Faculty Bibliography

OBJECTIVE:To report outcomes on patients with multiple sclerosis (MS) and related disorders with coronavirus disease 2019 (COVID-19) illness. METHODS:From March 16 to April 30, 2020, patients with MS or related disorders at NYU Langone MS Comprehensive Care Center were identified with laboratory-confirmed or suspected COVID-19. The diagnosis was established using a standardized questionnaire or by review of in-patient hospital records. RESULTS:We identified 76 patients (55 with relapsing MS, of which 9 had pediatric onset; 17 with progressive MS; and 4 with related disorders). Thirty-seven underwent PCR testing and were confirmed positive. Of the entire group, 64 (84%) patients were on disease-modifying therapy (DMT) including anti-CD20 therapies (n = 34, 44.7%) and sphingosine-1-phosphate receptor modulators (n = 10, 13.5%). The most common COVID-19 symptoms were fever and cough, but 21.1% of patients had neurologic symptom recrudescence preceding or coinciding with the infection. A total of 18 (23.7%) were hospitalized; 8 (10.5%) had COVID-19 critical illness or related death. Features more common among those hospitalized or with critical illness or death were older age, presence of comorbidities, progressive disease, and a nonambulatory status. No DMT class was associated with an increased risk of hospitalization or fatal outcome. CONCLUSIONS:Most patients with MS with COVID-19 do not require hospitalization despite being on DMTs. Factors associated with critical illness were similar to the general at-risk patient population. DMT use did not emerge as a predictor of poor COVID-19 outcome in this preliminary sample.

The occurrence of high-risk cardiac arrhythmias during electrographic seizures has been proposed as a possible cause for sudden unexpected death in patients with epilepsy. Several anecdotal case reports have documented various cardiac irregularities during seizures. We reviewed simultaneous 24-hour electroencephalographic - electrocardiographic studies obtained by ambulatory cassette electroencephalography in 45 patients who experienced 106 electrographic seizures. An increase in heart rate was seen in 96% of seizures, while in four seizures, the rate was unchanged. Heart rate increase measured from 1 minute preictally to intraictal peak ranged from 0% to 160% (mean, 60%). The onset of tachycardia was usually within several seconds (before or after) of the seizure onset, and often persisted for several minutes after termination of the discharge. No difference was found in patients with lateralized vs generalized seizures. Neither ventricular ectopia, conduction defects, or bradycardia were observed during the ictal episodes. We conclude that ictal tachycardia is the rule during electrographic seizures, and that high-risk cardiac arrhythmias are uncommon.

In a retrospective study involving several medical centers we identified 52 patients under age 5 years who met the adult clinical criteria for brain death and had at least one EEG with electrocerebral silence. Of the 52 patients, 31 died spontaneously and 21 were disconnected from the respirator. Repeat EEGs were obtained in 28 patients, and in all electrocerebral silence persisted. The study suggests that clinical criteria similar to those used for adults in the determination of brain death can also be applied to children above age 3 months and that a single EEG with electrocerebral silence is sufficient to confirm brain death in this age group.

Some investigators believe that patients with epilepsy are at increased risk of sudden death, perhaps because of cardiac arrhythmias. We studied 338 patients with epilepsy referred for simultaneous ambulatory EEG/ECG monitoring. High-risk cardiac arrhythmias were detected in 18 (5.3%) patients while low-risk arrhythmias or negative studies were found in the others. Fifty-six electrographic seizures were seen in 17 patients, but no associated ventricular arrhythmias or conduction defects were identified. We conclude that the incidence of serious cardiac arrhythmias predisposing to sudden death is not increased in patients with epilepsy.