Discussion
On March 11, 2020, concerned by the severity of the infection and the significant level of spread, the World Health Organization classified COVID-19 as a pandemic.1 One week later, the US CMS released guidance recommending that elective surgeries and nonessential medical procedures be postponed to preserve PPE, reduce exposure among health care workers, and allow for the redeployment of medical personnel to provide care where gaps existed.2 This guidance resulted in an unprecedented change in health care delivery for all patients. People with epilepsy have a chronic disease, often associated with other comorbidities and daily medication use, making them particularly vulnerable to changes in health care delivery induced by the pandemic. Moreover, medical practitioners suddenly found themselves confronted with finding innovative methods of delivering medical care, while worrying about their personal health. It was against this backdrop that the AES commissioned this survey of its membership. Importantly, this survey was not sent to PWE, rather it focused on AES members perspectives during the pandemic.

Seizures and COVID-19
Initially thought to be mainly a respiratory infection, it is now clear that COVID-19 is associated with neurological involvement in more than 30% of patients, with approximately 25% having symptoms indicating CNS dysfunction. Fortunately, the incidence of seizures appears to be low (0.5%).3 Although there are case reports of seizures at onset in both adults and children, new-onset seizures and status epilepticus (SE) are rarely described. In a recent multicenter, retrospective study of 304 people with no known history of epilepsy in China, neither acute symptomatic seizures nor SE was observed.4 Two people had seizure-like symptoms during hospitalization that were thought to be related to acute stress reaction and hypocalcemia. There was no evidence suggesting an additional risk of acute symptomatic seizures in people with COVID-19. About a third (30%) of respondents in the current survey reported seeing COVID-19 patients with new-onset seizures. This high rate, which is much higher than we might expect given the reported rate of new-onset seizures in the literature (0.5%), is likely reflective of the population surveyed, namely epilepsy specialists.3
A number of mechanisms of neuropathogenesis related to COVID-19 have been described, including manifestations of systemic disease including hypoxia, metabolic derangements, and multi-organ failure; direct invasion of the nervous system (meningitis/encephalitis); and a postinfection immune-mediated process.5,6 All of these may lead to seizures, but the specific contribution of each mechanism is unclear, and in some cases the cause may be multifactorial. Meningoencephalitis associated with COVID 19 with transient seizures has been described in one patient.7 The responses in the AES survey reflected similar uncertainty of possible mechanisms causing seizures.
There are very few data regarding the type of new-onset seizures seen in patients with COVID-19 in the literature. There is a single case report of focal SE as a presenting manifestation in a patient with underlying postencephalitic epilepsy.8 A small case series of 7 patients with COVID-19 presenting with seizures, of which 4 had new-onset seizures, has been reported.9 A patient with COVID-19 related meningoencephalitis was reported to have generalized seizures lasting about a minute.7 One EEG-based case series demonstrates abnormalities seen in encephalopathic patients with COVID-19, including generalized slowing, generalized epileptiform discharges and focal seizures, although many of the patients in the series had preexisting epilepsy.10 In this study, there were 2 patients with focal seizures, 1 was new onset and 1 was in a PWE. Additionally, in this study several patients had generalized periodic discharges of triphasic morphology. Other patients with COVID-19 related new onset seizures and SE have also been described.11,12
Respondents in the current survey did not notice an increase in susceptibility of PWE to COVID-19. This is supported by a consensus statement which finds no increased risk of acquiring COVID-19 in most PWE.13 Exceptions include PWE who are being treated with immunosuppressant medications or those particularly sensitive to fever. However, a recent study that reported on EEG findings in 8 patients with COVID-19 related neurologic problems found 5 (63%) had a history of epilepsy.10 These authors raised the concern that PWE may be at increased risk developing neurologic manifestations if they acquire COVID-19.

Obtaining and Delivering Epilepsy Care
Concerns were raised in this survey that PWE could not get the usual care for their medical issues during the pandemic. Many of these issues were due to new financial and logistical constraints for patients during the pandemic. No comparable data regarding these issues are currently available in the literature.
Care was also affected due to limitations imposed by hospitals, clinics, and medical practices. Institutions across the United States began to restrict or cancel admissions to epilepsy monitoring units (which are typically elective in nature). In addition, performing both inpatient and outpatient EEGs was significantly reduced due to the close contact of the EEG technologist with patients and to reduce depletion of PPE.14 Telemedicine visits were encouraged for the care of PWE during the pandemic wherever possible to reduce the risk for PWE and their family for being exposed to the infection in health care facilities.13
The effect of reduced access to in-person epilepsy care and neurodiagnostic procedures has not been clearly studied. An Italian study that surveyed people with and without epilepsy found that those with epilepsy reported a significantly increased risk of seizures and difficulties in obtaining follow-up clinic appointments.15
Shortage of ASM has not been a major concern during the current pandemic. Most respondents did not notice lack of availability of ASM, with the exception of long acting levetiracetam. However, the Food and Drug Administration has reported intermittent shortages of medications used to treat acute seizure, such as midazolam and propofol, during the pandemic.16 This is likely due to use of these medications in critically ill patients, not necessarily those with seizures. There is also little evidence of the effects of various medications used to treat COVID-19 on seizures and ASM. In response, the AES Treatments Committee has created a resource, Managing Patients with Epilepsy during COVID-19: Pharmacotherapy-related Recommendations.17 American Epilepsy Society has created a COVID-19 and Epilepsy web portal with information relating to various aspect to care delivery.18 Interestingly, despite almost all participants being impacted in some way by COVID-19, only 41% of respondents to the survey were aware of these resources, and 38% had used them. A campaign to increase awareness of this resource may help members.

Telehealth
The value of telehealth in neurology has been recognized well before the COVID-19 pandemic, with particularly successful implementation in stroke care.19,20 The feasibility of telehealth in epilepsy care, including delivery of complex care to patients with refractory epilepsy, has similarly been demonstrated, with comparable outcome and high patient satisfaction.13,21-23 The lack of commensurate reimbursement has historically been the barrier to greater adoption.24
Several early studies have examined the effect of transition to telehealth during the COVID-19 pandemic. A recent survey of child neurologists conducting telehealth encounters, in which epilepsy was somewhat overrepresented, revealed >90% satisfactory encounters despite 40% reporting technical challenges. Most (86%) reported intending to pursue telehealth in future encounters.25 An international survey of pediatric neurologists treating children with epilepsy revealed that about 25% of practitioners were seeing outpatients exclusively with telehealth and 95% were seeing at least some patients by telehealth.26 A US-based single hospital system evaluation revealed that 67% of outpatient visits were completed via telehealth, 32% with phone visits, and only 1% of visits were in-person clinic encounters.27
Similar to previous studies, the respondents in the current survey overwhelmingly found value in telehealth. Many benefits were noted, including efficiency of the clinic visits. Respondents even noted that many of the examination elements that they routinely perform, such as mental status and gait evaluations, could be done via telehealth. One shortcoming that was mentioned was the lack of diagnostic monitoring and laboratory testing. However, a recent randomized trial revealed little benefit in monitoring serum levels of modern ASMs.28
Whereas previous efforts in telehealth in epilepsy care have focused on the delivery of care to resource-limited or poorly accessible regions, the current situation has affected health care delivery across all socioeconomic spectra. Unfortunately, the most socioeconomically vulnerable patients have difficulty in getting telehealth services as well due to lack of access to technology. This is an area that should be promptly and actively addressed, particularly since the near-term outlook for the pandemic remains extremely concerning.
An important consideration about telehealth raised by respondents to the survey is continued reimbursement. While there was overwhelming recognition of the value of telehealth and many respondents saw the value in continuing it long term, they expressed concern that reimbursement models changed after the pandemic, they would be unable to continue it. Encouragingly, professional societies are collaborating in a variety of way to advocate for telehealth for PWE as well as others that greatly benefit from this method of care.29

Limitations
There are several limitations inherent in this type of study including the potential for recall, sample, and responder biases. Furthermore, the survey asks clinicians their impressions of the impact of COVID-19 on PWE in their practice, not patients themselves. In addition, the COVID-19 pandemic has been a rapidly evolving phenomenon and this survey represents a snapshot in time early in the pandemic. Responses might change if members were surveyed later in the pandemic or even postpandemic.