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Introduction: To evaluate overall ischemic stroke rates, specific subtypes, and clinical presentation during the COVID-19 pandemic in a multicenter observational study from eight states across US. Methods: We compared all ischemic strokes admitted between January 2019 and May 2020, grouped as;March-May 2020 (COVID-19 period), March-May 2019 (seasonal pre-COVID period) and November 2019-January 2020 (immediate pre-COVID-19 period). Primary outcome was stroke severity at admission measured by NIHSS stratified as mild (0-7), moderate (8-14), and severe (>14) symptoms. Secondary outcomes were number of large vessel occlusions (LVOs), stroke etiology, IV-tPA rates, and disposition. Results: Of the 7,969 patients diagnosed with acute stroke during the study period, 933 (12%) presented in the COVID-19 period, 1319 (17%), and 1254 (16%) presented in the seasonal pre- COVID-19 and immediate pre-COVID-19 periods, respectively. Significant decline was observed in the weekly mean volume of newly diagnosed strokes (98±7.3 vs 50±20, p<0.01 and 95±10.5 vs 50±20, p<0.01), LVOs (16.5±3.8 vs 8.3±5.9, p<0.01 and 14.3± 4.5 vs 8.3±5.9, p<0.01), and IV-tPA (5.3±2.9 vs 10.9±3.4 and 12.7±4.1, p<0.01). Mean weekly proportion of LVOs remained the same, when compared with seasonal pre-COVID-19 period (18%±5 vs 16%±7, p=0.24) and immediate pre-COVID-19 period (17.4%±4 vs. 16%±7, p=0.32). Additionally, these patients presented with less severe disease (NIHSS<14;aOR: 0.63, 95%CI: 0.41-0.97, p=0.035) during the COVID-19 period ascompared to immediate pre-COVID-19 period. Conclusions: We observed a decrease in newly diagnosed stroke cases and rates of IV-tPAadministration, while the LVO frequency remained unchanged during the COVID-19 pandemic.Additionally, these stroke patients had more severe presentations.
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Background: Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) has been associated with a significant risk of thrombotic events in critically ill patients. Aims: To summarize the findings of a multinational observational cohort of patients with SARS-CoV- 2 and cerebrovascular disease. Methods: Retrospective observational cohort of consecutive adults evaluated in the emergency department and/or admitted with coronavirus disease 2019 (COVID-19) across 31 hospitals in 4 countries (2/1/2020 - 06/16/2020). The primary outcome was the incidence rate of cerebrovascular events, inclusive of acute ischemic stroke, intracranial hemorrhages (ICH), and cortical vein and/or sinus thrombosis (CVST). Results: Of the 14,483 patients with laboratory-confirmed SARS-CoV-2, 172 were diagnosed with an acute cerebrovascular event (1.13% of cohort;1130/100,000 patients, 95%CI 970- 1320/100,000), 68/171 (40.5%) of whom were female and 96/172 (55.8%) were between the ages 60-79 years. Of these, 156 had acute ischemic stroke (1.08%;1080/100,000 95%CI 920- 1260/100,000), 28 ICH (0.19%;190/100,000 95%CI 130 - 280/100,000) and 3 with CVST (0.02%;20/100,000, 95%CI 4-60/100,000). The in-hospital mortality rate for SARS-CoV-2-associated stroke was 38.1% and for ICH 58.3%. After adjusting for clustering by site and age, baseline strokeseverity, and all predictors of in-hospital mortality found in univariate regression (p<0.1: male sex,tobacco use, arrival by emergency medical services, lower platelet and lymphocyte counts, andintracranial occlusion), cryptogenic stroke mechanism (aOR 5.01, 95%CI 1.63-15.44, p<0.01), olderage (aOR 1.78, 95%CI 1.07-2.94, p=0.03), and lower lymphocyte count on admission (aOR 0.58,95%CI 0.34-0.98 p=0.04) were the only independent predictors of mortality among patients withstroke and COVID-19. Conclusions: COVID-19 is associated with a small but significant risk of clinically relevantcerebrovascular events, particularly ischemic stroke. The mortality rate is high for COVID-19associated cerebrovascular complications, therefore aggressive monitoring and early interventionshould be pursued to mitigate poor outcomes.
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Background: The degree to which the COVID-19 pandemic has affected systems of care, in particular those for time-sensitive conditions such as stroke, remains poorly quantified. We sought to evaluate the impact of COVID-19 in the overall screening for acute stroke utilizing a commercial clinical artificial intelligence (AI) platform. Methods: Data were derived from the Viz Platform, an AI application designed to optimize the workflow of acute stroke patients. Neuroimaging data on suspected stroke patients across 97 hospitals in 20 US states were collected in real-time and retrospectively analyzed with the number of patients undergoing imaging screening serving as a surrogate for the amount of stroke care. The main outcome measures were the number of CTA, CTP, Large vessel occlusions (LVOs) (defined according to the automated software detection), and severe strokes on CTP (defined as those with hypoperfusion volumes>70mL) normalized as number of patients per day per hospital. Data from the pre-pandemic (November 4, 2019 to February 29, 2020) and pandemic (March 1 to May 10, 2020) periods were compared at national and state levels. Correlations were made between the inter-period changes in imaging screening, stroke hospitalizations, and thrombectomy procedures using state-specific sampling. Results: A total of 23,223 patients were included. The incidence of LVO on CTA and severe strokes on CTP were 11.2%(n=2,602) and 14.7%(n=1,229/8,328), respectively. There were significant declines in the overall number of CTAs (-22.8%;1.39 to 1.07 patients/day/hospital,p<0.001) and CTPs (-26.1%;0.50 to 0.37 patients/day/hospital,p<0.001) as well as in the incidence of LVO (-17.1%;0.15 to 0.13 patients/day/hospital,p<0.001) and severe strokes on CTP (-16.7%;0.12 to 0.10 patients/day/hospital, p<0.005). The sampled cohort showed similar declines in the rates of LVOs versus thrombectomy (18.8%vs.19.5%, p=0.9) and CSC hospitalizations (18.8%vs.11.0%, p=0.4). Conclusions: A significant decline in stroke imaging screening has occurred during the COVID-19 pandemic. This underscores the broader application of AI neuroimaging platforms for the real-time monitoring of stroke systems of care.
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Background: We sought to evaluate whether the coronavirus disease 2019 (COVID-19) pandemic may have contributed to delays in acute stroke management at Comprehensive Stroke Centers (CSCs). Methods: Pooled clinical data of consecutive adult stroke patients from 12 U.S. CSCs (1/1/2019- 5/31/2020) were queried. The rate of thrombolysis for non-transferred patients within the Target: Stroke goal of 60min was compared between patients admitted 3/1/2019-5/31/2019 (pre-COVID-19) and 3/1/2020-5/31/2020 (COVID-19). The time from arrival to imaging and treatment with thrombolysis or thrombectomy, as continuous variables, were also assessed. Results: Of the 7906 patients included, 1319 were admitted pre-COVID-19 and 933 were admitted during COVID-19, 15% of whom underwent intravenous thrombolysis. There was no difference in the rate of thrombolysis within 60min during COVID-19 (OR 0.88, 95%CI 0.42-1.86, p=0.74), despite adjustment for variables associated with earlier treatment (adjusted OR 0.82, 95%CI 0.38-1.76, p=0.61). There was no significant overall delay to thrombolysis during the COVID-19 period vs. pe- COVID-19 (p=0.42), even after multivariable adjustment (p=0.63) or after comparison across months leading to COVID-19 (Figure). The only independent predictor of delayed treatment time between periods was the use of emergency medical services (adjusted β=-6.93, 95%CI -12.83 -1.04, p=0.03). There was no significant delay from hospital arrival to imaging in all patients, or imaging to skin puncture in patients who underwent thrombectomy. Conclusions: There was no independent effect of the COVID-19 period on delays in acute care with respect to thrombolysis or thrombectomy in this multicenter observational cohort. Further studies are warranted to externally validate these findings, and determine if site volume or center accreditation may mediate a collateral effect of the pandemic on stroke care paradigms.
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INTRODUCTION: Although there is evidence to suggest a high rate of cerebrovascular complications in patients with SARS-CoV-2 infection, anecdotal reports indicate a falling rate of new ischemic stroke diagnoses. We conducted an exploratory single-center analysis to estimate the change in number of new stroke diagnoses in our region, and evaluate the proximate reasons for this change during the COVID-19 pandemic at a tertiary care center in New Jersey. PATIENTS AND METHODS: A Comprehensive Stroke Center prospective cohort was retrospectively analyzed for the number of stroke admissions, demographic features, and short-term outcomes 5 months prior to 3/1/2020 (pre-COVID-19), and in the 6 weeks that followed (COVID-19 period). The primary outcome was the number of new acute stroke diagnoses before and during the COVID-19 period, as well as the potential reasons for a decline in the number of new diagnoses. RESULTS: Of the 328 included patients, 53 (16%) presented in the COVID-19 period. There was a mean fall of 38% in new stroke diagnoses (mean 1.13/day [SD 1.07] from 1.82/day [SD 1.38], p<0.01), which was related to a 59% decline in the number of daily transfers from referral centers (p<0.01), 25% fewer telestroke consultations (p=0.08), and 55% fewer patients presenting directly to our institution by private vehicle (p<0.01) and 29% fewer patients through emergency services (p=0.09). There was no significant change in the monthly number of strokes due to large vessel occlusion (LVO), however the proportion of new LVOs nearly doubled in the COVID-19 period (38% vs. 21%, p=0.01). CONCLUSIONS: The observations at our tertiary care center corroborate anecdotal reports that the number of new stroke diagnoses is falling, which seems related to a smaller proportion of patients seeking healthcare services for milder symptoms. These preliminary data warrant validation in larger, multi-center studies.