuronal]] [[hyperexcitability]] and development of [[seizures]]. <ref name="KarimiSharifi Razavi2020">{{cite journal|last1=Karimi|first1=Narges|last2=Sharifi Razavi|first2=Athena|last3=Rouhani|first3=Nima|title=Frequent Convulsive Seizures in an Adult Patient with COVID-19: A Case Report|journal=Iranian Red Crescent Medical Journal|volume=22|issue=3|year=2020|issn=2074-1804|doi=10.5812/ircmj.102828}}</ref>
 
 
[[Image:covid 19 seizure.jpeg|500px|thumb|center|Pathophysiology <ref name="AbboudAbboud2020">{{cite journal|last1=Abboud|first1=Hilal|last2=Abboud|first2=Fatima Zahra|last3=Kharbouch|first3=Hanane|last4=Arkha|first4=Yasser|last5=El Abbadi|first5=Najia|last6=El Ouahabi|first6=Abdessamad|title=COVID-19 and SARS-Cov-2 Infection: Pathophysiology and Clinical Effects on the Nervous System|journal=World Neurosurgery|volume=140|year=2020|pages=49–53|issn=18788750|doi=10.1016/j.wneu.2020.05.193}}</ref>]]


==Causes==
==Causes==


The aetiology of [[seizure]] regardless whether it is covid-19 or not ,is divided into two categories:
*Cause of COVID-19-associated seizure is viral infection by [[SARS-CoV-2]] and its consequences which include:<ref name="pmid32416567">{{cite journal |vauthors=Asadi-Pooya AA |title=Seizures associated with coronavirus infections |journal=Seizure |volume=79 |issue= |pages=49–52 |date=July 2020 |pmid=32416567 |pmc=7212943 |doi=10.1016/j.seizure.2020.05.005 |url=}}</ref>
**[[Hypoxia]]
**[[Metabolic]] derangement
**[[Organ failure]]
**[[Cerebral]] damage.<ref><nowiki>{{</nowiki>https://www.ncbi.nlm.nih.gov/books/NBK430765/<nowiki>}}</nowiki></ref>
**To view causes of COVID-19, [[COVID-19 causes|click here]].
 
==Differentiating COVID-19-associated seizure from other Diseases==


*'<nowiki/>''Provoked seizures''' : '''''these seizures usually have a temporary trigger such as ''[[CNS infection]]''','''electrolytes disturbance''', '''[[withdrawal syndrome]]''','''[[ sepsis]] '',fever, sleep deprivation and [[stroke]].
*Unprovoked  seizures: In this catrgory ,there isn't any obvious cause or precipitating factor  .<ref><nowiki>{{</nowiki>https://www.ncbi.nlm.nih.gov/books/NBK430765/<nowiki>}}</nowiki></ref>


==Differentiating COVID-19-associated seizure from other Diseases==
*For further information about the differential diagnosis, [[COVID-19-associated seizure differential diagnosis|click here]].
Apart from infectious causes, the differential diagnosis of seizures should include:
*To view the differential diagnosis of COVID-19, [[COVID-19 differential diagnosis|click here]].
*[[Epilepsy]]
*Drug overdose
*Toxins
*Metabolic imbalance
*[[Febrile]] convulsions
*[[Psychogenic]] seizures
*[[Cerebral hypoxia]]


==Epidemiology and Demographics==
==Epidemiology and Demographics==
By now there isn't any sufficient evidence for demographic and epidemiologic data about  covid- 19 associated seizure.
 
*More data is required to comment on [[epidemiology]] and [[demographics]] of [[COVID-19]]-associated [[seizure]].
*One study, specifically investigated the neurological manifestations of [[COVID-19]] and documented [[CNS]] manifestations in 25% of the patients ([[headache]] (13%), [[dizziness]] (17%), impaired [[consciousness]] (8%), acute [[cerebrovascular]] problems (3%), [[ataxia]] (0.5), and [[seizures]] (0.5%)]<ref name="MaoJin2020">{{cite journal|last1=Mao|first1=Ling|last2=Jin|first2=Huijuan|last3=Wang|first3=Mengdie|last4=Hu|first4=Yu|last5=Chen|first5=Shengcai|last6=He|first6=Quanwei|last7=Chang|first7=Jiang|last8=Hong|first8=Candong|last9=Zhou|first9=Yifan|last10=Wang|first10=David|last11=Miao|first11=Xiaoping|last12=Li|first12=Yanan|last13=Hu|first13=Bo|title=Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China|journal=JAMA Neurology|volume=77|issue=6|year=2020|pages=683|issn=2168-6149|doi=10.1001/jamaneurol.2020.1127}}</ref>


==Risk Factors==
==Risk Factors==
There are no established risk factors for covid-19 associated seizure.
 
*Several risk factors of [[seizure]] in [[COVID-19]] patients were considered in a multicenter [[restrospective]] study from Jan 18th to FEb 18th, 2020 in China.<ref><nowiki>{{</nowiki>https://onlinelibrary.wiley.com/doi/full/10.1111/epi.16524<nowiki>}}</nowiki></ref>
*[[Risk factor]]s that were studied include acute [[cerebrovascular disease]], [[traumatic brain injury]] (TBI), [[central nervous system]] (CNS) [[infection]], [[shock]], [[hypoxia]], severe [[metabolic disturbance]], [[multiple‐organ dysfunction syndrome]], [[sepsis]], and exposure to drugs or [[toxic]] substances.
*According to the study, [[hypoxia]] and [[imipenem]] were shown to be important risk factors, among several others, for [[seizure]] in a [[COVID-19]] patient.
*To view the risk factors of COVID-19, [[COVID-19 risk factors|click here]].


==Screening==
==Screening==
There is insufficient evidence to recommend routine screening for covid-19 associated seizure.
 
*There is insufficient evidence to recommend routine screening for [[COVID-19]] associated [[seizure]].


==Natural History, Complications, and Prognosis==
==Natural History, Complications, and Prognosis==
The global case fatality rate is currently estimated to be 4.6% according to  WHO , 9th,June. .The covid-19 fatality rate depends on several factors such as:
*patient demographics
*availability of health care
*test limitation
Also , the more comorbidities the patient has ,the poorer covid-19 clinical output would be. Some  of the prognostic factor of covid-19 are listed as below:
*Above 65 years old
*smoking
*male sex
*elevated inflammatory markers
*elevated D-Dimer
*elevated interleukin 6
*[[thrombocytopenia]]
* high neutrophil to lymphocyte ratio
*higher acute physiology and chronic health evaluation score.<ref><nowiki>{{</nowiki> https://bestpractice.bmj.com/topics/en-gb/3000168/prognosis<nowiki> }}</nowiki></ref>


==Diagnosis==
'''Natural History'''
===Diagnostic Study of Choice===
 
*[[Seizure]] activity in a patient with or without [[COVID-19]] usually lasts for a few seconds to less than 5 minutes with return to normal after the [[seizure]] episode.
*If [[seizure]] episode lasts for more than 5 minutes it is called [[status epilepticus]].
*This is followed by a period of [[confusion]], called [[Postictal state|postictal period]] that can last 3-15 minutes and sometimes hours.
 
'''Complications'''
 
*Complications of COVID-19-associated seizure include:
**[[Headache]]
**[[Tiredness]]
**Difficulty [[speaking]]
**[[Difficulty breathing]] (due to blockage of airway)
**Abnormal behavior
**[[Psychosis]]
**Injury to [[tongue]] due to [[bite]] during [[seizure]] activity
**[[Trauma]] due to sudden [[fall]] and/or [[loss of consciousness]]


The [[diagnosis]] of [[COVID]]-19-associated [[seizure]] is made through:
'''Prognosis'''
*Electroencephalogram ([[EEG]], brain waive activity)<ref name="pmid32374647">{{cite journal| author=Haines S, Caccamo A, Chan F, Galaso G, Catinchi A, Gupta PK| title=Practical Considerations When Performing Neurodiagnostic Studies on Patients with COVID-19 and Other Highly Virulent Diseases. | journal=Neurodiagn J | year= 2020 | volume= 60 | issue= 2 | pages= 78-95 | pmid=32374647 | doi=10.1080/21646821.2020.1756132 | pmc=7212538 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32374647  }} </ref>.


Other diagnostic tests include:
*In general, after the first [[seizure]], subsequent [[seizure]] episodes can be predicted using [[EEG]] and [[brain imaging]].<ref name="pmid22963022">{{cite journal |vauthors=Wilden JA, Cohen-Gadol AA |title=Evaluation of first nonfebrile seizures |journal=Am Fam Physician |volume=86 |issue=4 |pages=334–40 |date=August 2012 |pmid=22963022 |doi= |url=}}</ref>
*[[Prognosis]] of seizure in a [[COVID-19]] patient is not known.
*However, if left untreated, [[seizure]] caused by acute brain event is known to have low risk of recurrence but higher risk of death compared to those with [[epilepsy]]. <ref name="pmid8965090">{{cite journal |vauthors=Sander JW, Shorvon SD |title=Epidemiology of the epilepsies |journal=J. Neurol. Neurosurg. Psychiatry |volume=61 |issue=5 |pages=433–43 |date=November 1996 |pmid=8965090 |pmc=1074036 |doi=10.1136/jnnp.61.5.433 |url=}}</ref>


* [[CT scan]] brain
==Diagnosis==
* [[MRI]] brain
===Diagnostic Study of Choice===
* Blood test
* [[Lumbar puncture]]
* [[Toxicology]] screening


===History===
*The diagnosis of COVID-19-associated seizure is made through [[Electroencephalography|electroencephalogram]] ([[EEG]], brain waive activity).<ref name="pmid32374647">{{cite journal| author=Haines S, Caccamo A, Chan F, Galaso G, Catinchi A, Gupta PK| title=Practical Considerations When Performing Neurodiagnostic Studies on Patients with COVID-19 and Other Highly Virulent Diseases. | journal=Neurodiagn J | year= 2020 | volume= 60 | issue= 2 | pages= 78-95 | pmid=32374647 | doi=10.1080/21646821.2020.1756132 | pmc=7212538 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32374647  }} </ref>


* [[Neurotropism]] is one common feature of [[coronaviruses]]<ref name="pmid30416428">{{cite journal| author=Bohmwald K, Gálvez NMS, Ríos M, Kalergis AM| title=Neurologic Alterations Due to Respiratory Virus Infections. | journal=Front Cell Neurosci | year= 2018 | volume= 12 | issue=  | pages= 386 | pmid=30416428 | doi=10.3389/fncel.2018.00386 | pmc=6212673 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30416428  }} </ref><ref name="pmid32104915">{{cite journal| author=Li YC, Bai WZ, Hashikawa T| title=The neuroinvasive potential of SARS-CoV2 may play a role in the respiratory failure of COVID-19 patients. | journal=J Med Virol | year= 2020 | volume= 92 | issue= 6 | pages= 552-555 | pmid=32104915 | doi=10.1002/jmv.25728 | pmc=7228394 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32104915  }} </ref>.
*Other diagnostic tests include:
* [[COVID-19]] document [[CNS]] manifestations in 25% of the patients, [[headache]] (13%), [[dizziness]] (17%), impaired [[consciousness]] (8%), acute [[cerebrovascular]] problems (3%), [[ataxia]] (0.5), and [[seizures]] (0.5%)<ref name="pmid32422545">{{cite journal| author=Montalvan V, Lee J, Bueso T, De Toledo J, Rivas K| title=Neurological manifestations of COVID-19 and other coronavirus infections: A systematic review. | journal=Clin Neurol Neurosurg | year= 2020 | volume= 194 | issue=  | pages= 105921 | pmid=32422545 | doi=10.1016/j.clineuro.2020.105921 | pmc=7227498 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32422545  }} </ref>.
**[[CT scan]] brain
**[[MRI]] brain
**Blood test
**[[Lumbar puncture]]
**[[Toxicology]] screening


===Symptoms===
===Symptoms===


General symptoms or [[aura]] in a patient with include:
'''Common symptoms:'''
 
*[[Staring]]
*[[Staring]]
*[[Jerking]] movements of the [[arms]] and [[legs]]
*[[Jerking]] movements of the [[Arm|arms]] and [[legs]]
*Stiffening of the [[body]]
*Stiffening of the [[body]]
*Loss of [[consciousness]]
*Loss of [[consciousness]]
*[[Breathing]] problems
*[[Breathing]] problems
*Loss of [[bowel]] or [[bladder]] control
 
===== Loss of [[bowel]] or [[bladder]] control =====
 
*Falling suddenly for no apparent reason, especially when associated with [[loss of consciousness]]
*Falling suddenly for no apparent reason, especially when associated with [[loss of consciousness]]
*Not responding to [[noise]] or words for brief periods
*Not responding to [[noise]] or words for brief periods
*Appearing confused or in a haze
*Appearing confused or in a haze
*Nodding your [[head]] rhythmically, when associated with loss of awareness or [[loss of consciousness]]
 
*Periods of rapid [[eye]] [[blinking]] and [[staring]]
'''Less common symptoms:'''
 
*Nodding of [[head]] rhythmically, associated with lack of awareness
*Periods of rapid [[eye]] [[blinking]]


===Physical Examination===
===Physical Examination===
* Vital Signs: Tachycardia may be present.
 
* Postictal drowsiness or confusion.
*Physical examination of a patient with COVID-19-associated seizure include:
* Finding a bite to the side of the tongue, when present, is helpful in making the diagnosis.
 
==== Vital Signs ====
 
*[[Vital signs]]: [[Tachycardia]] may be present.
 
===== HEENT =====
 
* Finding a [[bite]] to the side of the [[tongue]] (when present, is helpful in making the diagnosis).
 
===== Neuromuscular =====
 
*[[Postictal state|Postictal]] [[drowsiness]] or [[confusion]].


===Laboratory Findings===
===Laboratory Findings===


[[Postictal]] levels of the following may be elevated in a patient with seizures:
*[[Postictal state|Postictal]] levels of the following may be elevated in a patient with [[seizures]]:
* Prolactin (within 20 minutes after a convulsive event)
**[[Prolactin]] (within 20 minutes after a convulsive event)
* Lactate (within 1 to 2 hours)
**[[Lactate]] (within 1 to 2 hours)
* Ammonia (within several hours)
**[[Ammonia]] (within several hours)
* Creatine kinase (especially 24 to 48 hours postictally)
**[[Creatine kinase]] (especially 24 to 48 hours postictally)
* To view the laboratory findings on COVID-19, [[COVID-19 laboratory findings|click here]].
**To view the laboratory findings on COVID-19, [[COVID-19 laboratory findings|click here]].


===Electrocardiogram===
===Electrocardiogram===
* There are no typical ECG findings associated with seizures in a COVID-19 patient.
 
* To view the electrocardiogram findings on COVID-19, [[COVID-19 electrocardiogram|click here]].<br />
*There are no typical [[ECG]] findings associated with seizures in a [[COVID-19]] patient.
*To view the [[electrocardiogram]] findings on COVID-19, [[COVID-19 electrocardiogram|click here]].<br />


===X-ray===
===X-ray===
* There are no x-ray findings associated with COVID-19 associated seizure.
 
* To view the x-ray finidings on COVID-19, [[COVID-19 x ray|click here]].<br />
*There are no [[X-rays|x-ray]] findings associated with [[COVID-19]] associated [[seizure]].
*To view the [[X-rays|x-ray]] finidings on COVID-19, [[COVID-19 x ray|click here]].<br />


===Echocardiography or Ultrasound===
===Echocardiography or Ultrasound===
* There are no typical [[Echocardiography|echocardiographic]] findings for [[seizure]] related to [[COVID-19]].
 
* To view the echocardiographic findings on COVID-19, [[COVID-19 echocardiography and ultrasound|click here]].<br />
*There are no typical [[Echocardiography|echocardiographic]] findings for [[seizure]] related to [[COVID-19]].
*To view the echocardiographic findings on COVID-19, [[COVID-19 echocardiography and ultrasound|click here]].<br />


===CT scan===
===CT scan===
* CT brain may show structural lesions but majority of patients will show nothing.
 
* To view the CT scan findings on COVID-19, [[COVID-19 CT scan|click here]].
*[[CT]] [[brain]] may show structural lesions but majority of patients will show nothing.
*To view the [[CT scan]] findings on COVID-19, [[COVID-19 CT scan|click here]].


===MRI===
===MRI===
* MRI brain may show structural lesions but majority of patients will show nothing.
 
* To view the MRI findings on COVID-19, [[COVID-19 MRI|click here]].<br />
*[[MRI]] brain may show structural lesions but majority of patients will show nothing.
*To view the MRI findings on COVID-19, [[COVID-19 MRI|click here]].<br />


===Other Imaging Findings===
===Other Imaging Findings===
* There are no other imaging findings associated with [[seizure]] related to [[COVID-19]].
 
* To view other imaging findings on COVID-19, [[COVID-19 other imaging findings|click here]].<br />
*There are no other imaging findings associated with [[seizure]] related to [[COVID-19]].
*To view other imaging findings on COVID-19, [[COVID-19 other imaging findings|click here]].<br />


===Other Diagnostic Studies===
===Other Diagnostic Studies===
* To view other diagnostic studies for COVID-19, [[COVID-19 other diagnostic studies|click here]].<br />
 
*To view other diagnostic studies for COVID-19, [[COVID-19 other diagnostic studies|click here]].<br />


==Treatment==
==Treatment==
===Medical Therapy===
===Medical Therapy===


* Development of [[seizures]] in a COVID-19 patient requires urgent treatment.
*Development of [[seizures]] in a [[COVID-19]] patient requires urgent treatment.<ref name="pmid25174548">{{cite journal |vauthors=Ueda R, Saito Y, Ohno K, Maruta K, Matsunami K, Saiki Y, Sokota T, Sugihara S, Nishimura Y, Tamasaki A, Narita A, Imamura A, Maegaki Y |title=Effect of levetiracetam in acute encephalitis with refractory, repetitive partial seizures during acute and chronic phase |journal=Brain Dev. |volume=37 |issue=5 |pages=471–7 |date=May 2015 |pmid=25174548 |doi=10.1016/j.braindev.2014.08.003 |url=}}</ref><ref name="pmid32283294">{{cite journal |vauthors=Ye M, Ren Y, Lv T |title=Encephalitis as a clinical manifestation of COVID-19 |journal=Brain Behav. Immun. |volume= |issue= |pages= |date=April 2020 |pmid=32283294 |pmc=7146652 |doi=10.1016/j.bbi.2020.04.017 |url=}}</ref><ref name="pmid32416567" />
* After the cause of seizure is determined, medical therapy should be aimed at treating the cause immediately (for example, [[hypoxia]], fever, metabolic imbalance).
*After the cause of [[seizure]] is determined, medical therapy should be aimed at treating the cause immediately (for example, [[hypoxia]], [[fever]], metabolic imbalance).
* [[Anti-seizure]] medication (ASM) is often necessary.
*Anti-seizure medication ([[levetiracetam]] 50-60 mg/kg/day) is often necessary.
* For a single seizure less than 5 min rescue treatment with [[benzodiazepine]] is not needed. [[Intravenous]] ASM are used with caution in [[COVID-19]] patients due to the adverse effects (e.g., [[Phenytoin]], [[Phenobarbital]] and [[Lacosamide]] in respiratory and cardiac problems) and drug interactions (e.g., [[Carbamazepine]], Phenytoin, Phenobarbital and [[Valproic acid]]). <ref name="pmid32416567">{{cite journal |vauthors=Asadi-Pooya AA |title=Seizures associated with coronavirus infections |journal=Seizure |volume=79 |issue= |pages=49–52 |date=July 2020 |pmid=32416567 |pmc=7212943 |doi=10.1016/j.seizure.2020.05.005 |url=}}</ref>
*Anti-epileptics therapy with [[mannitol]] has been documented in decreasing [[cerebral edema]].
* [[Brivaracetam]] and [[Levetiracetam]] have less adverse effects and drug interactions. <ref name="pmid32416567">{{cite journal |vauthors=Asadi-Pooya AA |title=Seizures associated with coronavirus infections |journal=Seizure |volume=79 |issue= |pages=49–52 |date=July 2020 |pmid=32416567 |pmc=7212943 |doi=10.1016/j.seizure.2020.05.005 |url=}}</ref>
*For a single [[seizure]] less than 5 min rescue treatment with [[benzodiazepine]] is not needed.
* In patients with more than one seizure (either shorter or longer than 5 min) and in [[status epilepticus]] rescue treatment with benzodiazepines in addition to ASM is needed. <ref name="pmid32416567">{{cite journal |vauthors=Asadi-Pooya AA |title=Seizures associated with coronavirus infections |journal=Seizure |volume=79 |issue= |pages=49–52 |date=July 2020 |pmid=32416567 |pmc=7212943 |doi=10.1016/j.seizure.2020.05.005 |url=}}</ref>
*[[Intravenous]] antiseizure medication are used with caution in [[COVID-19]] patients due to the adverse effects (e.g., [[Phenytoin]], [[Phenobarbital]] and [[Lacosamide]] in [[respiratory]] and [[cardiac]] problems) and [[drug]] interactions (e.g., [[Carbamazepine]], [[Phenytoin]], [[Phenobarbital]] and [[Valproic acid]]).  
*[[Brivaracetam]] and [[Levetiracetam]] have less adverse effects and drug interactions.  
*In patients with more than one [[seizure]] (either shorter or longer than 5 min) and in [[status epilepticus]] rescue treatment with [[benzodiazepines]] in addition to ASM is needed.  


===Surgery===
===Surgery===
Surgical intervention is not recommended for the management of COVID-19 associated seizure.
 
* Surgical intervention is not recommended for the management of [[COVID-19]] associated [[seizure]].


===Primary Prevention===
===Primary Prevention===
There are no established measures for the primary prevention of seizures associated with COVID-19.
 
* There are no established measures for the [[primary prevention]] of [[seizures]] associated with [[COVID-19]].


===Secondary Prevention===
===Secondary Prevention===
There are no established measures for the secondary prevention of seizures associated with COVID-19.
 
* There are no established measures for the [[secondary prevention]] of [[seizures]] associated with [[COVID-19]].


==References==
==References==
{{reflist|2}}
{{reflist|2}}
[[Category:Up-To-Date]]


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Latest revision as of 23:49, 12 December 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mandana Safakhah, MD[2] Tayebah Chaudhry[3], Fahimeh Shojaei, M.D., Syed Musadiq Ali M.B.B.S.[4]

Synonyms and keywords:

Overview

Seizure refers to an episode of symptoms due to abnormally excessive or synchronous neuronal activity in the brain followed by return to normal state. Seizures manifest as abnormal uncontrolled shaking movements that involve much of the body with loss of consciousness, shaking movements of part of the body with variable level of consciousness or a subtle momentary loss of consciousness. As COVID-19 (caused by SARS-Cov2) is now known to have several neurological complications, seizure is one of the complications seen in a few cases so far. Brain waive activity can be seen on EEG to confirm diagnosis since structural changes are very rarely seen on brain imaging. Anti-seizure medications are used for symptomatic treatment of seizure along with treatment of COVID-19.

Historical Perspective

Classification

Pathophysiology


Pathophysiology [7]

Causes

Differentiating COVID-19-associated seizure from other Diseases

  • For further information about the differential diagnosis, click here.
  • To view the differential diagnosis of COVID-19, click here.

Epidemiology and Demographics

Risk Factors

Screening

  • There is insufficient evidence to recommend routine screening for COVID-19 associated seizure.

Natural History, Complications, and Prognosis

Natural History

Complications

Prognosis

Diagnosis

Diagnostic Study of Choice

Symptoms

Common symptoms:

Loss of bowel or bladder control
  • Falling suddenly for no apparent reason, especially when associated with loss of consciousness
  • Not responding to noise or words for brief periods
  • Appearing confused or in a haze

Less common symptoms:

  • Nodding of head rhythmically, associated with lack of awareness
  • Periods of rapid eye blinking

Physical Examination

  • Physical examination of a patient with COVID-19-associated seizure include:

Vital Signs

HEENT
  • Finding a bite to the side of the tongue (when present, is helpful in making the diagnosis).
Neuromuscular

Laboratory Findings

Electrocardiogram

X-ray

Echocardiography or Ultrasound

CT scan

  • CT brain may show structural lesions but majority of patients will show nothing.
  • To view the CT scan findings on COVID-19, click here.

MRI

  • MRI brain may show structural lesions but majority of patients will show nothing.
  • To view the MRI findings on COVID-19, click here.

Other Imaging Findings

  • There are no other imaging findings associated with seizure related to COVID-19.
  • To view other imaging findings on COVID-19, click here.

Other Diagnostic Studies

  • To view other diagnostic studies for COVID-19, click here.

Treatment

Medical Therapy

Surgery

  • Surgical intervention is not recommended for the management of COVID-19 associated seizure.

Primary Prevention

Secondary Prevention

References

  1. ↑ Moriguchi T, Harii N, Goto J, Harada D, Sugawara H, Takamino J, Ueno M, Sakata H, Kondo K, Myose N, Nakao A, Takeda M, Haro H, Inoue O, Suzuki-Inoue K, Kubokawa K, Ogihara S, Sasaki T, Kinouchi H, Kojin H, Ito M, Onishi H, Shimizu T, Sasaki Y, Enomoto N, Ishihara H, Furuya S, Yamamoto T, Shimada S (May 2020). "A first case of meningitis/encephalitis associated with SARS-Coronavirus-2". Int. J. Infect. Dis. 94: 55–58. doi:10.1016/j.ijid.2020.03.062. PMC 7195378 Check |pmc= value (help). PMID 32251791 Check |pmid= value (help).
  2. ↑ Template:Citejournal
  3. ↑ {{https://www.sciencedirect.com/science/article/pii/S1059131120301151}}
  4. ↑ {{https://onlinelibrary.wiley.com/doi/full/10.1111/epi.16524}}
  5. ↑ {{https://pubmed.ncbi.nlm.nih.gov/32458193/}}
  6. ↑ 6.0 6.1 Karimi, Narges; Sharifi Razavi, Athena; Rouhani, Nima (2020). "Frequent Convulsive Seizures in an Adult Patient with COVID-19: A Case Report". Iranian Red Crescent Medical Journal. 22 (3). doi:10.5812/ircmj.102828. ISSN 2074-1804.
  7. ↑ Abboud, Hilal; Abboud, Fatima Zahra; Kharbouch, Hanane; Arkha, Yasser; El Abbadi, Najia; El Ouahabi, Abdessamad (2020). "COVID-19 and SARS-Cov-2 Infection: Pathophysiology and Clinical Effects on the Nervous System". World Neurosurgery. 140: 49–53. doi:10.1016/j.wneu.2020.05.193. ISSN 1878-8750.
  8. ↑ 8.0 8.1 Asadi-Pooya AA (July 2020). "Seizures associated with coronavirus infections". Seizure. 79: 49–52. doi:10.1016/j.seizure.2020.05.005. PMC 7212943 Check |pmc= value (help). PMID 32416567 Check |pmid= value (help).
  9. ↑ {{https://www.ncbi.nlm.nih.gov/books/NBK430765/}}
  10. ↑ Mao, Ling; Jin, Huijuan; Wang, Mengdie; Hu, Yu; Chen, Shengcai; He, Quanwei; Chang, Jiang; Hong, Candong; Zhou, Yifan; Wang, David; Miao, Xiaoping; Li, Yanan; Hu, Bo (2020). "Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China". JAMA Neurology. 77 (6): 683. doi:10.1001/jamaneurol.2020.1127. ISSN 2168-6149.
  11. ↑ {{https://onlinelibrary.wiley.com/doi/full/10.1111/epi.16524}}
  12. ↑ Wilden JA, Cohen-Gadol AA (August 2012). "Evaluation of first nonfebrile seizures". Am Fam Physician. 86 (4): 334–40. PMID 22963022.
  13. ↑ Sander JW, Shorvon SD (November 1996). "Epidemiology of the epilepsies". J. Neurol. Neurosurg. Psychiatry. 61 (5): 433–43. doi:10.1136/jnnp.61.5.433. PMC 1074036. PMID 8965090.
  14. ↑ Haines S, Caccamo A, Chan F, Galaso G, Catinchi A, Gupta PK (2020). "Practical Considerations When Performing Neurodiagnostic Studies on Patients with COVID-19 and Other Highly Virulent Diseases". Neurodiagn J. 60 (2): 78–95. doi:10.1080/21646821.2020.1756132. PMC 7212538 Check |pmc= value (help). PMID 32374647 Check |pmid= value (help).
  15. ↑ Ueda R, Saito Y, Ohno K, Maruta K, Matsunami K, Saiki Y, Sokota T, Sugihara S, Nishimura Y, Tamasaki A, Narita A, Imamura A, Maegaki Y (May 2015). "Effect of levetiracetam in acute encephalitis with refractory, repetitive partial seizures during acute and chronic phase". Brain Dev. 37 (5): 471–7. doi:10.1016/j.braindev.2014.08.003. PMID 25174548.
  16. ↑ Ye M, Ren Y, Lv T (April 2020). "Encephalitis as a clinical manifestation of COVID-19". Brain Behav. Immun. doi:10.1016/j.bbi.2020.04.017. PMC 7146652 Check |pmc= value (help). PMID 32283294 Check |pmid= value (help).


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