Status epilepticus due to COVID-19; a cases series and literature review

Abstract

Complications are increasingly recognized with SARS-CoV-2, the causative pathogen for COVID-19. Various mechanisms have been proposed to justify the cause of seizures in Covid-19 patients. To our knowledge, 13 cases of status epilepticus (SE) associated with COVID-19 have been reported so far. Here, we present a single-center case series, including the clinical, laboratory, and imaging characteristics, and the EEG and the outcome of SE in 5 Iranian patients with laboratory-confirmed SARS-CoV-2 virus. SE was para-infectious in four patients and post-infectious in one other patient. In Three patients, the causes of seizure were included severe hyponatremia, acute ischemic stroke, and meningoencephalitis. However, in two other patients, no specific reason for seizure was found, but there are possibilities for lesser-known mechanisms of Covid-19 that play roles in developing SE. Two of the patients recovered, and three patients, older and with higher comorbidities, failed to recover and died.

Keywords: COVID-19; Status epilepticus; seizures.

Figure 1

Electroencephalogram (EEG) findings. A. Scalp EEG in a transverse montage from patient 1 after 48 hr, demonstrating generalized background slowing and bilateral poly-spike and wave, suggesting generalized epilepsy, no evidence in favor of status epilepticus. Sensitivity 10 uV/mm, LFF 1 Hz, HFF 70 Hz. B. Scalp EEG in a transverse montage from patient 2 after 12 hr, demonstrating continuous bilateral generalized periodic discharge, suggesting non-convulsive status epilepticus. Sensitivity 10 uV/mm, LFF 1 Hz, HFF 70 Hz. C. Scalp EEG in a bipolar montage from patient 3 after 2 hr. Demonstrating Ictal EEG was done and demonstrated continuous 4 hz spike and wave in right fronto-temporal hemisphere with evolution to right centro-parietal and left side myogenic artifact, suggested focal status epilepticus. Sensitivity 10 uV/mm, LFF 1 Hz, HFF 70 Hz. D. Scalp EEG in a bipolar montage from patient #4 after 24 hr demonstrating general background slowing and left hemisphere sharp wave, suggested epileptogenic focus but no evidence of non convulsive status epilepticus is seen at that stage. Sensitivity 10 uV/mm, LFF 1 Hz, HFF 70 Hz. E. Scalp EEG in a bipolar montage from patient 4 after 24 hr demonstrating general background slowing and left hemisphere sharp wave, suggesting epileptogenic focus but no evidence of non convulsive status epilepticus is seen at that stage. Sensitivity 10 uV/mm, LFF 1 Hz, HFF 70 Hz.

Figure 2

Cortical hyper-intensity in DWI sequence (A) in right temporal lobe with matched restriction ADC sequence (yellow arrow) (B).

Figure 3

Symmetric signal change in both centrum semiovale bilateral external capsules and caudate nuclei (A). Focal diffusion restriction in centrum semiovle (B, C).