Abstracts

Rationale:
COVID-19 infection can involve the nervous system involvement with manifestations including: strokes, impaired consciousness, and seizures. Only limited case reports and case series describing EEG abnormalities in patients with COVID-19 have been published. The most common reason for obtaining an EEG is altered mental status (AMS). Prior EEG studies report that COVID-19 patients with AMS have shown non-specific encephalopathic patterns and epileptiform discharges, mostly frontal or frontally predominant generalized discharges, and rarely seizures. We describe two cases in which EEG played a critical role in diagnosis and treatment.
Method:
In our practice, we encountered two adult patients with COVID-19 infection who underwent EEG monitoring for AMS. Both had Ceribell Rapid Response EEG recordings initially and one continued with conventional long-term video EEG monitoring. Both patients had multiple medical comorbidities and symptomatic COVID-19 infections, requiring intubation and compassionate use remdesvir.
Results:
The first patient is a 37-year old woman who was admitted to Stanford Hospital. EEG monitoring was requested by the Neurology consult service due to worsening AMS and myoclonic movements. Her Ceribell EEG initially showed bifrontally-predominant discharges in runs reaching 3 Hz, correlating with myoclonic movements. Keppra was administered emergently due to concern for status epilepticus. Her EEG and myoclonic movements improved, but did not resolve completely, so Dilantin was administered, and maintenance doses of both were given. Subsequent Ceribell recordings showed resolution of status epilepticus.  She was transitioned to conventional EEG, and these recordings confirmed bifrontal discharges, though occurring at a frequency of  < 1 Hz. Additionally her EEG showed non-specific encephalopathic patterns. Her mental status improved in parallel with her EEG improvement after anti-seizure medications. The second patient is a 60-year old woman who was admitted to Stanford Valley Care Hospital. EEG was requested by the Neurology consult service due to worsening encephalopathy. Her initial recording with Ceribell EEG showed generalized periodic discharges (GPDs) reaching 2-3 Hz at times. Given concern for nonconvulsive status epilepticus and these Ceribell EEG results,  she was started on Keppra with subsequent Ceribell recordings showing improvement in the discharges. However, her mental status remained altered. She did also have many other ongoing medical issues, including persistent fevers, anemia, and hypernatremia.
Conclusion:
We described two critically ill patients, with COVID-19 infection, who underwent EEG monitoring due to AMS. This report adds to the literature further cases of EEG abnormalities seen in COVID-19 patients with encephalopathy. Similarly to others, we found nonspecific indicators of encephalopathy like diffuse slowing as well as epileptiform activity including bifrontally-predominant discharges and seizures. Our findings demonstrate that there is a pathogenic role of COVID-19 infection in triggering epileptiform activity and seizures in patients, highlighting the importance of EEG monitoring in high-risk patients. EEG recordings in such patients may identify pathological patterns that will benefit from treatment with anti-seizure medications.
Funding:
:NA