Telestroke Across the Continuum of Care: Lessons from the COVID-19 Pandemic.

While use of telemedicine to guide emergent treatment of ischemic stroke is well established, the COVID-19 pandemic motivated the rapid expansion of care via telemedicine to provide consistent care while reducing patient and provider exposure and preserving personal protective equipment. Temporary changes in re-imbursement, inclusion of home office and patient home environments, and increased access to telehealth technologies by patients, health care staff and health care facilities were key to provide an environment for creative and consistent high-quality stroke care. The continuum of care via telestroke has broadened to include prehospital, inter-facility and intra-facility hospital-based services, stroke telerehabilitation, and ambulatory telestroke. However, disparities in technology access remain a challenge. Preservation of reimbursement and the reduction of regulatory burden that was initiated during the public health emergency will be necessary to maintain expanded patient access to the full complement of telestroke services. Here we outline many of these initiatives and discuss potential opportunities for optimal use of technology in stroke care through and beyond the pandemic.

Alarming downtrend in mechanical thrombectomy rates in African American patients during the COVID-19 pandemic-Insights from STAR.

BACKGROUND: The coronavirus disease (COVID-19) pandemic has affected stroke care globally. In this study, we aim to evaluate the impact of the current pandemic on racial disparities among stroke patients receiving mechanical thrombectomy (MT). METHODS: We used the prospectively collected data in the Stroke Thrombectomy and Aneurysm Registry from 12 thrombectomy-capable stroke centers in the US and Europe. We included acute stroke patients who underwent MT between January 2017 and May 2020. We compared baseline features, vascular risk factors, location of occlusion, procedural metrics, complications, and discharge outcomes between patients presenting before (before February 2020) and those who presented during the pandemic (February to May 2020). RESULTS: We identified 2083 stroke patients: of those 235 (11.3%) underwent MT during the COVID-19 pandemic. Compared with pre-pandemic, stroke patients who received MT during the pandemic had longer procedure duration (44 vs 38 min, P=0.006), longer length of hospitalization (6 vs 4 days, P<0.001), and higher in-hospital mortality (18.7% vs 11%, P<0.001). Importantly, there was a lower number of African American patients undergoing MT during the COVID-19 pandemic (609 (32.9%) vs 56 (23.8%); P=0.004). CONCLUSION: The COVID-19 pandemic has affected the care process for stroke patients receiving MT globally. There is a significant decline in the number of African American patients receiving MT, which mandates further investigation.

Blacks Are Less Likely to Present With Strokes During the COVID-19 Pandemic: Observations From the Buckle of the Stroke Belt.

BACKGROUND AND PURPOSE: The impact of the coronavirus disease 2019 (COVID-19) pandemic on stroke systems has not been systematically evaluated. Our study aims to investigate trends in telestroke consults during the pandemic. METHODS: We did retrospective chart review of consecutive patients seen through a telestroke network in South Carolina from March 2019 to April 2020. We dichotomized patients to preCOVID-19 pandemic (March 2019 to February 2020) and during COVID-19 pandemic (March to April 2020). RESULTS: A total of 5852 patients were evaluated during the study period, 613 (10.5%) were seen during the pandemic. The median number of weekly consults dropped from 112 to 77 during the pandemic, P=0.002. There was no difference in baseline features; however, Black patients were less likely to present with strokes during the pandemic (13.9% versus 29%, P≤0.002). CONCLUSIONS: The COVID-19 pandemic has led to a significant drop in telestroke volume. The impact seems to disproportionately affect Black patients.

International experience of mechanical thrombectomy during the COVID-19 pandemic: insights from STAR and ENRG.

BACKGROUND: In response to the COVID-19 pandemic, many centers altered stroke triage protocols for the protection of their providers. However, the effect of workflow changes on stroke patients receiving mechanical thrombectomy (MT) has not been systematically studied. METHODS: A prospective international study was launched at the initiation of the COVID-19 pandemic. All included centers participated in the Stroke Thrombectomy and Aneurysm Registry (STAR) and Endovascular Neurosurgery Research Group (ENRG). Data was collected during the peak months of the COVID-19 surge at each site. Collected data included patient and disease characteristics. A generalized linear model with logit link function was used to estimate the effect of general anesthesia (GA) on in-hospital mortality and discharge outcome controlling for confounders. RESULTS: 458 patients and 28 centers were included from North America, South America, and Europe. Five centers were in high-COVID burden counties (HCC) in which 9/104 (8.7%) of patients were positive for COVID-19 compared with 4/354 (1.1%) in low-COVID burden counties (LCC) (P<0.001). 241 patients underwent pre-procedure GA. Compared with patients treated awake, GA patients had longer door to reperfusion time (138 vs 100 min, P=<0.001). On multivariate analysis, GA was associated with higher probability of in-hospital mortality (RR 1.871, P=0.029) and lower probability of functional independence at discharge (RR 0.53, P=0.015). CONCLUSION: We observed a low rate of COVID-19 infection among stroke patients undergoing MT in LCC. Overall, more than half of the patients underwent intubation prior to MT, leading to prolonged door to reperfusion time, higher in-hospital mortality, and lower likelihood of functional independence at discharge.