Neurology and COVID-19: Adapting Specialty Care During the Pandemic

Matthew Robbins, MD

This is the first of a 2-part interview. For Part 2 of this interview, click here.

As the coronavirus 2019 (COVID-19) pandemic surged across the United States and around the world, clinicians at every level were impacted and asked to take on new roles in patient care. For neurologists like Matthew Robbins, MD, and his staff, that meant exchanging some of their specialty neurology training for fast-paced critical care scenarios, adapting to what was needed at the time.

The director of the Neurology Residency Program at Weill Cornell Medicine has continued to learn more about the virus and how it impacts patients with existing neurological disorders, putting non-COVID-19-related research on the the back burner. During his plenary presentation at the American Headache Society (AHS) Virtual Annual Scientific Meeting, Robbins outlined the responsibilities and challenges of integrating telemedicine into patient care, as well as being a mentor to residents during this time of clinical upheaval.

In part 1 of this 2-part interview, Robbins sheds light on how his daily routine changed and how the neurology department changed with him. He provides insights from his observations of patients with COVID-19and the effect the virus has had on migraine.

NeurologyLive: If there was one word or phrase to describe your experience as a neurologist and headache specialist in the COVID-19 epicenter, what would it be and why?

Matthew Robbins, MD: I would say probably to be open-minded. The way this has impacted both our patients and the way we care for them has been extraordinary and unpredictable. In the beginning, the focus was on the most severely impacted and sickest patients with respiratory illnesses by our hospital systems in critical care. In addition to those, there was this massive undercurrent of patients with chronic neurologic disorders that might be impacted directly by COVID-19 but also the way we care for them as well. Due to the lack of in-person visits, immediate adoption of telemedicine and teaching the next generation of neurologists how to care for patients with COVID-19 has been impacted as well.

How has the neurology department adapted throughout the COVID-19 pandemic?

Any real academic department has 3 legs. There’s clinical care, teaching, and research. Clinical care became the focus obviously. Our department, much like many others, was faced with having to contribute to a hospital system, with a humongous influx of critically ill patients with COVID-19. In the inpatient setting, many of our trainees, nurses, advanced practice providers, and faculty had to become COVID-19 doctors, not just neurologists. They had to embrace the overlying threat of being just a doctor. The place that we saw directly impact the most was our neurological ICU [intensive care unit], which basically became a COVID-19 ICU. The rapid transformation included lots of terrific educational initiatives to bring our department up to speed on how to take care of these patients, and not just the neurological aspects.

The counter to that is on the outpatient medicine side; how do we take care of our neurologic patients whose medical illnesses are not going away and may be impacted by COVID-19 and headache, whom which we saw a lot of? We had to rapidly adapt to telemedicine and try to use our judgment on who should be seen in person versus who can be seen over tele-video visits. On the education side, like all others, we had to become Zoom-savvy, and thankfully, our department prioritized keeping an educational cornerstone such as morning report, which was a daily occurrence. In fact, we did it for 40 consecutive days, including weekends. It became the meeting place for our department every single day, which included our operational updates from myself and other department leaders and could be discussed. We would also discuss the COVID-19 neurology and non-COVID-19 neurology to maintain an educational presence for our trainees and others. For research, a lot of the clinical bench research associated with our department had to go on pause, with our clinical research efforts turning towards COVID-19. We documented a lot of interesting findings and observations, but it was hard to know if they were necessarily valid in real time because of the lack of comparative data to other illnesses.

What were some of the headache presentations observed related to COVID-19? Did you observe any associations with any other neurovascular complications?

The way we can organize headache in COVID-19 features is just how we divide headache disorders in general. Primary headaches are genetically driven headache disorders with environmental influences, and then secondary headaches or symptomatic headaches are from other causes. We’ve seen a number of secondary headache disorders with COVID-19 at our institution. This includes various types of cerebrovascular disease, including cerebral venous thrombosis, cervical artery dissection, and posterior reversible encephalopathy syndrome. Much of this could be related to the ability of COVID-19 to induce thrombosis. Our stroke group at Cornell have a large research study looking comparatively at COVID-19 versus influenza-a and showing a 7-fold rate of ischemic stroke in such patients. We expect to see more thrombotic complications that can feature headache with COVID-19. The counter is that the primary headache disorders, which could include COVID-19 as a viral illness inciting a condition like migraine, could get worse over time. Many patients with COVID-19 who have migraine seem to have an intractable type of migraine attack in the midst of having COVID-19 infection in the earlier stages, which could be perhaps related to the viral illness or related to the inflammatory response from a cytokine storm that comes thereafter in the later stages. Another headache condition that we expect to see is this new daily persistent headache, where a viral illness incites a daily headache from onset that develops some inflammatory consequence that could have a migraine phenotype or chronic migraine phenotype. The virus may have long cleared but the headache may remain, which has been seen in many other viral illnesses before.

Transcript edited for clarity.

REFERENCE

Robbins M. COVID-19 and headache: New York experience. Presented at: 2020 American Headache Society Annual Scientific Meeting. June 13, 2020.