Reader Response: A Prospective Study of Neurologic Disorders in Hospitalized Patients With COVID-19 in New York City

Frontera et al.¹ should be commended on the breadth of their report on neurologic diagnoses in COVID-19. Although stroke, seizure, GBS, encephalitis, and meningitis rates are similar to our recent study,² and others,^3,4 their rates of encephalopathy were markedly lower (6.9% vs 31.8%).^1,2 This likely reflects their methodology of adjudicating diagnoses only from chart review of patients with neurologic consultation. Our study similarly included patients with confirmed SARs-CoV-2 RT PCR and ascribed diagnoses by neurologist adjudication. We recognized that delirium—an entity within the encephalopathy spectrum—is the purview of multiple specialties.⁵ As such, encephalopathy would not reliably result in neurologic consultation; we adjudicated all charts and leveraged protocolized delirium assessments. The methodology of Frontera et al. likely failed to identify many encephalopathic patients, limiting their estimation of neurologic morbidity. Nevertheless, encephalopathy remained the most frequent neurologic diagnosis. In addition, prematurely excluding headache as a “neurologic symptom” limits the scope and understanding of SARS-CoV-2 neuropathogenesis. As we determine optimal management and decipher the long-term consequences of COVID-19 and encephalopathy, study methodologies should consider that not all neurologic complications result in in-hospital neurologic consultation. Consistently, neurologic manifestations of COVID-19 are common and encephalopathy impacts morbidity. Interestingly, despite similar ventilation rates (26.3% vs 22.0%), our cohort's hospital mortality was considerably lower (8.4% vs 21.4%).^1,2 Although New York experienced a critical strain on hospital infrastructure early in the pandemic, our Chicago area hospital system never experienced the same overwhelming case surge. Taken together, Frontera et al. and our study may reflect the magnitude of public health benefit that could be realized by avoiding case volumes that overwhelm health care infrastructure. This should further emphasize the benefit of universal masking, social distancing, and building redundancy into health care infrastructure.