Albumino-cytological dissociation in CSF may help diagnose GBS [58]

Albumino-cytological dissociation in CSF may help diagnose GBS [58]. patients. acute disseminated meningoencephalitis, critical illness myopathy, critical illness neuropathy, coronavirus disease 2019, cerebral venous sinus thrombosis, GuillainCBarre syndrome, Middle East respiratory syndrome coronavirus, MillerCFisher syndrome, multiple sclerosis, N-methyl-D-aspartate, posterior reversible encephalopathy syndrome, severe acute respiratory syndrome coronavirus Dizziness Dizziness is a non-specific symptom encountered in several IL1B neurological and non-neurological disorders [5]. It is the most common neurological feature described in COVID-19, involving up to 17% cases, especially those in ICU due to severe illness [11, 24]. Headache Although most series describe headache in 6C13% of COVID-19 cases [1, 10, 11, 51, 61], it was reported in 82% cases in a French study [62]. Its pathophysiology and character may differ according to phase of COVID-19 illness. While acute headache related to flu-like illness, migraine, and tension-type headache predominate in initial days of illness, headache resulting from hypoxia and systemic inflammation due to cytokine storm may occur later in the course [61]. Headache may also be a sentinel sign in COVID-19-related meningitis and venous sinus thrombosis [24]. A recent cross-sectional study of 130 hospitalized COVID-19 patients revealed that headache was bilateral, of severe intensity with frontal predominance and oppressive quality among three-fourth patients. In 62% patients, headache occurred within 24 h of illness. Nearly all (94%) cases fulfilled ICHD-3 criteria for headache attributed to systemic viral infection. While migrainous phenotype was reported in one-fourth cases, nearly half the cases had tension-type headache [63]. Interestingly, presence of headache in patients with COVID-19 pneumonia has been associated with a shorter course of non-neurological systemic illness, but disabling headache often persisted [64]. Altered mentation Impairment in the level NVP-BGJ398 phosphate or content of consciousness may involve up to 9% of hospitalized COVID-19 patients, especially severe cases [11, 21]. Agitation and confusion affect more than two-third cases admitted in ICU and nearly one-third patients can manifest executive dysfunction after discharge [53]. MRI brain in 13 cases with undiagnosed encephalopathy revealed leptomeningeal enhancement in eight (62%), ischemic stroke in three (23%) cases, while bilateral fronto-temporal hypoperfusion in eleven (84%) cases [53]. Various factors contributing to altered mentation in COVID-19 include toxic-metabolic encephalopathy resulting from cytokine storm with systemic hyperinflammation, cerebrovascular events, seizures, para- or postinfectious immune-mediated CNS syndromes and a possible CNS infection by SARS-CoV-2 [11]. In addition, new-onset immune-mediated psychotic symptoms have also been described in COVID-19 cases [65]. Meningitis or meningoencephalitis In 33 meningoencephalitis cases reported in association with SARS-CoV-2 infection, varied manifestations have been described including delirium/altered sensorium (71%), aphasia/dysarthria (53%), headache (34%), seizures/status epilepticus (34%), focal neurological deficits (18%), and myoclonus (9%) with a single patient having parkinsonian syndrome (3%) [18, 21, 49, 62, 66]. Three case reports described more fulminant course of COVID-19-associated encephalitis in patients of acute hemorrhagic necrotizing encephalopathy and NVP-BGJ398 phosphate rhombencephalitis [18, 20, 21]. Meningeal signs (including nuchal rigidity, Kerning, and Brudzinski signs) along with extensor plantar response were present among all. Commonly reported viral and bacterial screening was negative. While only a single case showed presence of SARS-CoV-2 in cerebrospinal fluid (CSF) [18], three cases had increased anti-S1 IgM antibodies with markedly elevated inflammatory markers in CSF [62], thereby suggesting a role of para-/postinfectious autoimmune response. All cases made good recovery with antiviral with or without immunosuppressants (high-dose methylprednisolone, intravenous immunoglobulins, plasmapheresis). Cerebrovascular events Ischemic and hemorrhagic NVP-BGJ398 phosphate arterial stroke, cortical venous sinus thrombosis (CVST), as well as intracranial vasculitis-induced microvascular occlusive disorder have been reported NVP-BGJ398 phosphate in COVID-19 cases, with ischemic stroke being most common. Of 214 COVID-19 cases in a series, six (2.8%) developed stroke including five ischemic and one hemorrhagic stroke [11]. Another series of 221 hospitalized COVID-19 cases reported 13 (5.8%) stroke cases including 11 (5%) ischemic and one (0.5%) case each of hemorrhagic stroke and CVST. Stroke commonly affects elderly patients with severe COVID-19 illness along with vascular risk factors including hypertension, diabetes, and prior stroke [11, 24]. Although ischemic stroke usually appears later in the course of COVID-19 illness with a mean duration being 12 days, early occurrence has also been reported. COVID-19-related ischemic stroke often result from large vessel occlusion and may be muti-territorial [24, 67, 68]. Several cases of COVID-19-associated CVST have been reported. They likely present in the second week of infection with no sex predilection, with headache being the most common symptom followed.