**4. Clinical features of seizures associated with COVID-19**

As mentioned above, in addition to respiratory symptoms, COVID-19 has been associated with neurologic complications, but minimal literature exists about seizures in these patients [50]. Seizures have been described as direct consequence of SARS-CoV infection in the context of encephalitis [51] or indirectly as a consequence of hypoxemia, metabolic derangement, medications, multiorganic failure, or even brain damage [52]. The evidence available points to the fact that the virus by itself does not carry an increased risk of seizure [50], and it is common to find accompanying seizure-triggering comorbidities in patients with a first seizure and COVID-19, mainly metabolic and electrolytic disturbances and ischemic stroke [27].

New-onset seizures in COVID-19 patients should be considered acute symptomatic, and long-term anti-seizure medication is usually not necessary, unless a subsequent episode occurs or a brain lesion is found to raise the risk for seizure recurrence [53].

COVID-19 may present in many different ways making early diagnosis difficult and delaying proper treatment in atypical cases [27]. Even though seizures are not a common manifestation of COVID-19, they have been described in a variety of forms, as focal motor, generalized motor, convulsive and nonconvulsive status epilepticus (CSE and NCSE, respectively) [52]. In most cases, they are not the presenting symptom and arise mostly in patients with severe disease [26].

New-onset seizures had been described as a possible early symptom of COVID-19 in patients with no preceding symptoms suggestive of that diagnosis and, in some cases, seizure is in fact the symptom that prompts presentation to the emergency room, mainly in children [27]. Fasano and colleagues [28] reported a case of first motor seizure as presenting symptom of SARS-CoV-2 infection; Kadono and coworkers [54] described a case of a patient presenting an acute symptomatic seizure with a recurrence of severe brain edema post cerebral venous thrombosis who was later found to have a COVID-19 infection.

Change in mental status has been reported in about 10% of patients with severe COVID-19, but **electroencephalogram** (EEG) has not been done as routine to investigate or exclude NCSE in patients with altered responsiveness and COVID-19 [4, 53]. Several studies report that, due to the contagious nature of the disease, COVID-19 patients had limited access to diagnostic investigations, including EEG, and this could seriously underestimate the incidence of non-motor seizures and NCSE [55].

*COVID-19 and Seizures DOI: http://dx.doi.org/10.5772/intechopen.102540*

According to semiology, CSE predominates over NCSE [56]. Nonetheless, COVID-19 patients with unexplained altered mental status should be studied for the possibility of NCSE [42]. Some authors recommend continuous EEG monitoring in patients with COVID-19 and altered mental status to rule out NCSE [8].
