Global uncertainty in the diagnosis of neurological complications of SARS-CoV-2 infection by both neurologists and non-neurologists: An international inter-observer variability study

Uniform case definitions are required to ensure harmonised reporting of neurological syndromes associated with SARS-CoV-2. Moreover, it is unclear how clinicians perceive the relative importance of SARS-CoV-2 in neurological syndromes, which risks under- or over-reporting. We invited clinicians thro...

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Published in:	Journal of the neurological sciences Vol. 449; p. 120646
Main Authors:	Wood, G.K., Garcia-Azorin, D., Schiess, N., Netravathi, M., Dervaj, R., Lant, S., Özge, A., Padovani, A., Saylor, D., Schmutzhard, E., Jackson, T., Ellul, M.A., Frontera, J.A., Thakur, K.T., Stark, R.J., Winkler, A.S., Michael, B.D., Aleksic, Dejan, Rivas, Susana Arias, Banzrai, Chimeglkham, Bar, Michal, Barone, Valentina, Baykan, Betul, Beghi, Ettore, Bilic, Ivica, Biller, Jose, Canete, Maria Teresa, Chishimba, Lorraine, Cotelli, Maria Sofia, De Cauwer, Harald, Debroucker, Thomas, Devaraj, Rashmi, D'Souza, Michelle, Fonseca, Ana Catarina, Furloni, Roberto, Gajre, Sunil, Azorin, David Garcia, Gasparic, Irena, Genç, Hamit, Glavica, Marinka, Guanaes, Luiz Gustavo, Gürsoy, Gizem, Hafiz, Nauman, Helbok, Raimund, Hor, Chee Peng, Hwang, Sungeun, Jamora, Roland Dominic, Kahwagi, Jamil, Kaprelyan, Ara, Kim, Hyunji, Kim, Hyun Kyung, Koffie, Desmond, Lee, Woo-Jin, Leonardo, Zerlyn, Lim, Christian Emmanuel, Lisak, Marijana, Huzjan, Arijana Lovrencic, Koh, Rosie Sue Luan Lu, Majdak, Maja, Mataa, Mataa, Matibag, Jessica Leika, Miranda, Miguel, Modequillo, Margaret, Shoab, Abul Kalam Mohammed, Motto, Cristina, Mwendaweli, Naluca, Ihsan, Mohd Khairul Nizam Nor, Nyein, Aye Myat, O'Connell, Karen, Oh, Seong-il, Ohnmar, Ohnmar, Pajo, Azalea, Palavra, Filipe, Payne, Catherine, Pensato, Umberto, Peters, Steven, Polat, Burcu, Punter, Martin Nicholas Michael, Quiles, Liz Edenberg, Ratković, Marija, Renales, Maria Lina, Šapina, Lidija, Schmutzhard, Erich, Sharma, Anahita, Sipilä, Jussi O.T., Sokhi, Dilraj, Stagno, Mauro, Stancheva, Kristina, Stojsavljević, Marija, Subir, Ahamed, Teoh, Sing Chiek, Vallejo, Dionis, Velioglu, Sibel K., Kit, Wong Wai, Welte, Tamara, Willekens, Barbara, Yesilot, Nilufer, Zaw, Moe Moe, Zhelyazkova, Sashka, Žitnik, Eva
Format:	Journal Article
Language:	English
Published:	Netherlands Elsevier B.V 15-06-2023 Published by Elsevier B.V
Subjects:	COVID-19 COVID-19 - complications COVID-19 - diagnosis COVID-19 Testing Diagnosis Encephalitis - complications Guillain-Barre Syndrome - complications Guillain-Barre Syndrome - diagnosis Headache - diagnosis Headache - etiology Humans Inter-rater agreement Nervous System Diseases - complications Nervous System Diseases - etiology Neurology Observer Variation SARS-CoV-2 Uncertainty COVID-19 Neurology SARS-CoV-2 GBS Diagnosis CVST Inter-rater agreement WFN WHO
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Summary:	Uniform case definitions are required to ensure harmonised reporting of neurological syndromes associated with SARS-CoV-2. Moreover, it is unclear how clinicians perceive the relative importance of SARS-CoV-2 in neurological syndromes, which risks under- or over-reporting. We invited clinicians through global networks, including the World Federation of Neurology, to assess ten anonymised vignettes of SARS-CoV-2 neurological syndromes. Using standardised case definitions, clinicians assigned a diagnosis and ranked association with SARS-CoV-2. We compared diagnostic accuracy and assigned association ranks between different settings and specialties and calculated inter-rater agreement for case definitions as “poor” (κ ≤ 0.4), “moderate” or “good” (κ > 0.6). 1265 diagnoses were assigned by 146 participants from 45 countries on six continents. The highest correct proportion were cerebral venous sinus thrombosis (CVST, 95.8%), Guillain-Barré syndrome (GBS, 92.4%) and headache (91.6%) and the lowest encephalitis (72.8%), psychosis (53.8%) and encephalopathy (43.2%). Diagnostic accuracy was similar between neurologists and non-neurologists (median score 8 vs. 7/10, p = 0.1). Good inter-rater agreement was observed for five diagnoses: cranial neuropathy, headache, myelitis, CVST, and GBS and poor agreement for encephalopathy. In 13% of vignettes, clinicians incorrectly assigned lowest association ranks, regardless of setting and specialty. The case definitions can help with reporting of neurological complications of SARS-CoV-2, also in settings with few neurologists. However, encephalopathy, encephalitis, and psychosis were often misdiagnosed, and clinicians underestimated the association with SARS-CoV-2. Future work should refine the case definitions and provide training if global reporting of neurological syndromes associated with SARS-CoV-2 is to be robust. [Display omitted] •146 clinicians from 45 countries on six continents assessed ten scenarios of acute neurological complications of COVID-19.•Using case definitions, non-neurologists achieved similar diagnostic accuracy to neurologists.•Diagnostic accuracy was lowest for conditions presenting with altered mental status.•Association between SARS-CoV-2 and neurological syndromes was underestimated in over 10% of cases.•Training and further refinement of case definitions will target these challenges.
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ISSN:	0022-510X 1878-5883
DOI:	10.1016/j.jns.2023.120646