Clinical and diagnostic features of long-COVID patients presenting with neurologic symptoms in Chicago.

Long COVID, a condition characterized by persistent symptoms after COVID-19 infection, is increasingly being recognized worldwide. Neurologic symptoms are frequently reported in survivors of COVID-19, making it crucial to better understand this phenomenon both on a societal scale and for the quality of life of these patients. Between January 1, 2020, and July 31, 2022, Illinois (IL) had a standardized cumulative death rate that ranked it 24th out of the 51 states in the United States (US). However, the US had one of the highest per capita COVID-19 death rates among large, high-income countries. [Bollyky T. et al. 2023] As a result of the increased number of COVID-19 infections, there was a rise in the number of patients experiencing Long COVID. At our neuro-infectious disease clinic in Chicago (IL), we observed an increasing number of patients presenting with cognitive and other neurologic symptoms after contracting COVID-19. Initially, we needed to provide these individuals with a better understanding of their condition and expected outcomes. We were thus motivated to further evaluate this group of patients for any patterns in presentation, neurologic findings, and diagnostic testing that would help us better understand this phenomenon. We aim to contribute to the growing body of research on Long COVID, including its presentation, diagnostic testing results, and outcomes to enlighten the long COVID syndrome. We hypothesize that the neurological symptoms resulting from long COVID persist for over 12 months. We conducted a retrospective analysis of clinical data from 44 patients with long-COVID. Cognitive symptoms were the most common presenting concern. Abnormalities in Montreal Cognitive Assessment, electroencephalogram, serum autoantibody testing, and cerebrospinal fluid were found in minority subsets of our cohort. At 12 months, most patients continue to experience neurologic symptoms, though more than half reported moderate or marked improvement compared to initial presentation. Although most of the patients in this study did not show a consistent occurrence of symptoms suggesting a cohesive underlying etiology, our clinical data demonstrated some features of Long COVID patients in Chicago (IL) that could lead to new research avenues, helping us better understand this syndrome that affects patients worldwide.

Critique of the 2017 epileptic seizure and epilepsy classifications.

This article critiques the International League Against Epilepsy (ILAE) 2015-2017 classifications of epilepsy, epileptic seizures, and status epilepticus. It points out the following shortcomings of the ILAE classifications: (1) they mix semiological terms with epileptogenic zone terminology; (2) simple and widely accepted terminology has been replaced by complex terminology containing less information; (3) seizure evolution cannot be described in any detail; (4) in the four-level epilepsy classification, level two (epilepsy category) overlaps almost 100% with diagnostic level one (seizure type); and (5) the design of different classifications with distinct frameworks for newborns, adults, and patients in status epilepticus is confusing. The authors stress the importance of validating the new ILAE classifications and feel that the decision of Epilepsia to accept only manuscripts that use the ILAE classifications is premature and regrettable.

Psychiatric comorbidities go untreated in patients with epilepsy: Ignorance or denial?

Psychiatric comorbidities are common in patients with epilepsy (PWE). Depression and anxiety are the most prevalent of these comorbidities and are associated with worse quality of life. Several screening tools are available to identify and follow up these conditions. However, time constrains in outpatient clinic visits and limited access to mental healthcare professionals discourage clinicians to use them. This paper discusses the advantage and limitations of screening tools and makes a compelling argument for neurologists to take an active role in the diagnosis and treatment of common psychiatric comorbidities in PWE. This article is part of the Special Issue "Obstacles of Treatment of Psychiatric Comorbidities in Epilepsy".

Status Epilepticus in the Intensive Care Unit.

Status epilepticus (SE) is a common neurologic emergency and a frequent reason for admission to the intensive care unit. During the last decade, the advent and availability of diagnostic tools for the recognition of nonconvulsive SE has highlighted an even higher incidence of this condition among the critically ill. New alternatives in treatment have also become available within recent years. The recommendation of early escalation toward the use of general anesthetics in the treatment of convulsive SE follows the theory that the duration of the event defines the aggressiveness of the condition and the potential for long-term neuronal injury. Whether these new diagnostic and treatment tools are applicable to all patients with SE; and how they impact functional outcome and mortality, remain active subjects of clinical research.

Psychogenic Non-epileptic Seizures: An Updated Primer.

BACKGROUND: Psychogenic non-epileptic seizures are the most common paroxysmal event misdiagnosed as epilepsy. They significantly affect quality of life, functional status, and use of medical resources. OBJECTIVE: The goal of this review is to provide guidance to psychiatrists and other mental health professionals in the understanding and practical management of this condition. RESULTS: An abundance of new reports on the pathogenesis and effective treatments have become available over the last decade, yet specific barriers impede the fluid transition to treatment and remain an important challenge in the management of patients with psychogenic non-epileptic seizures. In the context of these difficulties, we initially present background information on psychogenic non-epileptic seizures covering their historic context, epidemiology, etiologic factors (including psychiatric, neuromedical, and neuropsychological factors), and current neurobiological models. Updated evidence-based treatments are discussed along with data on long-term outcomes. We also provide practical tools to help clinicians navigate differential diagnoses, establish their interdisciplinary roles, communicate the diagnosis, deliver treatment, and sort out commonly encountered challenges in the management of this condition.

Setting up EEG Source Imaging in Practice.

SUMMARY: Adding EEG source imaging to a clinical practice has clear advantages over visual inspection of EEG. This article offers insight on incorporating EEG source imaging into an EEG laboratory and the best practices for producing optimal source analysis results.

Modern technology calls for a modern approach to classification of epileptic seizures and the epilepsies.

In the last 10-15 years the ILAE Commission on Classification and Terminology has been presenting proposals to modernize the current ILAE Classification of Epileptic Seizures and Epilepsies. These proposals were discussed extensively in a series of articles published recently in Epilepsia and Epilepsy Currents. There is almost universal consensus that the availability of new diagnostic techniques as also of a modern understanding of epilepsy calls for a complete revision of the Classification of Epileptic Seizures and Epilepsies. Unfortunately, however, the Commission is still not prepared to take a bold step ahead and completely revisit our approach to classification of epileptic seizures and epilepsies. In this manuscript we critically analyze the current proposals of the Commission and make suggestions for a classification system that reflects modern diagnostic techniques and our current understanding of epilepsy.

Strokes or Seizures? What's the Score?

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Could the 2017 ILAE and the four-dimensional epilepsy classifications be merged to a new "Integrated Epilepsy Classification"?

Over the last few decades the ILAE classifications for seizures and epilepsies (ILAE-EC) have been updated repeatedly to reflect the substantial progress that has been made in diagnosis and understanding of the etiology of epilepsies and seizures and to correct some of the shortcomings of the terminology used by the original taxonomy from the 1980s. However, these proposals have not been universally accepted or used in routine clinical practice. During the same period, a separate classification known as the "Four-dimensional epilepsy classification" (4D-EC) was developed which includes a seizure classification based exclusively on ictal symptomatology, which has been tested and adapted over the years. The extensive arguments for and against these two classification systems made in the past have mainly focused on the shortcomings of each system, presuming that they are incompatible. As a further more detailed discussion of the differences seemed relatively unproductive, we here review and assess the concordance between these two approaches that has evolved over time, to consider whether a classification incorporating the best aspects of the two approaches is feasible. To facilitate further discussion in this direction we outline a concrete proposal showing how such a compromise could be accomplished, the "Integrated Epilepsy Classification". This consists of five categories derived to different degrees from both of the classification systems: 1) a "Headline" summarizing localization and etiology for the less specialized users, 2) "Seizure type(s)", 3) "Epilepsy type" (focal, generalized or unknown allowing to add the epilepsy syndrome if available), 4) "Etiology", and 5) "Comorbidities & patient preferences".

Making Rash Decisions in Epilepsy: Evaluating Hypersensitivity Reactions to Anti-seizure Medications.

The Frequency and Clinical Features of Hypersensitivity Reactions to Antiepileptic Drugs in Children: A Prospective Study Guvenir H, Dibek Misirlioglu E, Civelek E. J Allergy Clin Immunol Pract. 2018;6(6):2043-2050. BACKGROUND: Antiepileptic drugs (AEDs) can cause hypersensitivity reactions during childhood. Studies report a wide clinical spectrum of reactions with AED use, ranging from a mild rash to severe cutaneous reactions. OBJECTIVE: To determine the prevalence and clinical features of AED hypersensitivity reactions during childhood. METHODS: Patients in our pediatric neurology clinic who were prescribed an AED for the first time between November 2015 and November 2016 were monitored and those who developed skin rash during this period were evaluated. RESULTS: A total of 570 patients were evaluated. The median age of the patients was 8.86 (interquartile range, 4.2-13.7) years, and 55.8% (318) of patients were male. The most frequently used AEDs were valproic acid (42%, n = 285) and carbamazepine (20.4%, n = 116). Hypersensitivity reactions to AEDs developed in 5.4% of patients. Of these patients, 71% (29) had cutaneous drug reactions and 29% (9) had severe cutaneous drug reactions; 61.3% (19) were using aromatic AEDs, and the leading suspected AED was carbamazepine (45.2%). Comparison of patients who did and did not develop AED hypersensitivity showed that hypersensitivity was more frequent among patients who were younger than 12 years, who used aromatic AEDs, or who used multiple AEDs. In addition, according to regression analysis results, aromatic AED use significantly increased the risk of AED hypersensitivity ( P < .001). CONCLUSIONS: Although allergic reactions to AEDs are rare, they are of significance because they can cause life-threatening severe cutaneous drug reactions. Therefore, patients receiving AEDs, especially aromatic AEDs, must be monitored closely. Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis With Antiepileptic Drugs: An Analysis of the US Food and Drug Administration Adverse Event Reporting System Borrelli EP, Lee EY, Descoteaux AM, Kogut SJ, Caffrey AR. Epilepsia. 2018;59(12):2318-2324. OBJECTIVE: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare and potentially fatal adverse skin reactions that are most commonly triggered by certain medications. One class of medications that has been highly associated with SJS/TEN reactions is antiepileptic drugs (AEDs). We sought to quantify the risk of SJS/TEN associated with AEDs as a class, as well as individual AEDs, in the United States. METHODS: An analysis was performed of the US Food and Drug Administration Adverse Event Reporting System from July 2014 through December 2017. Rates of SJS/TEN were calculated for each AED compared with all other non-AEDs. Reporting odds ratios (RORs), proportional reporting ratios (PRRs), and 95% confidence intervals (CIs) were calculated using OpenEpi. RESULTS: With 198 reports, AEDs had more reports of SJS/TEN than any other medication class. The AEDs as a class had an ROR of 8.7 (95% CI, 7.5-10.2) and a PRR of 8.7 (95% CI, 7.5-10.2) compared with all other non-AEDs. The AEDs with the highest risk estimates were zonisamide (ROR, 70.2; 95% CI, 33.1-148.7; PRR, 68.7; 95% CI, 32.9-143.5), rufinamide (ROR, 60.0; 95% CI, 8.3-433.5; PRR, 58.9; 95% CI, 8.4-411.5), clorazepate (ROR, 56.0; 95% CI, 7.8-404.1; PRR, 55.1; 95% CI, 7.8-385.0), lamotrigine (ROR, 53.0; 95% CI, 43.2-64.9; PRR, 52.2; 95% CI, 42.7-63.7), phenytoin (ROR, 26.3; 95% CI, 15.5-44.7; PRR, 26.1; 95% CI, 15.4-44.2), and carbamazepine (ROR, 24.5; 95% CI, 16.0-37.5; PRR, 24.3; 95% CI, 16.0-37.1). SIGNIFICANCE: Although AEDs as a class were associated with 9 times the risk of SJS/TEN compared with non-AEDs, there were 6 AEDs with risk estimates greater than 20. Increased awareness of this risk among both prescribers and patients, particularly variations in risk among different AEDs, along with education on early recognition of SJS/TEN signs/symptoms, may help mitigate the number and severity of these adverse events.

Bringing EEG Back to the Future: Use of cEEG in Neurocritical Care.

Continuous EEG Is Associated With Favorable Hospitalization Outcomes for Critically Ill Patients. Hill CE, Blank LJ, Thibault D, et al. Willis Neurology. 2018. doi: https://doi.org/10.1212/WNL.0000000000006689 Objective: To characterize continuous electroencephalography (cEEG) use patterns in the critically ill and to determine the association with hospitalization outcomes for specific diagnoses. METHODS: We performed a retrospective cross-sectional study with National Inpatient Sample data from 2004 to 2013. We sampled hospitalized adult patients who received intensive care and then compared patients who underwent cEEG to those who did not. We considered diagnostic subgroups of seizure/status epilepticus, subarachnoid or intracerebral hemorrhage, and altered consciousness. Outcomes were in-hospital mortality, hospitalization cost, and length of stay. RESULTS: In total, 7 102 399 critically ill patients were identified, of whom 22 728 received cEEG. From 2004 to 2013, the proportion of patients who received cEEG increased from 0.06% (95% confidence interval [CI]: 0.03%-0.09%) to 0.80% (95% CI: 0.62%-0.98%). While the cEEG cohort appeared more ill, cEEG use was associated with reduced in-hospital mortality after adjustment for patient and hospital characteristics (odds ratio [OR]: 0.83, 95% CI: 0.75-0.93, P < .001). This finding held for the diagnoses of subarachnoid or intracerebral hemorrhage and for altered consciousness, but not for the seizure/status epilepticus subgroup. Cost and length of hospitalization were increased for the cEEG cohort (OR: 1.17 and 1.11, respectively, P < .001). CONCLUSIONS: There was a >10-fold increase in cEEG use from 2004 to 2013. However, this procedure may still be underused; cEEG was associated with lower in-hospital mortality but used for only 0.3% of the critically ill population. While administrative claims analysis supports the utility of cEEG for critically ill patients, our findings suggest variable benefit by diagnosis, and investigation with greater clinical detail is warranted.

Classification of paroxysmal events and the four-dimensional epilepsy classification system.

This educational review describes the classification of paroxysmal events and a four-dimensional epilepsy classification system. Paroxysmal events are classified as epileptic and non-epileptic paroxysmal events. Non-epileptic events are, in turn, classified as psychogenic and organic paroxysmal events. The following four dimensions are used to classify epileptic paroxysmal events: ictal semiology, the epileptogenic zone, etiology, and comorbidities. Efforts are made to keep these four dimensions as independent as possible. The review also includes 12 educational vignettes and three more detailed case reports classified using the 2017 classification of the ILAE and the four-dimensional epilepsy classification. In addition, a case is described which is classified using the four-dimensional epilepsy classification with different degrees of precision by an emergency department physician, a neurologist, and an epileptologist. [Published with video sequences on www.epilepticdisorders.com].