Preserving stroke care during the COVID-19 pandemic: Potential issues and solutions

COVID-19 pandemic and trends in clinical outcomes and medication use for patients with established atrial fibrillation: A nationwide analysis of claims data

Study objective

The COVID-19 pandemic disrupted multiple aspects of the health care system, including the diagnosis and control of chronic conditions. This study aimed to quantify pandemic-related changes in the rates of clinical events among patients with atrial fibrillation (AF).

Design/setting/participants

In this retrospective cohort study, we identified individuals with established AF at any time before 2019 using de-identified Optum's Clinformatics® Data Mart, and followed them from 3/18/2019 to death, or disenrollment, or the end of the study (09/30/2021).

Main outcome

Rates of clinical event, including all-cause hospitalization, ischemic stroke, and bleeding. We constructed interrupted time series to test changes in outcomes after the onset of the COVID-19 pandemic (3/11/2020, date of pandemic declaration). We then identified the first month after the start of the pandemic in which outcomes returned to pre-pandemic levels.

Results

A total of 561,758 patients, with a mean age of 77 ± 9.9 years, were included in the study. The monthly incidence rate of all-cause hospitalization decreased from 2.8 % in the period immediately before the pandemic declaration to 1.7 % in the period immediately after, with p-value for level change<0.001. The rate of new ischemic stroke diagnoses decreased from 0.28 % in the period immediately before pandemic declaration to 0.20 % in the period immediately after, and the rate of major bleeding diagnoses from 0.81 % to 0.59 %, both p-values for level change<0.01. The incidence rate of ischemic stroke and bleeding events returned to pre-pandemic levels in October and November 2020, respectively.

Conclusions

The COVID-19 pandemic was associated with a decrease in health care visits for ischemic stroke and bleeding in a nationwide cohort of patients with established AF.

COVID-19 and Surgical Practice in Slovenia: Managing the Crisis in Neurosurgery during the COVID-19 Pandemic

Worldwide, the novel coronavirus disease 2019 (COVID-19) has become a significant threat to global health. Worldwide, COVID-19 has affected the health service also in Slovenia. During this time, neurosurgery is facing difficulties in its service, both in emergency and elective surgeries. In the article, we describe the anti-COVID-19 measures taken at our neurosurgical department in a medical centre in Ljubljana, Slovenia, and analysed and compared the number of emergency and elective neurosurgical procedures during the time of the pandemic.

The early impact of COVID-19 pandemic on mobile stroke unit care delivery: A worldwide survey

OBJECTIVE

To report COVID -19 pandemic impact on mobile stroke units (MSUs) a world-wide survey of MSU programs.

METHODS

Contact information of MSU program was obtained through the Pre-hospital Stroke Treatment Organization. Anonymous electronic questionnaire was developed and sent through the email to one representative of each program on May 15, 2020.

RESULTS

Of 26 programs queried, 20 responded and completed survey based on the data or personal impression. Eighteen programs were in the regions with pandemic lockdown. Six either suspended or reduced MSU availability at some point. The reasons given for change in availability were as follows: decreased personnel availability (5 programs), risk of exposure (5 programs), and financial concerns (1 program). Staff availability was a concern among 8 programs. MSU activations were reported to be unchanged by 10 programs, but 9 programs experienced decline in activation, 1 program had more activations. Sixteen programs reported change in MSU protocol including introduction of screening questionnaire, PPE, reducing patient contact, and cleaning protocols. Nine reported that the crew was under greater stress. Only 2 respondents felt that the pandemic delayed stroke care on MSU and the remainder did not.

CONCLUSION

Overall Stroke care delivery had no major disruptions despite COVID 19 pandemic posed challenges to MSU Operations.

Impact of the COVID-19 pandemic on emergent stroke care in Beijing, China

The coronavirus disease 2019 (COVID-19) pandemic has caused an unprecedented disruption to health care systems around the globe. Stroke is still an ongoing issue during the pandemic. We investigated the impact of the COVID-19 outbreak on emergent stroke care in Beijing, China. This is a retrospective analysis of two groups of patients with acute ischaemic stroke (AIS) registered in the Beijing Emergency Care Database between January 1, 2019, and December 31, 2020. Based on a database including 77 stroke centres, the quantity and quality of emergency care for stroke were compared. Subgroup analyses based on hospitals in different areas (high-risk and low/medium-risk areas) were carried out. A total of 6440 and 8699 admissions with suspected stroke were recorded in 2020 and 2019, respectively. There were no significant differences in the mean age and sex distribution for the patients between the two observational periods. The number of AIS admissions decreased by approximately 23.9% during the COVID-19 pandemic compared to that during the prepandemic period. The proportions of intravenous thrombolysis and endovascular treatment were 76.4% and 13.1%, respectively, in 2020, which were higher than those in 2019 (71.7% and 9.3%, respectively). There was no statistically significant difference in the time from stroke onset to arrival at the hospital (97.97 ± 23.09 min vs. 99.40 ± 20.76 min, p = 0.832) between the two periods. The door-to-needle time for thrombolysis (44.92 ± 9.20 min vs. 42.37 ± 9.06 min, p < 0.001) and door-to-thrombectomy time (138.56 ± 32.45 min vs. 120.55 ± 32.68 min, p < 0.001) were increased significantly in the pandemic period compared to those in the prepandemic period, especially in hospitals in high-risk areas. The decline in the number of patients with AIS and delay in treatment started after the launch of the level-1 public health emergency response and returned to stability after the release of professional protocols and consensus statements. Disruptions to medical services during the COVID-19 pandemic have substantially impacted AIS patients, with a clear drop in admission and a decline in the quality of emergent AIS care, especially in hospitals in high-risk areas and at the time of the initial outbreak of COVID-19. Health care systems need to maintain rapid adaptation to possible outbreaks of COVID-19 or similar crises in the future.

Factors and Behaviors Related to Successful Transition of Care After Hospitalization for Ischemic Stroke

BACKGROUND

Our objective is to describe adoption of the posthospitalization behaviors associated with successful transition of care and related baseline characteristics.

METHODS

This study includes 550 participants in the Transition of Care Stroke Disparities Study, a prospective observational cohort derived from the Florida Stroke Registry. Participants had an ischemic stroke (2018-2021), discharged home or to rehabilitation, with modified Rankin Scale score=0-3 (44% women, 24% Black, 48% White, 26% Hispanic, 35% foreign-born). We collected baseline sociodemographic and clinical characteristics. A structured telephone interview at 30-day postdischarge evaluated outcomes including medication adherence, medical appointment attendance, outpatient therapy, exercise, diet modification, toxic habit cessation, and a calculated composite adequate transition of care measure. Multivariable analyses assessed the association of baseline characteristics with 30-day behaviors.

RESULTS

At 30 days, medication adherence was achieved by 89%, medical appointments by 82%, outpatient therapy by 76%, exercise by 71%, diet modification by 68%, toxic habit cessation by 35%, and adequate transition of care measure by 67%. Successful adequate transition of care participants were more likely to be used full-time (42% versus 31%, P=0.02), live with a spouse (60% versus 47%, P=0.01), feel close to ≥3 individuals (84% versus 71%, P<0.01), have history of dyslipidemia (45 versus 34%, P=0.02), have thrombectomy (15% versus 8%, P=0.02), but less likely to have a history of smoking (17% versus 32%, P<0.001), coronary artery disease (14% versus 21%, P=0.04), and heart failure (3% versus 11%, P<0.01). Multivariable logistic regression analyses revealed that multiple socio-economic factors and prestroke comorbid diseases predicted fulfillment of transition of care measures. There was no difference in outcomes during the Covid-19 pandemic (2020-2021) compared with prepandemic years (2018-2019).

CONCLUSIONS

One in 3 patients did not attain adequate 30-day transition of care behaviors. Their achievement varied substantially among different measures and was influenced by multiple socioeconomic and clinical factors. Interventions aimed at facilitating transition of care from hospital after stroke are needed.

REGISTRATION

URL: https://clinicaltrials.gov/; Unique identifier: NCT03452813.

Neural stem cell-derived exosome as a nano-sized carrier for BDNF delivery to a rat model of ischemic stroke

Our previous study demonstrated the potential therapeutic role of human neural stem cell-derived exosomes (hNSC-Exo) in ischemic stroke. Here, we loaded brain-derived neurotrophic factor (BDNF) into exosomes derived from NSCs to construct engineered exosomes (BDNF-hNSC-Exo) and compared their effects with those of hNSC-Exo on ischemic stroke both in vitro and in vivo. In a model of H₂O₂-induced oxidative stress in NSCs, BDNF-hNSC-Exo markedly enhanced cell survival. In a rat middle cerebral artery occlusion model, BDNF-hNSC-Exo not only inhibited the activation of microglia, but also promoted the differentiation of endogenous NSCs into neurons. These results suggest that BDNF can improve the function of NSC-derived exosomes in the treatment of ischemic stroke. Our research may support the clinical use of other neurotrophic factors for central nervous system diseases.

Burdens on caregivers of patients with stroke during a pandemic: relationships with support satisfaction, psychological distress, and fear of COVID-19

BACKGROUND

Caregivers have faced unprecedented circumstances throughout the COVID-19 pandemic, but previous research only minimally addresses the caregivers' burden. Therefore, this study aimed to investigate the relationship between caregiver burden, psychological stress, satisfaction with support, and fear of COVID-19 in caregivers of patients with stroke during the pandemic.

METHODS

A cross-sectional survey study with total of 171 caregivers of patients with stroke in a community hospital in Taiwan. All participants completed the Zarit Burden Interview, Depression, Anxiety, Stress Scale (DASS-21), satisfaction of support survey, and Fear of COVID-19 Scale. Pearson correlations were used to examine the bivariate correlations between study variables. Then, with the control of demographic confounders, a multiple linear regression model was applied with significant variables to construct and explain caregiver burden.

RESULTS

The proposed model significantly explained the caregiver burden of caregivers of patients with stroke. Specifically, the caregiver burden was negatively correlated with satisfaction with family support, but positively with psychological distress and the fear of COVID-19.

CONCLUSIONS

Caregivers of patients with stroke will suffer a greater burden if they have lower satisfaction with family support, experienced higher psychological distress, and perceived more fear of the COVID-19 pandemic. Health professionals must address these concerns, support caregivers, and enhance available resources.

Impact of COVID-19 on neurocritical care delivery and outcomes in patients with severe acute brain injury - Assessing the initial response in the first US epicenter

To investigate the pandemic’s impact on critically ill patients with neurological emergencies, we compared care metrics and outcomes of patients with severe acute brain injury (SABI) before and during the initial COVID-19 surge at our institution. We included adult patients with SABI during two separate three-month time periods: 'pre-COVID vs COVID'. We further stratified the COVID cohort to characterize outcomes in patients requiring COVID-19 precautions (Patient Under Investigation, ‘PUI’). The primary endpoint was in-hospital mortality; secondary endpoints included length of stay (LOS), diagnostic studies performed, time to emergent decompressive craniectomies (DCHC), ventilator management, and end-of-life care. We included 394 patients and found the overall number of admissions for SABI declined by 29 % during COVID (pre-COVID n = 231 vs COVID, n = 163). Our primary outcome of mortality and most secondary outcomes were similar between study periods. There were more frequent extubation attempts (72.1 % vs 76 %) and the mean time to extubation was shorter during COVID (55.5 h vs 38.2 h). The ICU LOS (6.10 days vs 4.69 days) and hospital LOS (15.32 days vs 11.74 days) was shorter during COVID. More PUIs died than non-PUIs (51.7 % vs 11.2 %), but when adjusted for markers of illness severity, this was not significant. We demonstrate the ability to maintain a consistent care delivery for patients with SABI during the pandemic at our institution. PUIs represent a population with higher illness severity at risk for delays in care. Multicenter, longitudinal studies are needed to explore the impact of the pandemic on patients with acute neurological emergencies.

Trends in outpatient rehabilitation use for stroke survivors

BACKGROUND

Stroke survivors with residual disabling deficits who are medically stable may be recommended for acute rehabilitation or outpatient therapy, depending partly on the severity of their deficits. Here we sought to determine if the location at which patients needing rehabilitation post-stroke has shifted from inpatient to an outpatient setting.

METHODS

For analysis, we used our Institutional Review Board-approved Get With The Guidelines®-Stroke Database to study stroke survivors discharged to receive either inpatient or outpatient rehabilitation services between 2014 and 2019. Logistic regression analysis was used to identify clinical factors associated with discharge type. Cochran-Armitage trend analysis was used to assess differences in rehabilitation services used over time.

RESULTS

A total of 3293 patients were included. Trend analysis demonstrated a significant increase over time in the proportion of patients needing rehabilitation being discharged home with rehabilitation services (P < 0.0001). In addition, older age was associated with discharge to inpatient rehabilitation (OR = 1.018, 95%CI, 1.011-1.026), as was a higher National Institutes of Health Stroke Scale score (OR = 1.149, 95%CI, 1.130-1.168).

CONCLUSIONS

We found that home discharges increased, highlighting outpatient rehabilitation as an expanding healthcare resource for reducing stroke-associated disability in adults.

Stroke Family Caregiver Life Changes From the COVID-19 Pandemic

ABSTRACT

BACKGROUND: Stroke family caregivers were already struggling with unmet needs and changes in their own lives from providing care. The COVID-19 pandemic added further stress and disruption to their lives. The purpose of this study was to describe life changes in 17 stroke family caregivers specifically resulting from the COVID-19 pandemic. METHODS: This study was conducted as a secondary data analysis from an ongoing randomized controlled clinical trial testing feasibility of the Telehealth Assessment and Skill-Building Kit (TASK III). Using a multimethod design, both quantitative and qualitative data were analyzed to determine caregiver life changes. Quantitative ratings regarding life changes were obtained using 17 items adapted specifically for COVID-19 from the Bakas Caregiving Outcomes Scale. Rigorous content analysis procedures for the qualitative data were guided by a start list of codes based on the 17 items, with additional themes possible. Representative quotes were selected based on author consensus. RESULTS: Findings revealed both negative and positive life changes from the COVID-19 pandemic. Negative life changes included such things as disrupted daily routines, limited access to healthcare providers and resources (eg, food, masks, hand sanitizers), reduced family and social contact and activities, decreased emotional well-being, and problems with performing caregiving activities for the survivor. Positive life changes were increased use of the Internet and videoconferencing, closer relationships with friends, and learning how to access needed resources in new ways. CONCLUSION: Stroke family caregivers experienced both negative and positive life changes specifically as a result of the COVID-19 pandemic. Responses further indicated that COVID-19 affected most caregivers in different ways and an individualized approach is needed in dealing with caregiver life changes.

Functional outcomes of COVID-19 patients with acute ischemic stroke: A prospective, observational, single-center study in North Jordan

We assessed whether stroke severity, functional outcome, and mortality in patients with ischemic stroke differed between patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and those without. We conducted a prospective, single-center cohort study in Irbid, North Jordan. All patients diagnosed with ischemic stroke and SARS-CoV-2 infection were consecutively recruited from October 15, 2020, to October 16, 2021. We recorded demographic data, vascular risk factors, National Institutes of Health Stroke Scale (NIHSS) score, stroke subtype according to the Trial of ORG 10172 in Acute Stroke Treatment Criteria (TOAST), treatments at admission, and laboratory variables for all patients. The primary endpoint was the functional outcome at 3 months assessed using the modified Rankin Score. Secondary outcomes involved in-hospital mortality and mortality at 3 months. We included 178 patients with a mean (standard deviation) age of 67.3 (12), and more than half of the cases were males (96/178; 53.9%). Thirty-six cases were coronavirus disease 2019 (COVID-19) related and had a mean (standard deviation) age of 70 (11.5). When compared with COVID-19-negative patients, COVID-19-positive patients were more likely to have a higher median NIHSS score at baseline (6 vs 11; P = .043), after 72 hours (6 vs 12; P = .006), and at discharge (4 vs 16; P < .001). They were also more likely to have a higher median modified Rankin Score after 3 months of follow-up (P < .001). NIHSS score at admission (odds ratio = 1.387, 95% confidence interval = 1.238-1.553]; P < .001) predicted having an unfavorable outcome after 3 months. On the other hand, having a concomitant SARS-CoV-2 infection did not significantly impact the likelihood of unfavorable outcomes (odds ratio = 1.098, 95% confidence interval = 0.270-4.473; P = .896). The finding conclude that SARS-CoV-2 infection led to an increase in both stroke severity and in-hospital mortality but had no significant impact on the likelihood of developing unfavorable outcomes.

Systematic Review of the Evidence for Stroke Family Caregiver and Dyad Interventions

Stroke family caregiver and dyad literature has expanded over the past few years. The purpose of this review was to build upon 2 prior systematic reviews to critique, analyze, and synthesize the evidence pertaining to the impact of family caregiver and dyad interventions on stroke survivor and family caregiver outcomes. CINAHL, PsychINFO, PubMed, and reference lists were searched from December 1, 2016 through March 31, 2021. Using PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses), articles were identified that tested outcomes from stroke family caregiver or dyad interventions that targeted the health or well-being of family caregivers. Data from the articles were abstracted into tables for analysis, then compared with recommendations from the 2 prior systematic reviews. A total of 18 articles met inclusion criteria (10 caregiver interventions; 8 dyad interventions) representing sample sizes ranging from 7 to 349 caregivers or dyads. Most were randomized controlled trials (n=13); 2 were cluster randomized trials; and 3 were single-group quasi-experimental designs. Of the 18 studies, 8 had <50 caregivers or dyads and 5 were small feasibility studies that reported data trends rather than testing for significance. Only 6 studies reported significant survivor outcomes. Eleven studies reported significant caregiver outcomes, the most common being burden. A number of survivor and caregiver outcomes were not significant, or only significant for certain subgroups. The limited number of studies, small sample sizes, and conflicting results, made it difficult to draw firm conclusions regarding the impact of these interventions on outcomes. Based on the available evidence from these 18 studies, recommendations from the 2 prior reviews were generally supported. Well-designed and well-powered randomized controlled clinical trials are still needed to confirm efficacy of stroke family caregiver and dyad interventions.

Lung Ultrasound Improves Outcome Prediction over Clinical Judgment in COVID-19 Patients Evaluated in the Emergency Department

In the Emergency Department (ED), the decision to hospitalize or discharge COVID-19 patients is challenging. We assessed the utility of lung ultrasound (LUS), alone or in association with a clinical rule/score. This was a multicenter observational prospective study involving six EDs (NCT046291831). From October 2020 to January 2021, COVID-19 outpatients discharged from the ED based on clinical judgment were subjected to LUS and followed-up at 30 days. The primary clinical outcome was a composite of hospitalization or death. Within 393 COVID-19 patients, 35 (8.9%) reached the primary outcome. For outcome prognostication, LUS had a C-index of 0.76 (95%CI 0.68−0.84) and showed good performance and calibration. LUS-based classification provided significant differences in Kaplan−Meier curves, with a positive LUS leading to a hazard ratio of 4.33 (95%CI 1.95−9.61) for the primary outcome. The sensitivity and specificity of LUS for primary outcome occurrence were 74.3% (95%CI 59.8−88.8) and 74% (95%CI 69.5−78.6), respectively. The integration of LUS with a clinical score further increased sensitivity. In patients with a negative LUS, the primary outcome occurred in nine (3.3%) patients (p < 0.001 vs. unselected). The efficiency for rule-out was 69.7%. In unvaccinated ED patients with COVID-19, LUS improves prognostic stratification over clinical judgment alone and may support standardized disposition decisions.

Management of neurosurgical patients during coronavirus disease 2019 pandemics: The Ljubljana, Slovenia experience

The novel coronavirus disease 2019 (COVID-19) is an emerging disease, caused by severe acute respiratory syndrome coronavirus-2. It bears unique biological characteristics, clinical symptoms and imaging manifestations, therefore presenting an important and urgent threat to global health. As a result, a new public health crisis arose, threatening the world with the spread of the 2019 novel coronavirus. Despite the maximal worldwide public health responses aimed at containing the disease and delaying its spread, many countries have been confronted with a critical care crisis, and even more, countries will almost certainly follow. In Slovenia, the COVID-19 has struck the health system immensely and among all the specialities, neurosurgery has also been experiencing difficulties in the service, not only in regular, elective surgeries but especially during emergencies. The management of these neurosurgical patients has become more difficult than ever. We describe our protocol in the management of neurosurgical patients in the University Medical Centre Ljubljana, Slovenia and how neurosurgical pathology was tackled during the pandemics.

Utilization of Telestroke Prior to and Following the COVID-19 Pandemic

For over two decades, telestroke has been utilized as a means for improving acute access to a stroke specialist when this expertise is otherwise unavailable. During this time, telestroke use has increased and improvements in care metrics have been widely reported. Several telestroke model variations are utilized; each has different workflow implications. A successful telestroke system should include adequate protocols and training, equipment, documentation system, and tracking of quality metrics. Upfront costs of needed technology and devices, credentialing hurdles, and limited reimbursement are all reported barriers to the utilization of telestroke. Emphasis on safety measures during the COVID-19 pandemic resulted in the dramatic upscaling of telehealth utilization, although overall stroke volumes declined in many areas in the early phases of the pandemic. Going forward, continued reduction in cost of required devices and broadband connections, increased use of automated and advanced analytical software, and a universal licensing and credentialing system are needed to continue the expansion of telestroke use.

Ischemic Stroke and SARS-CoV-2 Infection: The Bidirectional Pathology and Risk Morbidities

Stroke is a fatal morbidity that needs emergency medical admission and immediate medical attention. COVID-19 ischemic brain damage is closely associated with common neurological symptoms, which are extremely difficult to treat medically, and risk factors. We performed literature research about COVID-19 and ischemia in PubMed, MEDLINE, and Scopus for this current narrative review. We discovered parallel manifestations of SARS-CoV-19 infection and brain ischemia risk factors. In published papers, we discovered a similar but complex pathophysiology of SARS-CoV-2 infection and stroke pathology. A patient with other systemic co-morbidities, such as diabetes, hypertension, or any respiratory disease, has a fatal combination in intensive care management when infected with SARS-CoV-19. Furthermore, due to their shared risk factors, COVID-19 and stroke are a lethal combination for medical management to treat. In this review, we discuss shared pathophysiology, adjuvant risk factors, challenges, and advancements in stroke-associated COVID-19 therapeutics.

Perceptions Regarding the SARS-CoV-2 Pandemic's Impact on Neurocritical Care Delivery: Results From a Global Survey

BACKGROUND

The SARS-CoV-2 (COVID-19) pandemic has impacted many facets of critical care delivery.

METHODS

An electronic survey was distributed to explore the pandemic's perceived impact on neurocritical care delivery between June 2020 and March 2021. Variables were stratified by World Bank country income level, presence of a dedicated neurocritical care unit (NCCU) and experiencing a COVID-19 patient surge.

RESULTS

Respondents from 253 hospitals (78.3% response rate) from 47 countries (45.5% low/middle income countries; 54.5% with a dedicated NCCU; 78.6% experienced a first surge) participated in the study. Independent of country income level, NCCU and surge status, participants reported reductions in NCCU admissions (67%), critical care drug shortages (69%), reduction in ancillary services (43%) and routine diagnostic testing (61%), and temporary cancellation of didactic teaching (44%) and clinical/basic science research (70%). Respondents from low/middle income countries were more likely to report lack of surge preparedness (odds ratio [OR], 3.2; 95% confidence interval [CI], 1.8-5.8) and struggling to return to prepandemic standards of care (OR, 12.2; 95% CI, 4.4-34) compared with respondents from high-income countries. Respondents experiencing a surge were more likely to report conversion of NCCUs and general-mixed intensive care units (ICUs) to a COVID-ICU (OR 3.7; 95% CI, 1.9-7.3), conversion of non-ICU beds to ICU beds (OR, 3.4; 95% CI, 1.8-6.5), and deviations in critical care and pharmaceutical practices (OR, 4.2; 95% CI 2.1-8.2). Respondents from hospitals with a dedicated NCCU were less likely to report conversion to a COVID-ICU (OR, 0.5; 95% CI, 0.3-0.9) or conversion of non-ICU to ICU beds (OR, 0.5; 95% CI, 0.3-0.9).

CONCLUSION

This study reports the perceived impact of the COVID-19 pandemic on global neurocritical care delivery, and highlights shortcomings of health care infrastructures and the importance of pandemic preparedness.

Effects of COVID-19 pandemic on intensive rehabilitation after severe acquired brain injuries

PURPOSE

COVID-19 pandemic has affected most components of health systems including rehabilitation. The study aims to compare demographic and clinical data of patients admitted to an intensive rehabilitation unit (IRU) after severe acquired brain injuries (sABIs), before and during the pandemic.

MATERIALS AND METHODS

In this observational retrospective study, all patients admitted to the IRU between 2017 and 2020 were included. Demographics were collected, as well as data from the clinical and functional assessment at admission and discharge from the IRU. Patients were grouped in years starting from March 2017, and the 2020/21 cohort was compared to those admitted between March 2017/18, 2018/19, and 2019/20. Lastly, the pooled cohort March 2017 to March 2020 was compared with the COVID-19 year alone.

RESULTS

This study included 251 patients (F: 96 (38%): median age 68 years [IQR = 19.25], median time post-onset at admission: 42 days, [IQR = 23]). In comparison with the pre-pandemic years, a significant increase of hemorrhagic strokes (p < 0.001) and a decrease of traumatic brain injuries (p = 0.048), a reduction of the number of patients with a prolonged disorder of consciousness admitted to the IRU (p < 0.001) and a lower length of stay (p < 0.001) were observed in 2020/21.

CONCLUSIONS

These differences in the case mix of sABI patients admitted to IRU may be considered another side-effect of the pandemic. Facing this health emergency, rehabilitation specialists need to adapt readily to the changing clinical and functional needs of patients' addressing the IRUs.

Advancing motor rehabilitation for adults with chronic neurological conditions through increased involvement of kinesiologists: a perspective review

Many people with neurological conditions experience challenges with movement. Although rehabilitation is often provided acutely and sub-acutely following the onset of a condition, motor deficits commonly persist in the long-term and are exacerbated by disuse and inactivity. Notably, motor rehabilitation approaches that incorporate exercise and physical activity can support gains in motor function even in the chronic stages of many neurological conditions. However, delivering motor rehabilitation on a long-term basis to people with chronic neurological conditions is a challenge within health care systems, and the onus is often placed on patients to find and pay for services. While neurological motor rehabilitation is largely the domain of physical and occupational therapists, kinesiologists may be able to complement existing care and support delivery of long-term neurological motor rehabilitation, specifically through provision of supported exercise and physical activity programs. In this perspective style review article, we discuss potential contributions of kinesiologists to advancing the field through exercise programming, focusing on community-based interventions that increase physical activity levels. We conclude with recommendations on how kinesiologists' role might be further optimized towards improving long-term outcomes for people with chronic neurological conditions, considering issues related to professional regulation and models of care.

Prior Stroke and Age Predict Acute Ischemic Stroke Among Hospitalized COVID-19 Patients: A Derivation and Validation Study

Objectives: Our objective was to identify characteristics associated with having an acute ischemic stroke (AIS) among hospitalized COVID-19 patients and the subset of these patients with a neurologic symptom.

Materials and Methods: Our derivation cohort consisted of COVID-19 patients admitted to Yale-New Haven Health between January 3, 2020 and August 28, 2020 with and without AIS. We also studied a sub-cohort of hospitalized COVID-19 patients demonstrating a neurologic symptom with and without an AIS. Demographic, clinical, and laboratory results were compared between AIS and non-AIS patients in the full COVID-19 cohort and in the sub-cohort of COVID-19 patients with a neurologic symptom. Multivariable logistic regression models were built to predict ischemic stroke risk in these two COVID-19 cohorts. These 2 models were externally validated in COVID-19 patients hospitalized at a major health system in New York. We then compared the distribution of the resulting predictors in a non-COVID ischemic stroke control cohort.

Results: A total of 1,827 patients were included in the derivation cohort (AIS N = 44; no AIS N = 1,783). Among all hospitalized COVID-19 patients, history of prior stroke and platelet count ≥ 200 × 1,000/μL at hospital presentation were independent predictors of AIS (derivation AUC 0.89, validation AUC 0.82), irrespective of COVID-19 severity. Among hospitalized COVID-19 patients with a neurologic symptom (N = 827), the risk of AIS was significantly higher among patients with a history of prior stroke and age <60 (derivation AUC 0.83, validation AUC 0.81). Notably, in a non-COVID ischemic stroke control cohort (N = 168), AIS patients were significantly older and less likely to have had a prior stroke, demonstrating the uniqueness of AIS patients with COVID-19.

Conclusions: Hospitalized COVID-19 patients who demonstrate a neurologic symptom and have either a history of prior stroke or are of younger age are at higher risk of ischemic stroke.

COVID-19 and supra-aortic trunks disease: review of literature about critical phase and sequelae

The acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is responsible for the COVID-19 disease, a global pandemic. A strong association has been documented between COVID-19 and cardiovascular events, although the exact pathophysiological mechanism is still unclear. Carotid atherothrombosis and ischemic stroke represents one of the possible severe manifestations of COVID-19, as a leading cause of long-term disability and death. Different complex intertwined mechanisms seem to underlie the endothelitis which is the cause of multiple cardiovascular manifestations. To date, few case series describing COVID-19 and acute ischemic stroke caused by cervical carotid thrombosis have been published. All the patients shared common similar radiographic features, comorbidities, and biomarker profiles. The aim of this brief review is to analyze the impact of COVID-19 pandemic in the management of a Vascular Surgery Department, changing the daily vascular practice, as well as to provide practical suggestions for symptomatic carotid stenosis, while reviewing published literature.

Fewer COVID-19-associated strokes and reduced severity during the second COVID-19 wave: The Madrid Stroke Network

Background and purpose

The experience gained during the first COVID‐19 wave could have mitigated the negative impact on stroke care in the following waves. Our aims were to analyze the characteristics and outcomes of patients with stroke admitted during the second COVID‐19 wave and to evaluate the differences in the stroke care provision compared with the first wave.

Methods

This retrospective multicenter cohort study included consecutive stroke patients admitted to any of the seven hospitals with stroke units (SUs) and endovascular treatment facilities in the Madrid Health Region. The characteristics of the stroke patients with or without a COVID‐19 diagnosis were compared and the organizational changes in stroke care between the first wave (25 February to 25 April 2020) and second wave (21 July to 21 November 2020) were analyzed.

Results

A total of 550 and 1191 stroke patients were admitted during the first and second COVID‐19 waves, respectively, with an average daily admission rate of nine patients in both waves. During the second wave, there was a decrease in stroke severity (median National Institutes of Health Stroke Scale 5 vs. 6; p = 0.000), in‐hospital strokes (3% vs. 8.1%) and in‐hospital mortality (9.9% vs. 15.9%). Furthermore, fewer patients experienced concurrent COVID‐19 (6.8% vs. 19.1%), and they presented milder COVID‐19 and less severe strokes. Fewer hospitals reported a reduction in the number of SU beds or deployment of SU personnel to COVID‐19 dedicated wards during the second wave.

Conclusions

During the second COVID‐19 wave, fewer stroke patients were diagnosed with COVID‐19, and they had less stroke severity and milder COVID‐19.

Delayed Comprehensive Stroke Unit Care Attributable to the Evolution of Infection Protection Measures across Two Consecutive Waves of the COVID-19 Pandemic

We aimed to assess how evidence-based stroke care changed over the two waves of the COVID-19 pandemic. We analyzed acute stroke patients admitted to a tertiary care hospital in Germany during the first (2 March 2020–9 June 2020) and second (23 September 2020–31 December 2020, 100 days each) infection waves. Stroke care performance indicators were compared among waves. A 25.2% decline of acute stroke admissions was noted during the second (n = 249) compared with the first (n = 333) wave of the pandemic. Patients were more frequently tested SARS-CoV-2 positive during the second than the first wave (11 (4.4%) vs. 0; p < 0.001). There were no differences in rates of reperfusion therapies (37% vs. 36.5%; p = 1.0) or treatment process times (p > 0.05). However, stroke unit access was more frequently delayed (17 (6.8%) vs. 5 (1.5%); p = 0.001), and hospitalization until inpatient rehabilitation was longer (20 (1, 27) vs. 12 (8, 17) days; p < 0.0001) during the second compared with the first pandemic wave. Clinical severity, stroke etiology, appropriate secondary prevention medication, and discharge disposition were comparable among both waves. Infection control measures may adversely affect access to stroke unit care and extend hospitalization, while performance indicators of hyperacute stroke care seem to be untainted.

Pitfalls in the Diagnosis of Posterior Circulation Stroke in the Emergency Setting

Posterior circulation stroke (PCS), caused by infarction within the vertebrobasilar arterial system, is a potentially life-threatening condition and accounts for about 20–25% of all ischemic strokes. Diagnosing PCS can be challenging due to the vast area of brain tissue supplied by the posterior circulation and, as a consequence, the wide range of—frequently non-specific—symptoms. Commonly used prehospital stroke scales and triage systems do not adequately represent signs and symptoms of PCS, which may also escape detection by cerebral imaging. All these factors may contribute to causing delay in recognition and diagnosis of PCS in the emergency context. This narrative review approaches the issue of diagnostic error in PCS from different perspectives, including anatomical and demographic considerations as well as pitfalls and problems associated with various stages of prehospital and emergency department assessment. Strategies and approaches to improve speed and accuracy of recognition and early management of PCS are outlined.

COVID-19 Lockdown Effects on Acute Stroke Care in Latin America

Objectives

COVID-19 pandemic has forced important changes in health care worldwide. Stroke care networks have been affected, especially during peak periods. We assessed the impact of the pandemic and lockdowns in stroke admissions and care in Latin America.

Materials and Methods

A multinational study (7 countries, 18 centers) of patients admitted during the pandemic outbreak (March-June 2020). Comparisons were made with the same period in 2019. Numbers of cases, stroke etiology and severity, acute care and hospitalization outcomes were assessed.

Results

Most countries reported mild decreases in stroke admissions compared to the same period of 2019 (1187 vs. 1166, p = 0.03). Among stroke subtypes, there was a reduction in ischemic strokes (IS) admissions (78.3% vs. 73.9%, p = 0.01) compared with 2019, especially in IS with NIHSS 0–5 (50.1% vs. 44.9%, p = 0.03). A substantial increase in the proportion of stroke admissions beyond 48 h from symptoms onset was observed (13.8% vs. 20.5%, p < 0.001). Nevertheless, no differences in total reperfusion treatment rates were observed, with similar door-to-needle, door-to-CT, and door-to-groin times in both periods. Other stroke outcomes, as all-type mortality during hospitalization (4.9% vs. 9.7%, p < 0.001), length of stay (IQR 1–5 days vs. 0–9 days, p < 0.001), and likelihood to be discharged home (91.6% vs. 83.0%, p < 0.001), were compromised during COVID-19 lockdown period.

Conclusions

In this Latin America survey, there was a mild decrease in admissions of IS during the COVID-19 lockdown period, with a significant delay in time to consultations and worse hospitalization outcomes.

Neuroimaging Findings in Patients with COVID-19: A Systematic Review and Meta-Analysis

Objective

Central nervous system involvement in coronavirus disease 2019 (COVID-19) has been increasingly reported. We performed a systematic review and meta-analysis to evaluate the incidence of radiologically demonstrated neurologic complications and detailed neuroimaging findings associated with COVID-19.

Materials and Methods

A systematic literature search of MEDLINE/PubMed and EMBASE databases was performed up to September 17, 2020, and studies evaluating neuroimaging findings of COVID-19 using brain CT or MRI were included. Several cohort-based outcomes, including the proportion of patients with abnormal neuroimaging findings related to COVID-19 were evaluated. The proportion of patients showing specific neuroimaging findings was also assessed. Subgroup analyses were also conducted focusing on critically ill COVID-19 patients and results from studies that used MRI as the only imaging modality.

Results

A total of 1394 COVID-19 patients who underwent neuroimaging from 17 studies were included; among them, 3.4% of the patients demonstrated COVID-19-related neuroimaging findings. Olfactory bulb abnormalities were the most commonly observed (23.1%). The predominant cerebral neuroimaging finding was white matter abnormality (17.6%), followed by acute/subacute ischemic infarction (16.0%), and encephalopathy (13.0%). Significantly more critically ill patients had COVID-19-related neuroimaging findings than other patients (9.1% vs. 1.6%; p = 0.029). The type of imaging modality used did not significantly affect the proportion of COVID-19-related neuroimaging findings.

Conclusion

Abnormal neuroimaging findings were occasionally observed in COVID-19 patients. Olfactory bulb abnormalities were the most commonly observed finding. Critically ill patients showed abnormal neuroimaging findings more frequently than the other patient groups. White matter abnormalities, ischemic infarctions, and encephalopathies were the common cerebral neuroimaging findings.

Management of Endovascular Treatment for Acute Ischemic Stroke During the COVID-19 Pandemic at a Single Institution in Beijing, China: A Brief Report

BACKGROUND

The coronavirus disease (COVID-19) pandemic is currently a major challenge for health care systems around the world. For a time-sensitive emergency such as acute ischemic stroke (AIS), streamlined workflow times are essential to ensure good clinical outcomes.

METHODS

The aim of this single-center, retrospective, observational study was to describe changes in stroke workflow patterns and clinical care during the COVID-19 pandemic. Data from AIS patients undergoing emergent endovascular treatment (EVT) between 23 January and 8 April 2020 were retrospectively collected and compared with data from patients admitted during a similar period in 2019. The primary outcome was difference in time from symptom onset to recanalization. Secondary outcomes included workflow times, clinical management, discharge outcomes, and health-economic data.

RESULTS

In all, 21 AIS patients were admitted for emergent EVT during the 77-day study period, compared with 42 cases in 2019. Median time from symptom onset to recanalization was 132 minutes longer during the pandemic compared with the previous year (672 vs. 540 min, P=0.049). Patients admitted during the pandemic had a higher likelihood of endotracheal intubation (84.6% vs. 42.4%, P<0.05) and a higher incidence of delayed extubation after EVT (69.2% vs. 45.5%, P<0.05). National Institutes of Health Stroke Scale at hospital discharge was similar in the 2 cohorts, whereas neurointensive care unit stay was longer in patients admitted during the pandemic (10 vs. 7 days, P=0.013) and hospitalization costs were higher (123.9 vs. 95.2 thousand Chinese Yuan, P=0.052).

CONCLUSION

Disruptions to medical services during the COVID-19 pandemic has particularly impacted AIS patients undergoing emergent EVT, resulting in increased workflow times. A structured and multidisciplinary protocol should be implemented to minimize treatment delays and maximize patient outcomes.

Cardiovascular and Cerebrovascular Complications With COVID-19

The coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus-2 has affected the health of people across the globe. Cardiovascular diseases (CVDs) have a significant relationship with COVID-19, both as a risk factor and prognostic indicator, and as a complication of the disease itself. In addition to predisposing to CVD complications, the ongoing pandemic has severely affected the delivery of timely and appropriate care for cardiovascular conditions resulting in increased mortality. The etiology behind the cardiac injury associated with severe acute respiratory syndrome coronavirus-2 is likely varied, including coronary artery disease, microvascular thrombosis, myocarditis, and stress cardiomyopathy. Further large-scale investigations are needed to better determine the underlying mechanism of myocardial infarction and other cardiac injury in COVID-19 patients and to determine the incidence of each type of cardiac injury in this patient population. Telemedicine and remote monitoring technologies can play an important role in optimizing outcomes in patients with established CVD. In this article, we summarize the various impacts that COVID-19 has on the cardiovascular system, including myocardial infarction, myocarditis, stress cardiomyopathy, thrombosis, and stroke.

Post-COVID seizure: A new feature of "long-COVID"

Novel coronavirus SARS-CoV-2 has created unprecedented healthcare challenges. Neurologic deficits are often an important presenting symptom. To date, the only reported post-infectious COVID-19 manifestations of neurologic disease include cognitive deficits and dysfunction of the peripheral nervous system. Here we report that seizure can also be a post-COVID-19 or “long-COVID” complication. We present a 71-year-old man with hypertension, diabetes mellitus, and COVID-19 diagnosed by RT-PCR who initially presented with posterior circulation stroke-like symptoms, which completely resolved after emergent thrombolysis. Six days later, the patient returned with seizure activity, supported by radiographic and electroencephalographic studies. Notably, he was negative for SARS-CoV-2, and no other provoking factor was uncovered after a comprehensive work-up. To our knowledge, this is the first report of post-infectious seizures after a case of COVID-19, highlighting the potential importance of monitoring for neurologic symptoms in COVID-19 patients, even after convalescence.

•

Patients with COVID-19 can develop multiple neurologic disorders.

•

Seizure can be a manifestation of the “Long-COVID” syndrome.

•

Longitudinal studies of neurologic disease in COVID-19 survivors are needed.

Impact of the pandemic of COVID-19 on emergency attendance for stroke and acute myocardial infarction in Beijing, China

To estimate the impact on emergency attendance for stroke and acute myocardial infarction (AMI) during the pandemic of COVID-19 in Beijing, China. Based on 17,123 and 8693 emergency attendance for stroke and AMI, an interrupted time-series (ITS) study was conducted. Since 01/24/2020, the top two levels of regulations on major public health have been implemented in Beijing. This study covered from 03/01/2018 to 06/03/2020, including 19 weeks of lockdown period and 99 weeks before. A segmented Poisson regression model was used to estimate the immediate change and the monthly change in the secular trend of the emergency attendance rates. The emergency attendance rates of stroke and AMI cut in half at the beginning of the lockdown period, with 52.1% (95% CI 45.8% to 57.7%) and 63.1% (95% CI 56.1% to 63.1%) immediate decreases for stroke and AMI, respectively. Then during the lockdown period, 7.0% (95% CI 2.5%, 11.6%) and 16.1% (95% CI 9.5, 23.1) increases per month in the secular trends of emergency attendance rates were shown for stroke and AMI, respectively. Though the accelerated increasing rates, there were estimated 1335 and 747 patients with stroke and AMI without seeking emergency medical aid during the lockdown, respectively. The emergency attendance for stroke and AMI cut in half at the beginning of the pandemic then had gradual restoration thereafter. The results hint the need for more engagement and communications with all stakeholders to reduce the negative impact on CVD emergency medical services during the crisis.

Hypertension, diabetes mellitus, and cerebrovascular disease predispose to a more severe outcome of COVID-19

INTRODUCTION

The world is currently facing the pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The total number of cases of coronavirus disease 2019 (COVID-19) is rising daily and no vaccine has yet been approved. While the pathophysiology behind the virus is still being studied, many possible several risk factors using small sample sizes have been found.

MATERIAL AND METHODS

We conducted a pooled analysis using several databases such as Medline, Scopus, Wangfang, Web of Science, Research Square, medrxiv, and Google Scholar to identify studies reporting severe and non-severe groups of COVID-19 patients. The odds ratios as well as the 95% confidence intervals for hypertension, diabetes, and cerebrovascular disease leading to severe COVID-19 were calculated using R-software.

RESULTS

Fifty-three articles were used for our analysis and they involved 30,935 confirmed cases of COVID-19 from several countries across the world. The odds ratio for severe COVID-19 in hypertensive patients, diabetics, and patients with a history of cerebrovascular disease was 2.58 (95% confidence interval (CI): 2.16-3.08, from 53 studies), 2.17 (95% CI: 1.72-2.74, from 44 studies), and 2.63 (95% CI: 1.80-3.85, from 25 studies), respectively.

CONCLUSIONS

Our analysis confirms that patients with hypertension, diabetes, or cerebrovascular disease are at a higher risk of a severe outcome of COVID-19. It is thus vital for physicians to identify the main risk factors for a severe outcome of this disease.

Impact of the COVID-19 Pandemic on Acute Stroke Care, Time Metrics, Outcomes, and Racial Disparities in a Southeast Michigan Health System

BACKGROUND

COVID-19 has impacted acute stroke care with several reports showing worldwide drops in stroke caseload during the pandemic. We studied the impact of COVID-19 on acute stroke care in our health system serving Southeast Michigan as we rolled out a policy to limit admissions and transfers.

METHODS

in this retrospective study conducted at two stroke centers, we included consecutive patients presenting to the ED for whom a stroke alert was activated during the period extending from 3/20/20 to 5/20/20 and a similar period in 2019. We compared demographics, time metrics, and discharge outcomes between the two groups.

RESULTS

of 385 patients presented to the ED during the two time periods, 58% were African American. There was a significant decrease in the number of stroke patients presenting to the ED and admitted to the hospital between the two periods (p <0.001). In 2020, patients had higher presenting NIHSS (median: 2 vs 5, p = 0.012), discharge NIHSS (median: 2 vs 3, p = 0.004), and longer times from LKW to ED arrival (4.8 vs 9.4 h, p = 0.031) and stroke team activation (median: 10 vs 15 min, p = 0.006). In 2020, stroke mimics rates were lower among African Americans. There were fewer hospitalizations (p <0.001), and transfers from outside facilities (p = 0.015).

CONCLUSION

a trend toward faster stroke care in the ED was observed during the pandemic along with dramatically reduced numbers of ED visits, hospitalizations and stroke mimics. Delayed ED presentations and higher stroke severity characterized the African American population, highlighting deepening of racial disparities during the pandemic.

Stroke Care during the COVID-19 Pandemic: International Expert Panel Review

BACKGROUND

Coronavirus disease 2019 (COVID-19) has placed a tremendous strain on healthcare services. This study, prepared by a large international panel of stroke experts, assesses the rapidly growing research and personal experience with COVID-19 stroke and offers recommendations for stroke management in this challenging new setting: modifications needed for prehospital emergency rescue and hyperacute care; inpatient intensive or stroke units; posthospitalization rehabilitation; follow-up including at-risk family and community; and multispecialty departmental developments in the allied professions.

SUMMARY

The severe acute respiratory syndrome coronavirus 2 uses spike proteins binding to tissue angiotensin-converting enzyme (ACE)-2 receptors, most often through the respiratory system by virus inhalation and thence to other susceptible organ systems, leading to COVID-19. Clinicians facing the many etiologies for stroke have been sobered by the unusual incidence of combined etiologies and presentations, prominent among them are vasculitis, cardiomyopathy, hypercoagulable state, and endothelial dysfunction. International standards of acute stroke management remain in force, but COVID-19 adds the burdens of personal protections for the patient, rescue, and hospital staff and for some even into the postdischarge phase. For pending COVID-19 determination and also for those shown to be COVID-19 affected, strict infection control is needed at all times to reduce spread of infection and to protect healthcare staff, using the wealth of well-described methods. For COVID-19 patients with stroke, thrombolysis and thrombectomy should be continued, and the usual early management of hypertension applies, save that recent work suggests continuing ACE inhibitors and ARBs. Prothrombotic states, some acute and severe, encourage prophylactic LMWH unless bleeding risk is high. COVID-19-related cardiomyopathy adds risk of cardioembolic stroke, where heparin or warfarin may be preferable, with experience accumulating with DOACs. As ever, arteritis can prove a difficult diagnosis, especially if not obvious on the acute angiogram done for clot extraction. This field is under rapid development and may generate management recommendations which are as yet unsettled, even undiscovered. Beyond the acute management phase, COVID-19-related stroke also forces rehabilitation services to use protective precautions. As with all stroke patients, health workers should be aware of symptoms of depression, anxiety, insomnia, and/or distress developing in their patients and caregivers. Postdischarge outpatient care currently includes continued secondary prevention measures. Although hoping a COVID-19 stroke patient can be considered cured of the virus, those concerned for contact safety can take comfort in the increasing use of telemedicine, which is itself a growing source of patient-physician contacts. Many online resources are available to patients and physicians. Like prior challenges, stroke care teams will also overcome this one. Key Messages: Evidence-based stroke management should continue to be provided throughout the patient care journey, while strict infection control measures are enforced.

Encephalopathy and encephalitis during acute SARS-CoV-2 infection. Spanish Society of Neurology's COVID-19 Registry

Objectives

Patients and methods

Results

Conclusions

Changes in Prehospital Stroke Care and Stroke Mimic Patterns during the COVID-19 Lockdown

The impact of COVID-19 lockdown on prehospital stroke care is largely unknown. We aimed to compare stroke care patterns before and during a state-wide lockdown. Thus, we analysed prospective data of stroke alerts referred to our stroke centre between 1 December 2019 and 16 June 2020, and compared them between two periods—15 weeks before and 13 weeks during the state-wide lockdown declared in Lithuania on 16 March 2020. Among 719 referrals for suspected stroke, there was a decrease in stroke alerts (rate ratio 0.61, 95% CI (0.52–0.71)), stroke admissions (0.63, 95% CI (0.52–0.76)), and decrease in prehospital stroke triage quality (positive predictive value 72.1% vs. 79.9%, p = 0.042) during the lockdown. The onset-to-door time was longer (153.0 vs. 120.5 min, p = 0.049) and seizures and intracranial tumours were more common among stroke mimics (16.9% vs. 6.7%, p = 0.012 and 9.6% vs. 3.0%, p = 0.037, respectively). We conclude that there was a decline in prehospital stroke triage quality during the lockdown despite low COVID-19 incidence in the country. Moreover, we observed an increase in hospital arrival delays and severe conditions presenting as stroke mimics. Our findings suggest that improved strategies are required to maintain optimal neurological care during public health emergencies.

Encephalopathy and encephalitis during acute SARS-CoV-2 infection. Spanish Society of Neurology COVID-19 Registry

OBJECTIVES

Since the beginning of the COVID-19 pandemic, the Spanish Society of Neurology has run a registry of patients with neurological involvement for the purpose of informing clinical neurologists. Encephalopathy and encephalitis were among the most frequently reported complications. In this study, we analyse the characteristics of these complications.

PATIENTS AND METHODS

We conducted a retrospective, descriptive, observational, multicentre study of patients with symptoms compatible with encephalitis or encephalopathy, entered in the Spanish Society of Neurology's COVID-19 Registry from 17 March to 6 June 2020.

RESULTS

A total of 232 patients with neurological symptoms were registered, including 51 cases of encephalopathy or encephalitis (21.9%). None of these patients were healthcare professionals. The most frequent syndromes were mild or moderate confusion (33%) and severe encephalopathy or coma (9.8%). The mean time between onset of infection and onset of neurological symptoms was 8.02 days. Lumbar puncture was performed in 60.8% of patients, with positive PCR results for SARS-CoV-2 in only one case. Brain MRI studies were performed in 47% of patients, with alterations detected in 7.8% of these. EEG studies were performed in 41.3% of cases, detecting alterations in 61.9%.

CONCLUSIONS

Encephalopathy and encephalitis are among the complications most frequently reported in the registry. More than one-third of patients presented mild or moderate confusional syndrome. The mean time from onset of infection to onset of neurological symptoms was 8 days (up to 24hours earlier in women than in men). EEG was the most sensitive test in these patients, with very few cases presenting alterations in neuroimaging studies. All patients treated with boluses of corticosteroids or immunoglobulins progressed favourably.

Decline and Recurrence of Stroke Consultations during the COVID-19 Pandemic Lockdown Parallels Population Activity Levels

Background

The COVID-19 pandemic lockdown (CPL) lead to a significant decrease in emergency admissions worldwide. We performed a timely analysis of ischemic stroke (IS) and related consultations using the telestroke TEMPiS “working diagnosis” database prior (PL), within (WL), and after easing (EL) of CPL.

Methods

Twelve hospitals were selected and data analyzed regarding IS (including intravenous thrombolysis [intravenous recombinant tissue plasminogen; IV rtPA] and endovascular thrombectomy [EVT]) and related events from February 1 to June 15 during 2017–2020. In addition, we aimed to correlate events to various mobile phone mobility data.

Results

Following the significant reduction of IS, IV rtPA, and EVT cases during WL compared to PL in 2020 longitudinally (p values <0.048), we observed increasing numbers of consultations, IS, recommendations for EVT, and IV rtPA with the network in EL over WL not reaching PL levels yet. Absolute numbers of all consultations paralleled best to mobility data of public transportation over walking and driving mobility.

Conclusions

While the decrease in emergency admissions including stroke during CPL can only be in part attributed by patients not seeking medical attention, stroke awareness in the pandemic, and direct COVID-19 triggered stroke remains of high importance. The number of consultations in TEMPiS during the lockdown parallels best with mobility of public transportation. As a consequence, exposure to common viruses, well-known triggers for acute cerebrovascular events and other diseases, are reduced and may add to the decline in stroke consultations. Further studies comparing national responses toward the course of the COVID-19 pandemic and stroke incidences are needed.

The Impact of SARS-CoV-2 on Stroke Epidemiology and Care: A Meta-Analysis

OBJECTIVE

Emerging data indicate an increased risk of cerebrovascular events with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and highlight the potential impact of coronavirus disease (COVID-19) on the management and outcomes of acute stroke. We conducted a systematic review and meta-analysis to evaluate the aforementioned considerations.

METHODS

We performed a meta-analysis of observational cohort studies reporting on the occurrence and/or outcomes of patients with cerebrovascular events in association with their SARS-CoV-2 infection status. We used a random-effects model. Summary estimates were reported as odds ratios (ORs) and corresponding 95% confidence intervals (CIs).

RESULTS

We identified 18 cohort studies including 67,845 patients. Among patients with SARS-CoV-2, 1.3% (95% CI = 0.9-1.6%, I² = 87%) were hospitalized for cerebrovascular events, 1.1% (95% CI = 0.8-1.3%, I² = 85%) for ischemic stroke, and 0.2% (95% CI = 0.1-0.3%, I² = 64%) for hemorrhagic stroke. Compared to noninfected contemporary or historical controls, patients with SARS-CoV-2 infection had increased odds of ischemic stroke (OR = 3.58, 95% CI = 1.43-8.92, I² = 43%) and cryptogenic stroke (OR = 3.98, 95% CI = 1.62-9.77, I² = 0%). Diabetes mellitus was found to be more prevalent among SARS-CoV-2 stroke patients compared to noninfected historical controls (OR = 1.39, 95% CI = 1.00-1.94, I² = 0%). SARS-CoV-2 infection status was not associated with the likelihood of receiving intravenous thrombolysis (OR = 1.42, 95% CI = 0.65-3.10, I² = 0%) or endovascular thrombectomy (OR = 0.78, 95% CI = 0.35-1.74, I² = 0%) among hospitalized ischemic stroke patients during the COVID-19 pandemic. Odds of in-hospital mortality were higher among SARS-CoV-2 stroke patients compared to noninfected contemporary or historical stroke patients (OR = 5.60, 95% CI = 3.19-9.80, I² = 45%).

INTERPRETATION

SARS-CoV-2 appears to be associated with an increased risk of ischemic stroke, and potentially cryptogenic stroke in particular. It may also be related to an increased mortality risk. ANN NEUROL 2021;89:380-388.

Implementation of the Stroke Action Plan for Europe 2018--2030 during coronavirus disease-2019

PURPOSE OF REVIEW

To describe the background, principles and implementation of the Stroke Action Plan for Europe 2018--2030 (SAP-E) in the perspective of the current COVID-19 pandemic.

RECENT FINDINGS

SAP-E sets targets for the implementation of evidence-based preventive actions and stroke services to 2030. A recent mapping of stroke care in Europe has documented massive inequalities and even in high-income European countries access to reperfusion therapy and mortality after ischaemic stroke varies significantly. Organized stroke care providing stroke unit care and access to reperfusion therapies reduces mortality and long-term disability. Stroke prevention and care are highly cost-effective. The COVID-19 pandemic has challenged organized care, diverged attention from stroke and necessitated a novel approach to the implementation program because of the continued need for social distancing and reduced travelling. Consequently, meetings, training and engagement will be handled by online resources.

SUMMARY

Stroke can be prevented and treated but there remain massive inequalities in Europe. SAP-E has set targets for development of stroke care. COVID-19 pandemic has led to further challenges for stroke care and implementation of the Action Plan will rely on online meetings and resources as it is yet unforeseeable when things will return to normal.

VIDEO ABSTRACT

http://links.lww.com/CONR/A53.

The role of telemedicine in acute stroke treatment in times of pandemic

PURPOSE OF REVIEW

The coronavirus disease 2019 (COVID-19) pandemic challenges many healthcare systems. This review provides an overview of the advantages of telemedicine during times of pandemic and the changes that have followed the outbreak of the COVID-19 disease.

RECENT FINDINGS

Telemedicine has been utilized during infectious outbreaks for many years. COVID-19 has induced a variety of changes in laws (i.e. data privacy protection) and reimbursement procedures to accelerate new setups of telemedicine. Existing networks provide novel data about teleactivation resulting from social restrictions during the nadir of the lockdown in spring 2020.

SUMMARY

Telemedicine is a safe and ideal expert support system for hospitals during infectious outbreaks. It makes high-quality medical procedures possible, limits potentially contagious interhospital transfers, saves critical resources such as protective gear and rescue/emergency transport services, and offers safe home office work for medical specialists.

Impact of COVID-19 on Future Ischemic Stroke Incidence

With the ever-expanding population of patients infected with SARS-CoV-2, we are learning more about the immediate and long-term clinical manifestations of coronavirus disease 2019 (COVID-19). Ischemic stroke (IS) is now one of the well-documented additional clinical manifestations of COVID-19. Most COVID-19 related IS cases have been categorized as cryptogenic or embolic stroke of undetermined source (ESUS), which are most often suspected to have an undiagnosed cardioembolic source. COVID-19 is known to also cause cardiac dysfunction, heart failure, and atrial arrhythmias (AA), but the long-term impact of this cardiac dysfunction on stroke incidence is unknown. With millions afflicted with COVID-19 and the ever-rising infection rate, it is important to consider the potential long-term impact of COVID-19 on future IS incidence. Accomplishing these goals will require novel strategies that allow for diagnosis, data capture, and prediction of future IS risk using tools that are adaptable to the evolving clinical challenges in patient care delivery and research.

Stroke epidemiology and COVID-19 pandemic

PURPOSE OF REVIEW

The aim of this study was to describe the impact of the COVID-19 outbreak on the epidemiology, cause and clinical characteristics of incident stroke in different settings and populations.

RECENT FINDINGS

Several studies have shown that there are three main themes in the epidemiology of stroke during the COVID-19 pandemic: COVID-19 seems to be associated with stroke in a significant number of patients. This association has been reported in several clinical series, mainly from China. There is a consistent trend towards a decreased number of hospital admissions of stroke patients during the pandemic. There are no population-based data available on incident stroke in individuals with COVID-19.

SUMMARY

In this review, we report on increased rates and severe prognosis of ischemic stroke among individuals with COVID-19, probably explained by hypercoagulability and inflammation, documented since the early phase of disease.We confirm the presence of falling rates of new ischemic stroke admissions in hospitals, probably due to social consequences of the pandemic: fear to be infected or not adequately treated in the hospital. This phenomenon is restricted to mild stroke and transient ischemic attacks.Short and long-term consequences of this trend of new strokes in the pandemic need to be evaluated.

Stroke and digital technology: a wake-up call from COVID-19 pandemic

Introduction

The pandemic has implemented the need for new digital technologies as useful tools during the emergency and the long recovery phase that will follow. SARS-CoV-2 has strongly impacted stroke care with significant contraction in a number of patients treated.

Methods

This mini-review is an initiative of the “Digital Technologies, Web and Social Media Study Group” of the Italian Society of Neurology and briefly discusses digital tools for managing the acute phase and the rehabilitation after stroke, even considering the new apps that will improve the process of remote monitoring of patients after discharge at home.

Results

Telemedicine and digital technologies could play a role in each of the three stroke-belt stages: hyperacute treatment and reperfusion, acute care, etiological classification and secondary prevention and rehabilitation.

Conclusion

The global emergency represented by the COVID-19 pandemic can be the stimulus to accelerate the digitalization process in the field of stroke for the use of new methods on a large scale.

Ethical considerations in neurology during the COVID-19 pandemic

Coronavirus disease 2019 (COVID-19) pandemic has struck many countries and caused a great number of infected cases and death. Healthcare system across all countries is dealing with the increasing medical, social, and legal issues caused by the COVID-19 pandemic, and the standards of care are being altered. Admittedly, neurology units have been influenced greatly since the first days, as aggressive policies adopted by many hospitals caused eventual shut down of numerous neurologic wards. Considering these drastic alterations, traditional ethical principles have to be integrated with state-of-the-art ethical considerations. This review will consider different ethical aspects of care in neurologic patients during COVID-19 and how this challenging situation has affected standards of care in these patients.

Neurological and Neuropsychiatric Impacts of COVID-19 Pandemic

BACKGROUND

Albeit primarily a disease of respiratory tract, the 2019 coronavirus infectious disease (COVID-19) has been found to have causal association with a plethora of neurological, neuropsychiatric and psychological effects. This review aims to analyze them with a discussion of evolving therapeutic recommendations.

METHODS

PubMed and Google Scholar were searched from 1 January 2020 to 30 May 2020 with the following key terms: "COVID-19", "SARS-CoV-2", "pandemic", "neuro-COVID", "stroke-COVID", "epilepsy-COVID", "COVID-encephalopathy", "SARS-CoV-2-encephalitis", "SARS-CoV-2-rhabdomyolysis", "COVID-demyelinating disease", "neurological manifestations", "psychosocial manifestations", "treatment recommendations", "COVID-19 and therapeutic changes", "psychiatry", "marginalised", "telemedicine", "mental health", "quarantine", "infodemic" and "social media". A few newspaper reports related to COVID-19 and psychosocial impacts have also been added as per context.

RESULTS

Neurological and neuropsychiatric manifestations of COVID-19 are abundant. Clinical features of both central and peripheral nervous system involvement are evident. These have been categorically analyzed briefly with literature support. Most of the psychological effects are secondary to pandemic-associated regulatory, socioeconomic and psychosocial changes.

CONCLUSION

Neurological and neuropsychiatric manifestations of this disease are only beginning to unravel. This demands a wide index of suspicion for prompt diagnosis of SARS-CoV-2 to prevent further complications and mortality.