COVID-19 and Stroke Trends in A Tertiary Care Center from South India -Our Monsoon Experience

INTRODUCTION

The unprecedented challenges during the COVID pandemic and the subsequent lockdown had resulted in a delay in treatment metrics for acute stroke. There is a rising concern that COVID-19 co-infection can adversely affect stroke outcome. We aim to investigate the impact of COVID-19 in the management of stroke patients. We also compared the differences in stroke manifestations, etiological pattern, treatment course, and outcome of acute stroke patients in COVID-19 confirmed cases.

METHODOLOGY

A single-center retrospective study was done at the Stroke Unit, Government Medical College, Thiruvananthapuram. Consecutive patients of acute stroke confirmed by imaging, presenting within 24 hours of the onset of symptoms in May to July 2020 and May to July 2019, were included. The primary data variables included baseline demographics, risk factors, admission NIHSS, stroke timings, thrombolysis rate, TOAST etiology, mRS at discharge, and in-hospital mortality.

RESULTS

Strokes with higher NIHSS, arrival blood sugar and blood pressure, and delays in door-to-CT and door-to-needle time were more during the pandemic. Intravenous thrombolysis was less and mortality was higher in COVID-19 strokes during the pandemic. COVID-19-positive stroke patients had more hemorrhagic strokes, more severe strokes with low CT ASPECTS, more hemorrhagic transformation, high in-hospital mortality, and poor functional outcome at discharge and 3 months.

CONCLUSION

Our study was a hypothesis-generating study with a limited number of patients. This study has reconfirmed the higher severity of the stroke, with a higher mRS score and mortality during the pandemic, especially among COVID-19-positive stroke patients.

Clinical Features and Outcome of Stroke with COVID-19. COVID-19 Stroke Study Group (CSSG), India

Background and Purpose:

Occurrence of stroke has been reported among patients with COVID-19. The present study compares clinical features and outcomes of stroke patients with and without COVID-19.

Methods:

The COVID-19 Stroke Study Group (CSSG) is a multicentric study in 18 sites across India to observe and compare the clinical characteristics of patients with stroke admitted during the current pandemic period and a similar epoch in 2019. The present study reports patients of stroke with and without COVID-19 (CoVS and non-CoVS, respectively) seen between February 2020 and July 2020. Demographic, clinical, treatment, and outcome details of patients were collected.

Results:

The mean age and gender were comparable between the two groups. CoVS patients had higher stroke severity and extent of cerebral involvement on imaging. In-hospital complications and death were higher among CoVS patients (53.06% vs. 17.51%; P < 0.001) and (42.31% vs. 7.6%; P < 0.001), respectively. At 3 months, higher mortality was observed among CoVS patients (67.65% vs. 13.43%; P < 0.001) and good outcome (modified Rankin score [mRS]: 0–2) was seen more often in non-CoVS patients (68.86% vs. 33.33%; P < 0.001). The presence of COVID-19 and baseline stroke severity were independent predictors of mortality.

Conclusions:

CoVS is associated with higher severity, poor outcome, and increased mortality. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and baseline stroke severity are independent predictors of mortality.

Pneumopericardium, pneumomediastinum and surgical emphysema in spontaneous pneumothorax

Spontaneous pneumothorax leading to pneumomediastinum, pneumopericardium and surgical emphysema is a benign condition. Progression to the development of epidural pneumatosis is rare. We report a 19-year-old man who presented with dyspnoea and swelling of the chest wall following a bout of cough. Bilateral subcutaneous emphysema was palpated on the anterior chest wall from the sternum to the midaxillary regions. His chest X-ray revealed subcutaneous emphysema and pneumopericardium. His computed tomography of the thorax to rule out life-threatening conditions revealed bilateral subcutaneous emphysema, pneumomediastinum, pneumo-pericardium and pneumothorax. He was transferred to the intensive care unit. An intercostal drainage tube was inserted in the left pleural cavity. The patient was followed up with repeat chest X-rays. The patient's symptom got relieved and was discharged after day 9. Diagnosis of pneumomedia-stinum may not be as lamentable as it is seen. Close cardio-pulmonary monitoring is mandatory for complications and accompanying conditions. Most patients with uncomplicated spontaneous pneumomediastinum respond well to oxygen and conservative management. In this case, the patient's symptoms and severe tachypnoea prompted the insertion of an intercostal drainage tube.

Clinical profile and outcome of non-COVID strokes during pandemic and the pre pandemic period: COVID-Stroke Study Group (CSSG) India

Background

As the health systems around the world struggled to meet the challenges of COVID-19 pandemic, care of many non-COVID emergencies was affected.

Aims

The present study examined differences in the diagnosis, evaluation and management of stroke patients during a defined period in the ongoing pandemic in 2020 when compared to a similar epoch in year 2019.

Methods

The COVID stroke study group (CSSG) India, included 18 stroke centres spread across the country. Data was collected prospectively between February and July 2020 and retrospectively for the same period in 2019. Details of demographics, stroke evaluation, treatment, in-hospital and three months outcomes were collected and compared between these two time points.

Results

A total of 2549 patients were seen in both study periods; 1237 patients (48.53%) in 2019 and 1312 (51.47%) in 2020. Although the overall number of stroke patients and rates of thrombolysis were comparable, a significant decline was observed in the month of April 2020, during the initial period of the pandemic and lockdown. Endovascular treatment reduced significantly and longer door to needle and CT to needle times were observed in 2020. Although mortality was higher in 2020, proportion of patients with good outcome were similar in both the study periods.

Conclusions

Although stroke admissions and rates of thrombolysis were comparable, some work flow metrics were delayed, endovascular stroke treatment rates declined and mortality was higher during the pandemic study period. Reorganization of stroke treatment pathways during the pandemic has likely improved the stroke care delivery across the globe.

Clinical profile of patients with nascent alcohol related seizures

Aim:

The aim of this study is to characterize the clinical profile of patients with alcohol related seizures (ARS) and to identify the prevalence of idiopathic generalized epilepsy (IGE) in the same.

Materials and Methods:

100 consecutive male patients presenting to a tertiary care center in South India with new onset ARS were analyzed with alcohol use disorders identification test (AUDIT) score. All underwent 19 channel digital scalp electroencephalography (EEG) and at least computed tomography (CT) scan.

Results:

A total of 27 patients (27%) who had cortical atrophy on CT had a mean duration of alcohol intake of 23.62 years compared with 14.55 years in patients with no cortical atrophy (P < 0.001). Twenty-two patients (22%) had clustering in the current episode of whom 18 had cortical atrophy. Nearly, 88% patients had generalized tonic clonic seizures while 12% who had partial seizures underwent magnetic resonance imaging (MRI), which identified frontal focal cortical dysplasia in one. Mean lifetime duration of alcohol intake in patients presenting with seizures within 6 hours (6H-gp) of intake of alcohol was significantly lower (P = 0.029). One patient in the 6H-gp with no withdrawal symptoms had EEG evidence for IGE and had a lower AUDIT score compared with the rest.

Conclusion:

CT evidence of cortical atrophy is related to the duration of alcohol intake and portends an increased risk for clustering. Partial seizures can be a presenting feature of ARS and those patients may benefit from MRI to identify underlying symptomatic localization related epilepsy (8.3% of partial seizures). IGE is more likely in patients presenting with ARS within first 6 hours especially if they do not have alcohol withdrawal symptoms and scalp EEG is helpful to identify this small subgroup (~1%) who may require long-term anti-epileptic medication.

Ice pack test: is it obsolete?

Ophthalmologic signs are the most often presenting symptoms of patients with myasthenia gravis (MG), most common being ptosis. However, ptosis may be caused by a variety of non-myasthenic disorders; hence, the distinction between them and myasthenic ptosis is critical. A battery of diagnostic tests are available to establish the diagnosis of MG, all having their pros and cons, some being life threatening. The authors present a case of 40-year-old male who presented to them with progressive weakness and double vision in which they were successful in narrowing the differentials to myasthenia by performing a simple bed side test.

Gronblad Strandberg syndrome with vertibrobasilar dolichoectasia

The constellation of pseudoxanthoma elasticum, ocular involvement and vascular disturbances is termed Gronblad Strandberg syndrome. Pseudoxanthoma elasticum is a genetic disorder characterized by progressive calcification and fragmentation of elastic fibres in the skin, retina and the cardiovascular system. Typically the cutaneous lesions begin in childhood, but because of their asymptomatic nature they are not noted until adolescence. In some individuals, skin lesions do not develop until later in life. If recognized early, the occurrence of retinal and gastrointestinal hemorrhage and cardiovascular complications can be minimized.

Splenic tumor presenting as pyrexia of unknown origin

Pyrexia of unknown origin has always been a challenging problem to diagnose for physicians. Here we present a case of a splenic tumor, which after histopathology and immunohistochemistry, two possibilities were considered, a diffuse large cell lymphoma--plasmablastic variant and second an anaplastic plasmacytoma. The patient was treated with chemotherapy and on followup he has no evidence of recurrence or any residual lesion.

Macrophage activation syndrome

Macrophage Activation Syndrome is a rare and potentially fatal disease, to be considered in patients with a SIRS like clinical presentation. Falling ESR and hyperferritinemia in the appropriate clinical setting can be the greatest clues. We report a case in which a female admitted with fever and rash, initially had systemic inflammatory response syndrome (SIRS) like clinical presentation, but eventually proved to be a rare case of fatal Macrophage Activation Syndrome.