Abstracts

Rationale: Posterior reversible encephalopathy syndrome (PRES) may be a rare complication of COVID-19 infection. The relationship between PRES and acute symptomatic seizures in COVID-19 patients is not well understood but may involve a common pathophysiologic mechanism. To our knowledge, we discuss the first case of COVID-19 infection complicated by PRES and focal Super Refractory Status Epilepticus (SRSE).

Methods: We present a 69-year-old man with history of type II diabetes mellitus and no abnormal neurological history who had new-onset focal SRSE as a manifestation of PRES in the setting of prolonged hospitalization for COVID-19 infection. The patient underwent continuous video-EEG (cvEEG) monitoring and MRI of the brain.

Results: The patient initially presented with shortness of breath, fever, and cough, and was diagnosed with COVID-19 pneumonia, requiring intubation and treated with remdesivir and methylprednisolone. The hospital course was complicated by septic shock, renal failure requiring dialysis, and bacterial pneumonia. Prior to the onset of seizures, the patient was weaned from ventilatory support and renal function improved. His blood pressure in this time period ranged 120 to 165 mmHg over 65 to 85 mmHg. He was witnessed to have right rhythmic hemibody twitching, rapidly resolving after lorazepam and levetiracetam administration. MRI brain showed bilateral posterior FLAIR hyperintensities suggestive of PRES (Figure 1). Unfortunately, clinical seizures recurred, and the patient became encephalopathic. cvEEG revealed an ictal pattern of waxing and waning periodic discharges with superimposed fast activity in the right posterior quadrant with propagation to left posterior quadrant (Figure 2). Lacosamide was added, and following bolus administration of benzodiazepines, midazolam infusion was started, requiring reintubation. Clobazam was subsequently added. Seizures subsided within 48-72 hours, and midazolam was gradually weaned with continuous EEG monitoring. Following weaning of midazolam, the patient remained minimally responsive, continued on ventilatory and pressor support, and ultimately expired after suffering asystolic cardiac arrest.

Conclusions: SRSE can be a rare and fatal complication in patients with PRES and COVID-19 infection. Seizures may be secondary to direct COVID-19-induced brain damage, endothelial disruption from angiotensin-converting enzyme 2 (ACE-2) receptor dysfunction, and high levels of inflammatory cytokines such as tumor necrosis factor-alpha (TNF- α), interleukin (IL) 1, and IL-8. These changes are also seen in patients with PRES. Despite similar pathophysiology, evidence is limited regarding a direct association between COVID-19 and PRES. Importantly, patients with severe COVID-19 infection and seizures or persistent encephalopathy may benefit from cvEEG to screen for non-convulsive status epilepticus in this at-risk population. Further study is merited for optimal treatment of this neurological complication and to increase understanding of these coincident pathologies.

Funding: Please list any funding that was received in support of this abstract.: None.