Changes in ischemic stroke presentations and associated workflow during the first wave of the COVID-19 pandemic: A population study

Background: Pandemics may promote hospital avoidance among patients with emergencies, and added precautions may exacerbate treatment delays. Methods: We used linked administrative data and data from the Quality Improvement and Clinical Research Alberta Stroke Program – a registry capturing stroke-related data on the entire Albertan population(4.3 million) – to identify all patients hospitalized with stroke in the pre-pandemic(01/01/2016-27/02/2020) and COVID-19 pandemic(28/02/2020-30/08/2020) periods. We examined changes in stroke presentation rates and use of thrombolysis and endovascular therapy(EVT), adjusted for age, sex, comorbidities, and pre-admission care needs;and in workflow, stroke severity(National Institutes of Health Stroke Scale/NIHSS), and in-hospital outcomes. Results: We analyzed 19,531 patients with ischemic stroke pre-pandemic versus 2,255 during the pandemic. Hospitalizations/presentations dropped(weekly adjusted-incidence-rate-ratio[aIRR]:0.48,95%CI:0.46-0.50), as did population-level incidence of thrombolysis(aIRR:0.49,0.44-0.56) or EVT(aIRR:0.59,0.49-0.69). However, proportions of presenting patients receiving thrombolysis/EVT did not decline (thrombolysis:11.7% pre-pandemic vs 13.1% during-pandemic, aOR:1.02,0.75-1.38). For out-of-hospital strokes, onset-to-door times were prolonged(adjusted-coefficient:37.0-minutes, 95%CI:16.5-57.5), and EVT recipients experienced greater door-to-reperfusion delays(adjusted-coefficient:18.7-minutes,1.45-36.0). NIHSS scores and in-hospital mortality did not differ. Conclusions: The first COVID-19 wave was associated with a halving of presentations and acute therapy utilization for ischemic stroke at a population level, and greater pre-/in-hospital treatment delays. Our data can inform public health messaging and stroke care in future pandemic waves.

Changes in ischemic stroke presentations and associated workflow during the first wave of the COVID-19 pandemic: A population study

Background: Pandemics may promote hospital avoidance among patients with emergencies, and added precautions may exacerbate treatment delays. Methods: We used linked administrative data and data from the Quality Improvement and Clinical Research Alberta Stroke Program - a registry capturing stroke related data on the entire Albertan population (4.3 million) - to identify all patients hospitalized with stroke in the pre-pandemic (01/01/2016-27/02/2020) and COVID-19 pandemic (28/02/ 2020-30/08/2020) periods. We examined changes in stroke presentation rates and use of thrombolysis and endovascular therapy (EVT), adjusted for age, sex, comorbidities, and preadmission care needs;and in workflow, stroke severity (National Institutes of Health Stroke Scale/NIHSS), and in-hospital outcomes. Results: We analyzed 19,531 patients with ischemic stroke pre-pandemic versus 2,255 during the pandemic. Hospitalizations/presentations dropped (weekly adjusted-incidencerate-ratio[aIRR]:0.48,95%CI:0.46-0.50), as did population-level incidence of thrombolysis (aIRR:0.49,0.44-0.56) or EVT (aIRR:0.59,0.49-0.69). However, proportions of presenting patients receiving thrombolysis/EVT did not decline (thrombolysis:11.7% pre-pandemic vs 13.1% during-pandemic, aOR:1.02, 0.75-1.38). For out-of-hospital strokes, onset-to-door times were prolonged(adjusted-coefficient:37.0-minutes, 95%CI:16.5-57.5), and EVT recipients experienced greater door-to-reperfusion delays (adjusted-coefficient:18.7-minutes,1.45-36.0). NIHSS scores and in-hospital mortality did not differ. Conclusions: The first COVID-19 wave was associated with a halving of presentations and acute therapy utilization for ischemic stroke at a population level, and greater pre-/in-hospital treatment delays. Our data can inform public health messaging and stroke care in future pandemic waves.

Frequency, Persistence, and Patient-reported Outcomes of Neurological Symptomsin Mild COVID-19: Resultsfrom the ALBERTA HOPE COVID-19 Trial

Objective: To examine the natural history of neurological symptoms in mild COVID-19. Background: Various neurological manifestations have been reported with COVID-19, mostly in retrospective studies of hospitalized patients. There are few data on patients with mild COVID19. Design/Methods: Consenting participants in the ALBERTA HOPE COVID-19 trial( NCT04329611, hydroxychloroquine vs placebo for 5-days), managed as outpatients, were prospectively assessed 3-months and 1-year after their positive test. They completed detailed neurological symptom questionnaires, Telephone Montreal Cognitive Assessment(T-MoCA), Kessler Psychological Distress Scale(K10), and the EQ-5D-3L(quality-of-life). Informants completed the Mild Behavioural Impairment Checklist(MBI-C) and Informant Questionnaire on Cognitive Decline(IQCODE). We tracked healthcare utilization and neurological investigations using medical records. Results: Among 198 patients (median age:45, IQR:37-54, 43.9% female);28(14.1%) had preexisting neurological/psychiatric disorders. Among 179 patients with symptom assessments, 139(77.7%) reported ≥1 neurological symptom, the most common being anosmia/dysgeusia(56.3%), myalgia(42.6%), and headache(41.8%). Symptoms generally began within 1-week of illness(median:6-days, IQR:4-8). Most resolved after 3-months;40 patients(22.3%) reported persistent symptoms at 1-year, with 27(15.1%) reporting no improvement. Persistent symptoms included confusion(50%), headache(52.5%), insomnia(40%), and depression(35%). Body mass index, prior neurologic/psychiatric history, asthma, and lack of full-time employment were associated with presence and persistence of neurological symptoms;only female sex was independently associated on multivariable logistic regression(aOR:5.04, 95%CI:1.58-16.1). Patients with persistent symptoms had more hospitalizations and family physician visits, worse MBI-C scores, and were less often independent for instrumental daily activities at 1-year(77.8% vs 98.2%, p=0.005). Patients with any or persistent neurological symptoms had greater psychological distress defined as K10≥20(aOR:21.0, 95%CI:1.96-225) and worse quality-of-life ratings(mean EQ-5D VAS:67.0 vs 82.8, p=0.0002). 50.0% of patients had T-MoCA<18 at 3-months versus 42.9% at 1-year;patients reporting memory complaints were more likely to have informant-reported cognitive-behavioural decline (aOR[1-year IQCODE>3.3]:12.7, 95%CI:1.08-150). Conclusions: Neurological symptoms were commonly reported in survivors of mild COVID-19 and persisted in one in five patients 1-year later. These symptoms were associated with worse patient-reported outcomes.

Quantifying changes in acute stroke presentations and associated workflow during the COVID-19 pandemic: A population-based study

Objective: To understand the effect of the COVID-19 pandemic on the presentation and treatment of acute ischemic stroke. Background: Pandemics may result in hospital avoidance among patients with emergencies, and the added demands of precautions during stroke codes may exacerbate treatment delays. There is a paucity of population-based data on these phenomena. Design/Methods: We extracted data from the Quality Improvement and Clinical Research(QuICR) Alberta Stroke Program, a Canadian population-based stroke registry capturing stroke-related data on the entire population of Alberta, Canada. We used linked administrative data to identify all patients hospitalized with stroke pre-COVID-19(1-January- 2016 to 27-February-2020) and post-COVID-19 (28-February-2020 to 30-June-2020). We used Poisson regressions to evaluate changes in stroke hospitalizations and use of thrombolysis and endovascular therapy(EVT), adjusted for age, sex, comorbidities, and continuing care needs. We compared proportions receiving treatment using logistic regressions, and compared workflow metrics and stroke severity (National Institutes of Health Stroke Scale, NIHSS) using generalized linear models. Results: We analyzed 19,531 patients with ischemic stroke pre-COVID-19 versus 1,400 postCOVID-19. Hospitalizations dropped post-COVID-19 (weekly aIRR:0.49,95%CI 0.46-0.52), as did incidence of thrombolysis (aIRR:0.50,0.42-0.59) and EVT (aIRR:0.56,0.44-0.72). However, the proportions of presenting patients receiving thrombolysis and EVT among all ischemic patients were unchanged (thrombolysis 12.9% pre- and post-COVID, aOR:0.86,0.58-1.29;EVT 6.2% pre- vs 6.8% post-COVID, aOR:1.30, 0.91-1.84). Call-to-ambulance-dispatch and call-toparamedics-on-scene times were prolonged post-COVID-19 (adjusted-coefficient for call-toparamedics-on-scene:9.05min, 5.41-12.7), and EVT recipients experienced a greater delay in CT-to-groin-puncture and door-to-groin-puncture times (e.g. CT-to-groin-puncture median 53min, IQR 35-79 pre- vs 73min, 44-108 post-COVID;adjusted-coefficient: 15.33min, 95%CI 2.09-28.6). Among treated patients, there were no relevant differences in NIHSS, onset-to-call, door-to-CT, or door-to-needle times. Conclusions: The pandemic was associated with a halving of presentations for ischemic stroke and use of acute therapies at a population level, and greater pre-hospital and in-hospital workflow delays. Our results may help inform public health messaging and help optimize stroke workflow.

Population-based rates of emergency department visits for stroke in the different phases of COVID19 restriction and reopening

Introduction: Reductions in hospital visits for stroke during the COVID19 pandemic have been reported, but few have studied this question on a population-basis and less is understood about the temporal trends after economic and social reopening. We aimed to describe the rate of emergency department visits for acute stroke before and after the declaration of the pandemic, through the different phases of reopening, in the population of Ontario, Canada (14 million people). Methods: Using administrative data linkage, we will show the age- and sex-standardized rate of weekly emergency department visits for ischemic or hemorrhagic stroke between January 1 to September 30, 2020. Pandemic declaration was on March 11, 2020 (week 11) and phase 1 reopening started on May 19, 2020 (week 20) in Ontario. We will use piecewise regression analysis models to evaluate the changes in rates during the pandemic and after reopening. Results: We identified 5,617 emergency department visits for stroke (53% male, median age 74 IQR [63,83]) between January 1 to May 19, 2020 (week 20). Data beyond May 19, 2020 are not available yet, but these will be presented at the ISC 2021. The proportion of patients treated at a comprehensive stroke center was similar pre- and post-pandemic (41.7% versus 42.7%, standard difference (SD) 0.02), as was the proportion of people admitted to hospital (87.9% versus 86.7%, SD 0.03), treated with intravenous thrombolysis (11.6% versus 11.8%, SD 0.01), or underwent endovascular thrombectomy (5.1% versus 4.8%, SD 0.02). Weekly rates of stroke visits decreased after the pandemic declaration, but they seem to increase after week 16 (Figure 1). We show rates from 2019 for comparison. Conclusions: Population-based rates of emergency department visits for stroke initially decreased after the pandemic compared to pre-pandemic rates. Changes in rates after reopening and the results of the piecewise regression analysis will be presented at the ISC 2021.(Figure Presented).