[ARTICLE] Stroke Recovery During the COVID-19 Pandemic: A Position Paper on Recommendations for Rehabilitation – Full Text

Abstract

Health care delivery shifted and adapted with the COVID-19 pandemic caused by the novel severe acute respiratory syndrome coronavirus 2. Stroke care was negatively affected across the care continuum and may lead to poor community living outcomes in those who survived a stroke during the ongoing pandemic. For instance, delays in seeking care, changes in length of stays, and shifts in discharge patterns were observed during the pandemic. Those seeking care were younger and had more severe neurologic effects from stroke. Increased strain was placed on caregivers and public health efforts, and community-wide lockdowns, albeit necessary to reduce the spread of COVID-19, had detrimental effects on treatment and recommendations to support community living outcomes. The American Congress of Rehabilitation Medicine Stroke Interdisciplinary Special Interest Group Health and Wellness Task Force convened to (1) discuss international experiences in stroke care and rehabilitation and (2) review recently published literature on stroke care and outcomes during the pandemic. Based on the findings in the literature, the task force proposes recommendations and interdisciplinary approaches at the (1) institutional and societal level; (2) health care delivery level; and (3) individual and interpersonal level spanning across the care continuum and into the community.

Statement of purpose

The COVID-19 pandemic caused by the novel severe acute respiratory syndrome (SARS) coronavirus (CoV) 2 posed unprecedented challenges to health care systems around the world. It is expected that the fallout from the COVID-19 pandemic will directly affect people who experience stroke during this time. The Health and Wellness Task Force within the American Congress of Rehabilitation Medicine Stroke Interdisciplinary Special Interest Group is concerned that during the ongoing pandemic, fewer people are seeking stroke care, and more people with stroke are living with the effects of untreated stroke or being discharged with minimal rehabilitation or without critical early and intensive rehabilitation that is recommended for improving stroke outcomes.¹ The purpose of this position article is to describe ongoing challenges and opportunities to support the short- and long-term needs of people surviving stroke during the COVID-19 pandemic. The task force proposes potential solutions across the care continuum to support a multilevel and interdisciplinary approach that addresses this major public health problem.

Rationale for position paper

Enduring a stroke during the pandemic

Before the COVID-19 pandemic, stroke was widely regarded as a leading global cause of disability², ³, ⁴ and the second leading cause of death (11.6% of global mortality).⁵ Despite advancements in medical interventions that increased stroke survival, disparities in stroke mortality and disability were prevalent, partly because of differences in country income and medical care quality (eg, cost, access, availability).³ The COVID-19 pandemic presented an additional risk factor for stroke: COVID-19 infection. While there is no exact mechanism linking COVID-19 to stroke, vascular symptoms associated with COVID-19 such as hypercoagulability and arterial and venous thrombosis are believed to be contributing factors to increased risk of stroke.⁶, ⁷ Other coronavirus respiratory syndromes of the same nature including the SARS-CoV-1 and Middle East Respiratory Syndrome coronavirus were also related to increased incidence of acute ischemic stroke.⁷  Further, people with stroke risk factors (eg, diabetes, smoking) have an increased COVID-19 mortality rate, possibly because of the same mechanisms attributed to stroke risk, such as large expression of angiotensin-converting enzyme 2 cell receptors for binding to SARS-CoV-2.⁸

Common deficits after stroke include impaired motor function; impaired ability to carry out activities of daily living; cognitive impairments in memory, language, attention, and executive function; and affected mood, sensation, and perception.^{9 10} Stroke attributed to the SARS-CoV-2 infection can cause greater severity of stroke,¹¹ potentially leading to prolonged acute care and rehabilitation.¹² Natural recovery of broad stroke-related impairments often occurs with haste within the first 6 months post stroke and then tends to plateau, although this may vary for cognitive, physical, and sensory-perceptual impairments.¹³ It is difficult to predict individual recovery because sequelae are multifaceted across multiple domains. As such, rehabilitation clinicians rely on their own judgment as to when to end rehabilitation post stroke.¹³ The long-term effects and recovery trajectory for individuals with simultaneous SARS-CoV-2 infection and stroke is unknown.

Stroke care

Before the COVID-19 pandemic, patients with stroke symptoms received hyperacute and acute treatment at the nearest specialist stroke unit, primary stroke center, or comprehensive stroke center.¹⁴ After acute treatment, the patient entered 1 of 2 main pathways for poststroke rehabilitation: (1) subacute rehabilitation (eg, inpatient rehabilitation, skilled nursing facility); or (2) community rehabilitation, normally delivered via an outpatient facility or in the patient’s home.¹⁵

 A large-scale RCT of working-aged survivors of stoke across the UK, Australia, and Southeast Asia found that within 3 months post stroke, 67% of survivors of stroke received either inpatient or community rehabilitation, and only 8% of those were still receiving rehabilitation 12 months post stroke.¹⁵Those with milder strokes had the highest rates of receiving no rehabilitation (40%), followed by a lower proportion of those with moderate strokes (12%) and severe strokes (4%) who required no rehabilitation.¹⁵

During the pandemic, regions with high incidence of COVID-19 were forced to reorganize health care services. This included implementation of triage systems, separating patients with confirmed or suspected COVID-19 from patients without COVID-19 and redeploying health care professionals to the frontline to deal with the influx of patients with COVID-19.¹⁶, ¹⁷, ¹⁸

 Resources and clinicians were spread across usual clinical care and COVID-19 specific care, increasing the potential short- and long-term negative consequences of high stress and burnout.¹⁹

 An overwhelmed health care system, attributed to reassignment of staff or beds, increased patient admissions without adequate staffing, and increased resource strain, likely led to care and service limitations.²⁰

Overarching rationale

Given the substantial number of adults enduring stroke annually, it is necessary to understand and address their needs during the ongoing COVID-19 pandemic. While it is well-documented that interdisciplinary stroke rehabilitation can enhance outcomes after stroke, the substantial shift in health care delivery during the COVID-19 pandemic may have major effects on short- and long-term outcomes. Researchers must further examine stroke outcomes related to the COVID-19 pandemic. Practitioners must be prepared to identify problems and challenges among this population to address the fallout the pandemic has imparted on a generation of survivors of stroke.[…]

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[ARTICLE] A review of the potential neurological adverse events of COVID-19 vaccines – Full Text PDF

Abstract

Despite the advantages of getting access to the coronavirus disease 2019 (COVID-19) vaccines, their potential ability to induce severe adverse events (AEs) has been a significant concern. Neurological complications are significant among the various adverse events following immunization (AEFI) due to their likely durability and debilitating sequelae. Neurological AEs following COVID-19 vaccination can either exacerbate or induce new-onset neuro-immunologic diseases, such as myasthenia gravis (MG) and Guillain–Barre syndrome (GBS). The more severe spectrum of AEs post-COVID19 vaccines has included seizures, reactivation of the varicella-zoster virus, strokes, GBS, Bell’s palsy, transverse myelitis (TM), and acute disseminated encephalomyelitis (ADEM). Here, we discuss each of these neurological adverse effects separately.

Follow the link to read the full content: https://rdcu.be/cZ1Oz

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[Abstract] Safety and Adverse Events Following COVID-19 Vaccination among People with Epilepsy: A Cross-Sectional Study

Abstract

Objective

Epilepsy is an under-discussed non-communicable disease costing massive burden globally. It is known that there is increased prevalence of morbidity and mortality following COVID-19 infection among people with epilepsy (PWE). However, there is limited information about the adverse events following COVID-19 immunisation among PWE. Hence, this study aimed to assess the safety and adverse events following immunisation (AEFI) of COVID-19 vaccinations among PWE who follow up in our centre, with a focus on neurologic AEFI.

Methods

This cross-sectional study recruited 120 adult PWE who are under the follow-up of the Neurology Clinic, Universiti Kebangsaan Malaysia Medical Centre (UKMMC). Consent-taking was conducted via synchronous or asynchronous approaches, followed by a phone call interview session. The interview collected socio-demographic information, epilepsy-related variables, and vaccination-related variables. Univariate analysis and multiple logistic regression analysis were done to confirm factors associated with the AEFI of COVID-19 vaccinations.

Results

Among all types of COVID-19 vaccines, most of the PWE received the Cominarty® COVID-19 vaccination (52.5%). Overall, local AEFI was the quickest to develop, with an average onset of within a day. PWE with normal body mass index (BMI) have a higher risk of developing both local and systemic AEFI compared to those underweight and obese PWE. (OR: 15.09, 95% CI 1.70-134.28, p=0.02).

Significance

COVID-19 vaccine is safe for PWE. AEFI among PWE are similar to the general population following COVID-19 vaccination. Therefore, clinicians should encourage their PWE patients to take COVID-19 vaccine.

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[ARTICLE] Neurological consequences of COVID-19 – Full Text

Abstract

In December 2019, cases of pneumonia caused by infection with the previously unknown severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), leading to coronavirus disease 2019 (COVID-19), were identified. Typical manifestations of COVID-19 are fever, cough, fatigue and dyspnoea. Initially, it was thought that the mechanism of action of SARS-CoV-2 was only associated with respiratory tract invasion, but it was later revealed that the infection might involve many other organs and systems, including the central and peripheral nervous systems. Neurological complications associated with SARS-CoV-2 infection include encephalopathy, encephalitis, meningitis, acute disseminated encephalomyelitis (ADEM), ischaemic and haemorrhagic stroke and cerebral venous sinus thrombosis. In cases of peripheral nervous system involvement, smell and taste disorders, myopathy or the signs and symptoms of Guillain‒Barré syndrome are observed. The most common early neurological complications, particularly during the first year of the epidemic, were anosmia and taste disorders, which, according to some studies, occurred in over 80 percent of patients with COVID-19. The proportion of patients with serious neurological manifestations was small compared to the global number of patients, but the numbers of SARS-CoV-2 infections and critical patients increased substantially. The experience from 2 years of the pandemic has shown that approximately 13% of infected patients suffer from severe neurological complications. The relationship between SARS-CoV-2 and the nervous system is not only a cause of neurological complications in previously healthy individuals but also directly and indirectly affects the courses of many nervous system diseases.

Introduction

Coronaviruses have been known for years as pathogens that commonly occur in humans and animals. They are responsible for approximately 10–20% of common cold and mild respiratory tract infections. At the end of 2019, a newly mutated form of coronavirus that causes severe pneumonia was identified in Wuhan, China. The disease spread rapidly, resulting in an epidemic in China and then a pandemic. In February 2020, the World Health Organization (WHO) defined ‘COVID-19’ as a disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [1]. On 11 March 2020, the WHO declared COVID-19 a pandemic. Nearly 550 million people were affected by the disease, and over 6 million people died over the next 2 years. Although the pandemic has not yet ended, it is already considered to be one of the most tragic epidemics in our history. The virus mainly attacks the respiratory system, but neurological complications following COVID-19 are common and develop in approximately 50 percent of patients [2].

Individuals with concomitant diseases (diabetes, hypertension or obesity) are at a particularly high risk of contracting the virus and suffering severe infection [3]. Genetic factors are also important. Certain patients with COVID-19 were seriously ill, while others experienced few signs or symptoms. New research has helped identify over 1000 genes related to a severe course of COVID-19. Moreover, it has been shown that severe COVID-19 is highly associated with a poor reaction of two immune cell types: natural killer (NK) cells and T lymphocytes (the ‘CD56 bright’ subtype) [4].

Due to its relationship with the nervous system, SARS-CoV-2 infection not only causes neurological complications in previously healthy individuals but also affects the courses of many nervous system diseases.[…]

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[WEB] Mental Health During the COVID-19 Pandemic

An Urgent Issue

Both SARS-CoV-2 and the COVID-19 pandemic have significantly affected the mental health of adults and children. In a 2021 study, nearly half of Americans surveyed reported recent symptoms of an anxiety or depressive disorder, and 10% of respondents felt their mental health needs were not being met. Rates of anxiety, depression, and substance use disorder have increased since the beginning of the pandemic. And people who have mental illnesses or disorders and then get COVID-19 are more likely to die than those who don’t have mental illnesses or disorders.

Mental health is a focus of NIH research during the COVID-19 pandemic. Researchers at NIH and supported by NIH are creating and studying tools and strategies to understand, diagnose, and prevent mental illnesses or disorders and improve mental health care for those in need.

How COVID-19 Can Impact Mental Health

If you get COVID-19, you may experience a number of symptoms related to brain and mental health, including:

• Cognitive and attention deficits (brain fog)
• Anxiety and depression
• Psychosis
• Seizures
• Suicidal behavior

Data suggest that people are more likely to develop mental illnesses or disorders in the months following infection, including symptoms of post-traumatic stress disorder (PTSD). People with long COVID may experience many symptoms related to brain function and mental health.

How the Pandemic Affects Developing Brains

The impact of the COVID-19 pandemic on the mental health of children is not yet fully understood. NIH-supported research is investigating factors that may influence the cognitive, social, and emotional development of children during the pandemic, including:

• Changes to routine
• Virtual schooling
• Mask wearing
• Caregiver absence or loss
• Financial instability

Not Everyone Is Affected Equally

While the COVID-19 pandemic can affect the mental health of anyone, some people are more likely to be affected than others. People who are more likely to experience symptoms of mental illnesses or disorders during the COVID-19 pandemic include:

• People from racial and ethnic minority groups
• Mothers and pregnant people
• People with financial or housing insecurity
• Children
• People with disabilities
• People with preexisting mental illnesses or substance use problems
• Health care workers

People who belong to more than one of these groups may be at an even greater risk for mental illness.

Telehealth’s Potential to Help

The pandemic has prevented many people from visiting health care professionals in person, and as a result, telehealth has been more widely adopted during this time. Telehealth visits for mental health and substance use disorders increased significantly from 2020 to 2021 and now make up nearly half of all total visits for behavioral health.

Widespread adoption of telehealth services may help people who otherwise would not be able to access mental health support, such as people in rural areas or places with few providers.

Frequently Asked Questions

I have a preexisting mental illness. Is COVID-19 more dangerous to me?

COVID-19 can be worse for people with mental illnesses. Data suggest that people who reported symptoms of anxiety or depression had a greater chance of being hospitalized after a COVID-19 diagnosis than people without those symptoms.

The Centers for Disease Control and Prevention (CDC) reports that having mood disorders and schizophrenia spectrum disorders can increase a person’s chances of having severe COVID-19. People with mental illnesses who belong to minority groups are also more likely to get COVID-19. And people with schizophrenia are significantly more likely to get COVID-19 and more likely to die from it.

Despite these risks, effective treatments are available. If you have a preexisting mental illness and get COVID-19, talk to your health care professional to determine the treatment plan that’s appropriate for you.

I’m experiencing symptoms of a mental illness or disorder. What should I do?

If you are experiencing symptoms of anxiety, depression, or any other mental illness or disorder, there are ways you can get help. For immediate help:

• Call 911
• Call or text the 988 Suicide & Crisis Lifeline at 988 (para ayuda en español, llame al 988)
• Call or text the Disaster Distress Helpline, 1-800-985-5990 (press 2 for Spanish)
• The Substance Abuse and Mental Health Services Administration can help you find mental health or substance use specialists.
• Talk to your health care professional or mental health care professional. Together, you can work on a plan to manage or reduce your symptoms.

What research is NIH doing on the mental health impacts of COVID-19?

The National Institute of Mental Health (NIMH) and other NIH Institutes have created research initiatives to address mental health for people in general and for the most vulnerable people specifically. Examples of this research include:

• NIMH launched a five-year research study called RECOUP-NY to promote the mental health of New Yorkers from communities hard-hit by COVID-19. The study will test the use of a new care model called Problem Management Plus (PM+) that can be used by non-specialists.
• A study funded by NIMH is examining the use of mobile apps to address mental health disparities.
• The Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) is funding research to understand the effects of mask usage for children, including any impacts on their emotional and brain development.
• NIMH is funding research on the impacts of the pandemic on underserved and vulnerable populations and on the cognitive, social, and emotional development of children.
• The National Institute on Alcohol Abuse and Alcoholism (NIAAA) is funding research on how COVID-19 and SARS-CoV-2 affect the causes and consequences of alcohol misuse.
• A collaborative study supported by NIMH and the National Center for Complementary and Integrative Health (NCCIH) enrolled more than 3,600 people from all 50 U.S. states to understand the stressors affecting people during the pandemic.

Source

[Abstract] Effectiveness of a Gamified and Home-Based Approach for Upper-limb Rehabilitation

Abstract

Rehabilitation treatments have been greatly enhanced by health-enabling technologies, as these enable more objective and interactive interventions. Multiple studies indicate that gamification is efficient in promoting treatment customization, adherence, motivation, and engagement, leading to increased patient satisfaction. In this work we study the effectiveness of a novel gamified telerehabilitation system. Patients exercise within a digital game-like experience, with their motion tracked using an userfriendly “invisibles” paradigm, i.e. without requiring sensor placed on the body. Pain, adherence and satisfaction data was collected and analysed. Our approach was particularly relevant during the acute stages of the pandemic, during severe restrictions in the access to in-person rehabilitation activities. A total of 62 patients participated in this study, during a 14-month period. Each patient completed an average of 16 sessions, and 85.5% of them were considered fully recovered after the protocol completion. All patients improved their pain level, with an overall 73.3% average pain reduction. Moreover, in the end of the treatment 79.4% of the patients reported their pain in the levels 0 or 1 (in a 0–10 scale). In terms of treatment satisfaction, 95% of the patients would reportedly recommend the proposed solution to a friend of family. Moreover, the main benefits reported were the convenience, time flexibility, and customization. Our results validate the clinical outcomes and the healthcare quality perceived by the patients in the use of the approach in telerehabilitation for shoulder-related conditions, and are encouraging for usage in further physical rehabilitation fields.

Published in: 2022 44th Annual International Conference of the IEEE Engineering in Medicine & Biology Society (EMBC)

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[Review] Should patients with epilepsy be vaccinated against coronavirus disease 2019? A systematic review and meta-analysis – Full Text

Highlights

•The vaccination coverage and willingness to be vaccinated against COVID-19 were still low in patients with epilepsy.

•Seizure status rather than seizure type associated with COVID-19 unvaccination.

•Vaccination against COVID-19 appears to be well-tolerated and safe in patients with epilepsy.

•Our findings supporting a positive outlook towards the vaccination in this population.

Abstract

Objective

The coronavirus disease 2019 (COVID-19) vaccination coverage, willingness, and safety profiles in patients with epilepsy remain poorly understood. We aimed to summarize the available evidences of COVID-19 vaccination coverage, willingness, and safety profiles among patients with epilepsy.

Methods

We performed a literature search in the Pubmed, EMBASE, and Cochrane Central Register database between 1 January 2020 and 30 April 2022. We included eligible studies that provided information on the COVID-19 vaccination coverage, willingness, and safety profiles among patients with epilepsy. We investigated the association between baseline characteristics of patients with epilepsy and unvaccination status using a fixed-effect model. We calculated the pooled overall willingness to be vaccinated against COVID-19. We systematically reviewed the safety profiles after COVID-19 vaccination in patients with epilepsy.

Results

Ten eligible observational studies and two case-reports yielded 2589 participants with epilepsy or their caregivers. Among 2145 participants that provided the information of vaccination status, 1508 (70.3%) patients with epilepsy were not administered COVID-19 vaccine, and 58% (95%CI 40% – 75%) of respondents were willing to be vaccinated against COVID-19. Seizure status (active versus inactive, OR 1.84 95%CI 1.41 – 2.39, I² = 0%) rather than seizure type (focal versus non-focal, OR 1.22 95%CI 0.94 – 1.58, I² = 0%) was associated with COVID-19 unvaccination status. Vaccines were well-tolerated; epilepsy related problems such as increase in seizure frequency and status epilepticus after COVID-19 vaccination were uncommon.

Conclusions

Our findings suggest a low COVID-19 vaccination coverage and willingness in patients with epilepsy. Vaccination against COVID-19 appears to be well-tolerated and safe in patients with epilepsy, supporting a positive outlook towards vaccination in this population.

Abbreviations

COVID-19

coronavirus disease 2019

SARS-CoV-2

severe acute respiratory syndrome coronavirus 2

PRISMA

Systematic Review and Meta-Analysis

EMBASE

Excerpta Medica database

AHRQ

Agency for Healthcare Research and Quality

ORs

odds ratios

DS

Dravet syndrome

DSUK

National Hospital for Neurology and Neurosurgery

CCE

Chalfont Centre for Epilepsy

ILAE

International League Against Epilepsy

HRQOL

Health-related quality of life

ASM

antiseizure medication

1. Introduction

As of 30 April 2022, coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection had affected more than 500 million confirmed cases and over six million fatalities worldwide [1]. The increased infectivity of the delta and omicron mutations of the SARS-CoV-2 exacerbates the public panic [2], [3]. Vaccines remain the most promising approach for controlling COVID-19 pandemic and reestablishing pre-pandemic routines.

Emerging COVID-19 vaccines protects from symptomatic SARS-CoV-2 infection. Neurologic complications of COVID-19 vaccines have been reported, including strokes, cranial neuropathies, peripheral neuropathies, acute disseminated encephalomyelitis, transverse myelitis, and acute idiopathic demyelinating polyneuropathy [4], [5], [6], [7], [8], [9], [10], [11], [12]. There are substantial concerns regarding the potential risks after vaccination in those with preexisting neurologic disorders. Epilepsy is one of the most common neurological disorders, affecting more than 70 million people worldwide [13]. A previous study suggested that patients with epilepsy were at a higher risk of experiencing unfavorable COVID-19 outcomes [14]. Taken the widespread of the COVID-19 pandemic, it is urgent to know the benefits and risks of vaccination for patients with epilepsy. To our knowledge, evidences of the COVID-19 vaccination coverage, willingness, and safety profiles in patients with epilepsy were limited. In this systematic review and meta-analysis, we aimed to summarize the currently available evidences regarding the COVID-19 vaccination coverage, willingness or hesitancy in patients with epilepsy. Moreover, we systematically reviewed the safety and tolerability of COVID-19 vaccines among patients with epilepsy.[…]

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[ARTICLE] Observational retrospective analysis of vaccination against SARS-CoV-2 and seizures: VACCI-COVID registry – Full Text

Highlights

• Seizure frequency increased after vaccination in 6.2% of people with epilepsy.

• Having monthly seizures (1-3/month) was the only associated risk factor.

• 1% of epileptic patients reported new and more severe seizure types after vaccination.

• 15 patients debuted with seizures within the first month after COVID-19 vaccination.

• SARS-CoV-2 vaccines have little impact on generation or decompensation of seizures.

Abstract

Background

We aimed to assess the risk of developing new-onset seizures or seizure decompensations in people with epilepsy (PWE) associated with SARS-CoV-2 vaccines.

Methods

A retrospective observational study in a tertiary hospital was conducted. Clinical records of all patients attended because of seizures or epilepsy at outpatient clinics, emergency department, or admitted to our hospital from January to December 2021 were reviewed, including patients older than 16 years who received some dose of COVID-19 vaccines.

Results

A total of 418 vaccinated PWE were analyzed: 6.2% presented an increase in seizure frequency and 1% reported different seizure types during the next month after vaccination. However, 61.5% had another possible cause for this decompensation. Having monthly seizures (1-3/month) was the only associated risk factor (OR 4.9, p<0.001) while being seizure-free >1 year had a protective role (OR 0.36, p=0.019). Patients with epileptic encephalopathies or a history of COVID-19 infection were not at increased risk of seizure decompensation. Besides this, 15 patients presented new-onset seizures within the first month post-vaccination, mean time from vaccination 15±8 days, 67% after the second dose. Again, 53.3% had another possible trigger for seizures. Eight debuted with status epilepticus or cluster of seizures.

Conclusions

A small proportion of PWE (6.2%) had an increase in seizure frequency after COVID-19 vaccination and 15 patients had new-onset seizures during the first month after vaccination, though another reason for seizure exacerbation was identified in 61.5% and 53.3% respectively. SARS-CoV-2 vaccines appear to have little impact on the generation or decompensation of seizures.

1. Introduction

The coronavirus disease 2019 (COVID-19) pandemic has caused a global sociosanitary crisis, leading to a radical change in our way of life. The recently developed vaccines against the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have made a decisive contribution, changing the course of the pandemic. The regulatory agencies conferred a temporary emergency use authorization in December 2020 to the first COVID-19 vaccines, rising the biggest vaccination campaign ever [1]. In Spain, the vaccination against SARS-CoV-2 started on December 27, 2020, being one of the countries with the highest percentage of vaccinated population in the world [2]. Like all other medications, vaccines have been associated with neurological adverse events, such as acute symptomatic seizures and status epilepticus [3]. Indeed, vaccine inoculation constitutes the second most frequent cause of seizures in children [4]. However, post-vaccination seizures or status also depend on other factors, such as having a genetic epileptic syndrome, age at vaccination, having a confirmed coinfection, or the type of vaccine [3], [5].

Several observational studies have reported that during the COVID-19 pandemic, people with epilepsy (PWE) worsened their seizure control [6], [7], [8], [9], [10], [11]. However, in most cases, this decompensation occurred because of circumstances derived from the pandemic and not due to COVID-19 infection [12]. Although previous studies have associated COVID-19 with different types of neurological involvement [13], acute symptomatic seizures resulting from COVID-19 are uncommon [9], [14], [15], [16]. Despite this, vaccination against SARS-CoV-2 may associate a relevant risk of acute symptomatic seizures or an increase in seizure frequency in PWE. So far, a few studies evaluating the adverse effects of the SARS-CoV-2 vaccines in PWE have approached this last question [17], [18], [19], [20], outlining that worsening of seizure control was infrequent. However, several biases cast doubts on these reports, and further studies to corroborate the results seem necessary [21]. Otherwise, the risk of developing a first seizure or status epilepticus associated with these vaccines remains unknown.

This study aims to assess the risk of developing new-onset seizures, as well as the risk of seizure control worsening in PWE associated with SARS-CoV-2 vaccines. We reviewed all patients who were attended at our hospital because of seizures or epilepsy during 2021, looking for those patients with new-onset seizures temporally related to COVID-19 vaccination, and those PWE who presented an increase in seizure frequency temporally related to these vaccines.[…]

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Figure 1. Flow chart of patient selection. Classification of patients according to inclusion/exclusion criteria

[Abstract] Breakthrough Seizures after COVID-19 Vaccines in Patients with Glioma (P4-9.005)

Abstract

Objective: Identify patients who had breakthrough seizures following COVID-19 vaccine administration.

Background: Neurologic complications occur following vaccinations. The coronavirus (COVID-19) vaccines are also associated with neurological side effects. For example, 100 cases of Guillian Barre Syndrome were reported following 12.5 million doses of the Johnson & Johnson vaccine. Five case reports of thrombosis and thrombocytopenia, with corresponding cerebral venous sinus thrombosis (CVST) were reported with the Johnson & Johnson vaccine. Lastly, a recent study noted that out of 54 patients with epilepsy, one patient had increased seizure frequency following vaccination and another patient had a new seizure semiology. The impact of the COVID-19 vaccines on primary brain tumor patients is unknown.

Design/Methods: We analyzed the 866 patients at the Alvord Brain Tumor Center from January 2021 to April 2021. We describe here 15 patients with primary brain tumors who experienced breakthrough seizures within a week of receiving the first or second dose of the Moderna or Pfizer vaccines.

Results: Sixty percent of patients had glioblastoma, the median age of 60 years, with males and females relatively equally affected (47% vs. 53%). Approximately 70% were not on active treatment at the time of seizure breakthrough. The last episode of seizure was at least six months prior to the seizure breakthrough in 33% of patients. Seizures occurred a median of one day after the most recent vaccine. Seizure breakthrough reports were similar between first and second vaccine doses (47% vs. 53%). In two patients, seizure following their COVID-19 vaccine was the first manifestation of their primary brain tumor.

Conclusions: COVID-19 vaccines may lower seizure threshold by systemic inflammation or sleep disruption. Given the likely increased risks of COVID-19 infection among patients with brain tumors, vaccination is still recommended. Patient counseling on sleep hygiene, fever, and strict adherence to seizure medication is crucial to mitigate the risk of seizure post-vaccination.

Disclosure: Dr. Shah has nothing to disclose. Ms. Figuracion has nothing to disclose. Mrs. Schteiden has nothing to disclose. Dr. Graber has received personal compensation in the range of $500-$4,999 for serving as a Consultant for American Society of Neuroimaging and Journal of Neuroimaging published by Wiley. Dr. Graber has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Veevo Biomedicines, Inc. Dr. Graber has a non-compensated relationship as a Editorial Board member with Neuro-Oncology: Practice, published by Oxford that is relevant to AAN interests or activities. Dr. Graber has a non-compensated relationship as a Editorial Board Member with Journal of Pain and Symptom Management that is relevant to AAN interests or activities. Dr. Graber has a non-compensated relationship as a Board of Directors with American Society of Neuroimaging that is relevant to AAN interests or activities. Dr. Graber has a non-compensated relationship as a Certification Exam Committee Member with United Council of Neurogical Subspecialties that is relevant to AAN interests or activities. Dr. Graber has a non-compensated relationship as a Question of the Day ‘app’ committee with American Academy of Neurology that is relevant to AAN interests or activities.

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[ARTICLE] Impact of COVID-19 vaccine on epilepsy in adult subjects: an Italian multicentric experience – Full Text

Abstract

Objectives

To investigate the safety and tolerability of COVID-19 vaccines in people with epilepsy (PwE).

Methods

In this multicentric observational cohort study, we recruited adult patients (age > 18 years old) with epilepsy who attended the Outpatient Epilepsy Clinic from 1st July to 30th October 2021. We administered to the patients a structured questionnaire and interview on demographic and epilepsy characteristics, current treatment, previous SARS-CoV-2 infection, vaccine characteristics, post-vaccine seizure relapse, other side effect, variation of sleep habits, caffeine, or alcohol intake. Seizure frequency worsening was defined as a ratio between mean monthly frequency post-vaccination and mean monthly frequency pre-vaccination superior to 1. Patients were categorized in two groups: patients with seizure frequency worsening (WORSE) and patients with seizure stability (STABLE).

Results

A total of 358 people participated with a mean age of 47.46 ± 19.04. Focal seizure (79.1%), generalized epilepsy (20.4%), and unknown types of epilepsy (0.5%) were detected among participants. In total, 31 (8.7%) people expressed that they were not willing to receive a COVID-19 vaccine; 302 patients (92.35%) did not experience an increase in the seizure frequency (STABLE-group) whereas 25 patients (7.65%) had a seizure worsening (WORSE-group). Post-vaccine seizures occurred mainly in the 7 days following the administration of the vaccine. Patients in the WORSE-group were treated with a mean higher number of anti-seizure medication (ASMs) (p = 0.003) and had a higher pre-vaccine seizure frequency (p = 0.009) compared with patients in the STABLE-group. Drug-resistant epilepsy was also associated with seizure worsening (p = 0.01). One-year pre-vaccination seizure frequency pattern demonstrated that patients in the WORSE-group had a higher frequency pattern (p < 0.001). Multivariate analysis of the vaccinated group showed that only the seizure frequency pattern (confidence interval [CI] = 1.257–2.028; p < 0.001) was significantly associated with seizure worsening.

Conclusion

In our cohort of vaccinated PwE, only a little percentage had a transient short-term increase of seizure frequency. The present study demonstrates that COVID-19 vaccines have a good safety and tolerability profile in the short term in PwE.

Introduction

Coronavirus disease 2019 (COVID-19), caused by acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has become a global pandemic [1]. Several vaccines for COVID-19 are now available and represent the most effective intervention to radically reduce the incidence of severe disease and death caused by SARS-CoV-2 infection. To date, 194 vaccines against COVID-19 are in preclinical evaluation and 132 vaccines are in clinical development, while 12 vaccines were approved by regulatory authorities [2]. During the study time, Pfizer/BNT162b2, Moderna Vaccine/mRNA1273, AstraZeneca/AZD122/ChAdOx1 n-CoV-19, and the Janssen vaccines/Ad26 were approved in Italy [2].

Up to now, the approved COVID-19 vaccines have demonstrated in clinical trials to be effective and safe [3,4,5].

According to literature, vaccines have been sporadically associated with neurologic complications including the occurrence of afebrile and febrile seizures, in particular in pediatric population [6, 7]. Seizure-relapse risk can be higher in patients with post-vaccination fever, a known factor which can lead to temporarily lower seizure threshold [8]. The importance of an effective vaccination campaign in people with epilepsy (PwE) lies behind the higher mortality and morbidity risk which these patients may have [9]. This issue is particularly relevant in the context of SARS-CoV-2 infection and COVID-19 where it has been shown that people with active epilepsy present a higher COVID-19 cumulative incidence and higher risk of mortality compared to general population [9].

Based on clinical trials, the International League Against Epilepsy (ILAE) recommended that PwE should receive COVID-19 vaccine (https://www.ilae.org/patient-care/covid-19-and-epilepsy/covid-19-vaccines-and-people-with-epilepsy). Moreover, PwE, as a vulnerable category, were listed as a priority group in Italy as other European countries during COVID-19 vaccination campaign (https://www.salute.gov.it).

However, real-world studies on PwE and safety profile of COVID-19 vaccination are underrepresented in the current literature.

This study aims to examine the safety and tolerability of vaccinations against COVID-19 in PwE and their correlation with epilepsy features.[…]

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