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How Neurologists Answer Patients' Questions About COVID-19

Article In Brief

Neurologists answer common patient questions about COVID-19 as they pertain to Parkinson's disease, multiple sclerosis, stroke, epilepsy, and migraine.

As the coronavirus pandemic swept through the country, people with neurologic conditions turned to their neurologists to ask how their disorders would be impacted by COVID-19. Neurology Today asked neurologists with expertise in Parkinson's disease (PD), multiple sclerosis (MS), stroke, epilepsy and migraine to share the most frequent questions they are hearing, how they are responding, and the rationale for their answers.

PARKINSON'S DISEASE

LISA M. SHULMAN, MD, FAAN,

the Eugenia Brin professor in Parkinson's disease and movement disorders at the University of Maryland School of Medicine

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LISA M. SHULMAN, MD, FAAN

How does the COVID-19 pandemic affect my Parkinson's disease?

PD isn't likely to pose a special risk for infection with the coronavirus and there should be little confusion between PD symptoms (slowness, tremor) and COVID-19 symptoms (fever, cough, or shortness of breath). Nonetheless, many people with PD are more vulnerable to infection due to age and general frailty, and if COVID-19 infection occurs, PD symptoms are likely to worsen, as with any infection.

Wearing masks, sheltering in, and social distancing can affect people with PD, in particular. Masks pose problems for people with impaired speech who may speak at a lower volume or slur their words or have a problem with drooling. Personal protective equipment, including masks and gloves, may exacerbate problems with dexterity, gait, and balance by interfering with vision or managing assistive devices. Physical, cognitive, and social activity are vital components to delay PD-related disability, and they have all become more difficult as the pandemic fosters stress and isolation. Even the basic routines of health care—visiting the neurologist, continuing physical therapy and refilling prescriptions are difficult. Responding to these obstacles demands creativity, proactive behavior and learning from one another.

Stress and social isolation with limited opportunities for physical, cognitive and social activity pose a special threat for people with PD. The uncertainty about when “normalcy” will return underscores the need to establish new guidelines for our patients, so they remain active, reduce stress and delay disability.

MULTIPLE SCLEROSIS

AARON E. MILLER, MD, FAAN,

medical director of the Corinne Goldsmith Dickinson Center for Multiple Sclerosis and vice-chair of education in the department of neurology at the Icahn School of Medicine at Mount Sinai

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AARON E. MILLER, MD, FAAN

Will my MS or disease-modifying therapy (DMT) increase my risk of getting infected?

We have no reason to believe that MS, in and of itself, creates greater risk for being infected or the likelihood of more severe consequences of the illness. The answers to questions about DMTs are more complicated. I always preface those concerns by acknowledging that we have virtually no firm data upon which to draw conclusions. Some organizations and individual authors have released recommendations for care, which sometimes differ, usually in minor ways, from one another. Virtually all emphasize that, generally speaking, patients should continue on their DMT because of concern that their MS can reactivate if they stop; however, individual situations must always be considered.

The older injectable therapies, interferons and glatiramer acetate, are likely to be extremely safe. Natalizumab is also generally felt to convey little additional risk, although some concern has been raised because COVID-19 does seem to have the capacity for neurotropism. Among the oral agents, teriflunomide (Aubagio) and dimethyl fumarate (Tecfidera), or the newer diroximel fumarate, (Vumerity) are regarded to have relatively low, if any, increased risk. (An exception might be the situation where dimethyl fumarate is associated with a very low lymphocyte count.) Fingolimod (Gilenya) and the more recently approved Siponimod (Mayzent), both sphingosine-1 receptor modulators, are considered to have higher (intermediate) risk. Cell-depleting therapies are regarded as potentially conveying higher risk. The B-cell depleting agents, ocrelizumab (Ocrevus) and the non-FDA approved agent, rituximab (Truxima), are considered to be less problematic than alemtuzumab (Lemtrada) and cladribine (Mavenclad), both of which affect broader lymphocytic populations.

Finally, choices about medications and strategies about the timing of infusions should reflect the COVID-19 situation in the particular community. In some cases, consideration should be given to delaying infusions in select patients in order to avoid travel and increased person-to-person contact during the period of greatest exposure risk.

STROKE

RALPH L. SACCO MD, MS, FAHA, FAAN,

professor and Olemberg chair of neurology, Miller School of Medicine, University of Miami

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RALPH L. SACCO MD, MS, FAHA, FAAN

I am older and have hypertension and diabetes, what should I do if I think I may be having a stroke but want to avoid the hospital?

Stroke is a medical emergency and urgent treatment is necessary to reduce morbidity and improve functional outcomes. Our stroke teams are operating 24/7 and we are maintaining our commitment to high-quality evidence-based stroke care. Stroke care can be accomplished safely even in a COVID-19 pandemic with the proper protocols and precautions to maintain the safety of our patients and staff. For example, our hospital separates patients with COVID-19 from other patients who have suspected strokes and need medical care. All patients are screened through survey questions and any suspected COVID-19 patients are tested and triaged to places where they can be separated and treated appropriately. At Jackson Memorial Hospital, we started testing suspected large vessel occlusion with rapid polymerase chain reaction (rRT-PCR) tests to allow for appropriate placement and health care protection.

At the University of Miami UHealth Tower, we are testing all patients in the emergency department. Our stroke team is fully active and working to respond rapidly to all cases with suspected stroke that are brought into the hospital by Emergency Medical Services. We have instituted virtual telemedicine systems in our emergency department and brain imaging suite so we can rapidly examine, diagnose, and treat stroke patients. Our staff have the proper personal protective equipment to properly care for possible COVID-19 patients with stroke. We have special protocols for intravenous rtPA and mechanical thrombectomy that have been adopted based on guidelines by the American Stroke Association and other professional organizations such as the Society of NeuroInterventional Surgery to maintain safety of our patients and health care providers.

We need to make sure that the public is aware that we are here to urgently treat them if they think they are having a stroke and not to delay calling 911.

EPILEPSY

JOSEPH I. SIRVEN, MD, FAAN,

professor of neurology, Mayo Clinic Alix School of Medicine, Jacksonville, FL

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JOSEPH I. SIRVEN, MD, FAAN

GREGORY D. CASCINO, MD, FAAN,

Whitney Macmillan, Jr. professor of neuroscience, Mayo Clinic Alix School of Medicine, Rochester, MN

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GREGORY D. CASCINO, MD, FAAN

I have seizures. Does that mean I am more susceptible to COVID-19? Will I have more seizures if I get infected and should I go to the emergency room if I have a seizure?

Having a history of seizures or epilepsy does not make patients more likely or susceptible to becoming infected with the novel coronavirus (SARS-CoV-2) that causes COVID-19. Epilepsy is not considered a “high-risk” co-morbid condition for individuals who develop COVID-19. Age, i.e., being 65 years old and older, and such comorbid conditions as diabetes mellitus, obesity, smoking dependency, and lung or heart disease are of greater concern.

COVID-19 is usually associated with a fever, however, which may be an important precipitating factor of seizure activity in patients with certain epileptic syndromes, such as generalized epilepsy with febrile seizures plus (GEFS+), and other seizure-types.

In addition, the round-the-clock media coverage of the pandemic, increasing financial concerns, and “stay-in-place” orders may increase stress, which potentially may increase seizure tendency. Sleep deprivation and disruption of normal activity in some people with epilepsy may also be proconvulsant and increase seizure frequency. Importantly, exacerbated mood disorders with anxiety and depression may affect seizure control in some patients.

We advise patients to try to minimize contact with their health care provider's offices, hospitals and emergency rooms during this pandemic. We suggest that to talk to their neurologist or primary care provider about how to deal with seizures if they occur and have a rescue plan in place. It's important to discuss answers to these and other questions: When to call your doctor or 911? Should I have rescue medications available such as a benzodiazepine drug? Also, we advise patients to ensure they have enough antiseizure medications at home in case a trip to the pharmacy becomes impossible because of self-isolation or quarantine.

MIGRAINE

LAWRENCE C. NEWMAN, MD,

professor, department of neurology at NYU Grossman School of Medicine and director of the headache division at NYU Langone

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LAWRENCE C. NEWMAN, MD

I am having more frequent headaches, do I have COVID-19?

Patients who are COVID-19 positive note that their headaches have changed in some way: they are more severe, not responsive to usual acute medications, or totally different. Many have features of an infectious headache with fever. Many of my healthy patients with pre-existing migraine have noted that their headaches have increased in frequency. They often attribute this to several factors that have to do with changes in their routines. They are feeling stressed from being out of work, trying to help children with schooling; eating poorly, unable to get to the gym, and feeling anxious about the effects of COVID-19 on their lives and health.

I have also seen several patients who report new onset of stabbing headaches and have classic COVID-19 symptoms but test negative or are pre-symptomatic and come down with COVID-19 symptoms after several days. I think those are virus-related, but thus far, we don't have evidence that the virus enters the central nervous system. It may be that these headaches are the result of activation of the trigeminal system from fever, inflammation, hypoxia or an infectious process.