COVID-19 Case Report form Thank you for reporting a case of interest. Please note that the detailed information recorded here will not be shared. We will provide summary information of interest in due course. Please complete as much information as you are able. If you agree we may come back to you for further information. Question Title * 1. Submitter contact information (this information is strictly confidential -- the League will only contact you if you give permission) Email Address Case detail Question Title * 2. Reason for report (select all that apply) New onset seizures Exacerbation of seizures (as judged by clinician) Severe COVID19 disease in epilepsy syndrome Drug interaction -- Antiepileptic drugs and COVID-19 treatment Encephalitis Encephalopathy Status epilepticus Stroke New neurological finding: hyposmia/anosmia, headaches, lethargy/sedation, weakness, other (please specify) Question Title * 3. Age 0-23 m 2-9 years 10-19 years 20-29 years 30-39 years 40-49 years 50-59 years 60-69 years 70-79 years 80-89 years 90 years and older Question Title * 4. Sex Male Female Other Question Title * 5. Pre-existent diagnosis of epilepsy Yes No Question Title * 6. Epilepsy diagnosis Genetic Metabolic Structural Infectious Immune Unknown Question Title * 7. Pre-existent diagnosis of neurological disease Yes No Question Title * 8. Diagnosis Question Title * 9. COVID-19 status: Select one Positive Presumed Question Title * 10. COVID-19 disease status: Check all that apply Ventilatory dependent Respiratory support: BIPAP/CPAP Respiratory support: HFNC Respiratory support: NRB Respiratory support: NC Respiratory support: ECMO Vasopressor support Renal dysfunction Liver dysfunction Encephalopathy Seizures Question Title * 11. COVID-19 severity Mild disease (Not requiring hospitalization -- OR -- Hospitalized patient with (SPO2 > 93%), and NO radiographic evidence of pneumonia) Moderate disease (Hospitalized patients with hypoxia (SPO2 < 94 %) OR Radiographic evidence of pneumonia) Severe disease with respiratory failure but no other end organ damage(Patient requiring high flow, NRB, BIPAP, or mechanical ventilation AND not on pressors, CrCl > 30 ml/min, ALT < 5x upper limit of normal) Severe disease with respiratory failure and other end organ damage Evidence of systemic inflammation (cytokine release syndrome)(Worsening of respiratory function with evidence of systemic inflammation including elevations of IL-6, fibrinogen, d-dimer, CRP) Question Title * 12. Treatment - Please list Antiepileptic drugs Other for COVID-19 Question Title * 13. Investigation Abnormal Normal N/A MRI MRI Abnormal MRI Normal MRI N/A CSF CSF Abnormal CSF Normal CSF N/A EEG EEG Abnormal EEG Normal EEG N/A Inflammatory markers Inflammatory markers Abnormal Inflammatory markers Normal Inflammatory markers N/A D-dimers D-dimers Abnormal D-dimers Normal D-dimers N/A For each selection above, please add further information if available Question Title * 14. Outcome from COVID-19 at discharge Yes No Recovery no sequelae Recovery no sequelae Yes Recovery no sequelae No Recovery, neurological sequelae Recovery, neurological sequelae Yes Recovery, neurological sequelae No If pre-existent epilepsy, back to baseline If pre-existent epilepsy, back to baseline Yes If pre-existent epilepsy, back to baseline No Death Death Yes Death No Question Title * 15. Would you be willing to be contacted for further information for research purposes? Yes No Done
