Virtual vs In-person Neurological Exam Study (VINES) in Response to the COVID-19 Crisis and Beyond

Objective: The objective of this study is to investigate the utility of the virtual neurological examination (VNE) in arriving at an accurate localization and diagnosis, in comparison with the traditional in-person neurological examination (IPNE). Background: The Coronavirus disease 2019 (COVID-19) pandemic forced a shift to virtual care within many neurological care settings. Little is known about the validity of the VNE for clinical decision-making compared to the IPNE. This study will provide further insight into the value of the VNE in the outpatient setting. Design/Methods: A retrospective chart review is being conducted of patients who were evaluated and examined virtually and in-person within 4 months in the outpatient general neurology, cognitive neurology, neuromuscular, and stroke clinics at two tertiary care centers at the University of Toronto during the COVID-19 pandemic. Descriptive statistical methods are used to compare virtual and in-person assessment results, accuracy, localization, diagnosis, investigations and management approaches. Results: Preliminary comparison of 10 patients from the neuromuscular clinic at St. Michael's Hospital, showed only 2 cases where the localization changed after the IPNE. Interestingly, in both cases, the additional findings on the IPNE, not documented on the VNE, were unrelated to the reason for referral. In 4 cases, the IPNE provided increased diagnostic certainty, but did not change the leading differential diagnosis after the virtual assessment. In the remaining 6 cases, the diagnosis made after both virtual and in-person assessments were unchanged. Conclusions: The study is ongoing, and full results will be presented (N=∼60). Preliminary results show that conclusions drawn from a VNE appear comparable to those from an INPE in diagnosis and localization of neurological complaints. The IPNE may provide a more detailed assessment to detect subtle abnormalities unrelated to the reason for referral. This study's outcomes will inform the use of virtual care across a variety of neurological presentations.

Protected Code Stroke: Updates from the Frontlines

Objective: We recently provided a framework, the protected code stroke, for the implementation of safety measures and other key considerations during the coronavirus disease 2019 (COVID-19) pandemic. Herein we provide updates to the framework from the frontlines as the pandemic evolves. Background: Hyperacute assessment and management of patients with stroke is a time-sensitive and high-stakes clinical scenario. In the context of the current COVID-19 pandemic, the ability to deliver timely and efficacious care must be balanced with the risk of infectious exposure to the clinical team. Furthermore, rapid and effective stroke care remains paramount to achieve maximal functional recovery while rapid triage is important for those who may be presenting with neurological symptoms, but have an alternative diagnosis. Design/Methods: Available resources, COVID-19-specific infection prevention and control recommendations, and expert consensus were used to identify clinical screening criteria for patients and provide the required nuanced considerations for the healthcare team, thereby modifying the conventional code stroke processes to achieve a protected designation. Feedback from frontline providers implementing the protocol was collected. Results: Features specific to pre-notification and clinical status of the patient were used to define pre-code screening. A focused framework was then developed with regard to a protected code stroke. Feedback was used to generate tips with regards to implementation, team management strategies, and an evolving understanding of infection control strategies during a code stroke. Conclusions: We introduce the concept of a protected code stroke during a pandemic, as in the case of COVID-19, and provide a framework for crucial considerations including screening, personal protective equipment, and crisis resource management. These considerations and suggested algorithms can be utilized and adapted for local practice. The protocol has since been endorsed and adopted at many centers globally.

Global impact of the COVID-19 pandemic on stroke care and intravenous thrombolysis

Objective: The objectives of this study were to measure the global impact of the pandemic on the volumes for intravenous thrombolysis (IVT), IVT transfers, and stroke hospitalizations over 4 months at the height of the pandemic (March 1 to June 30, 2020) compared with two control 4-month periods. Background: The COVID-19 pandemic led to widespread repercussions on the delivery of health care worldwide. Design/Methods: We conducted a cross-sectional, observational, retrospective study across 6 continents, 70 countries, and 457 stroke centers. Diagnoses were identified by ICD-10 codes and/or classifications in stroke center databases. Results: There were 91,373 stroke admissions in the 4 months immediately before compared to 80,894 admissions during the pandemic months, representing an 11.5% (95%CI,-11.7 to-11.3, p<0.0001) decline. There were 13,334 IVT therapies in the 4 months preceding compared to 11,570 procedures during the pandemic, representing a 13.2% (95%CI,-13.8 to-12.7, p<0.0001) drop. Interfacility IVT transfers decreased from 1,337 to 1,178, or an 11.9% decrease (95%CI,-13.7 to-10.3, p=0.001). There were greater declines in primary compared to comprehensive stroke centers (CSC) for stroke hospitalizations (-17.3% vs-10.3%, p<0.0001) and IVT (-15.5% vs-12.6%, p=0.0001). Recovery of stroke hospitalization volume (9.5%, 95%CI 9.2-9.8, p<0.0001) was noted over the two later (May, June) versus the two earlier (March, April) months of the pandemic, with greater recovery in hospitals with lower COVID-19 hospitalization volume, high volume stroke center, and CSC. There was a 1.48% stroke rate across 119,967 COVID-19 hospitalizations. SARS-CoV-2 infection was noted in 3.3% (1,722/52,026) of all stroke admissions. Conclusions: The COVID-19 pandemic was associated with a global decline in the volume of stroke hospitalizations, IVT, and interfacility IVT transfers. Primary stroke centers and centers with higher COVID19 inpatient volumes experienced steeper declines. Recovery of stroke hospitalization was noted in the later pandemic months, with greater recovery in hospitals with lower COVID-19 hospitalizations, high volume stroke centers, and CSCs.

The virtual neurologic exam: Instructional videos and guidance for the COVID-19 Era

Objective: To outline features of the neurologic examination that can be performed virtually through telemedicine platforms (the virtual neurological examination [VNE]), and provide guidance for rapidly pivoting in-person clinical assessments to virtual visits during the COVID- 19 pandemic and beyond. Background: The arrival of the COVID-19 pandemic necessitated a swift transition from inperson to virtual care for most physicians. For neurologists, the ability to perform a detailed neurological examination is critical, and poses a barrier to virtual care adoption. Many aspects of the examination are not amenable to virtual platforms and require adapting standard techniques. Design/Methods: We sought to develop a complete screening "virtual" neurological exam" (VNE) that can be performed reliably in most circumstances, and also virtually and tailored depending on the nature of the referral. Videos were created to help with rapid adoption and demonstrate the techniques. Results: Collaborating with general neurologists and various subspecialists (neuromuscular, cognitive neurology, movement disorders and neuro-ophthalmology), a complete VNE was developed, and is described in detail - complete with accompanying videos that demonstrate the most common maneuvers. We also provide guidance on the VNE for specific neurologic complaints, including cognitive impairment, neuromuscular disorders and movement disorders. Conclusions: Given the importance of the physical exam to the practice of neurology, proficiency in performing a virtual neurological exam is an indispensable skill in the context of the COVID-19 pandemic and beyond. We have developed a practical approach to the VNE along with short instructional videos that can be easily implemented in clinical practice.

Integrating New Staff into Endovascular Stroke-Treatment Workflows in the COVID-19 Pandemic.

A health care crisis such as the coronavirus disease 2019 (COVID-19) pandemic requires allocation of hospital staff and resources on short notice. Thus, new and sometimes less experienced team members might join the team to fill in the gaps. This scenario can be particularly challenging in endovascular stroke treatment, which is a highly specialized task that requires seamless cooperation of numerous health care workers across various specialties and professions. This document is intended for stroke teams who face the challenge of integrating new team members into endovascular stroke-treatment workflows during the COVID-19 pandemic or any other global health care emergency. It discusses the key strategies for smooth integration of new stroke-team members in a crisis situation: 1) transfer of key knowledge (simple take-home messages), 2) open communication and a nonjudgmental atmosphere, 3) strategic task assignment, and 4) graded learning and responsibility. While these 4 key principles should generally be followed in endovascular stroke treatment, they become even more important during health care emergencies such as the COVID-19 pandemic, when health care professionals have to take on new and additional roles and responsibilities in challenging working environments for which they were not specifically trained.

Hyperacute stroke management during the coronavirus disease 2019 (COVID-19) pandemic

Background and Purpose- Hyperacute assessment and management of patients with stroke, termed code stroke, is a time-sensitive and high-stakes clinical scenario. In the context of the current coronavirus disease 2019 (COVID-19) pandemic caused by the SARS-CoV-2 virus, the ability to deliver timely and efficacious care must be balanced with the risk of infectious exposure to the clinical team. Furthermore, rapid and effective stroke care remains paramount to achieve maximal functional recovery for those needing admission and to triage care appropriately for those who may be presenting with neurological symptoms but have an alternative diagnosis. Methods- Available resources, COVID-19-specific infection prevention and control recommendations, and expert consensus were used to identify clinical screening criteria for patients and provide the required nuanced considerations for the healthcare team, thereby modifying the conventional code stroke processes to achieve a protected designation. Results- A protected code stroke algorithm was developed. Features specific to prenotification and clinical status of the patient were used to define precode screening. These include primary infectious symptoms, clinical, and examination features. A focused framework was then developed with regard to a protected code stroke. We outline the specifics of personal protective equipment use and considerations thereof including aspects of crisis resource management impacting team role designation and human performance factors during a protected code stroke. Conclusions- We introduce the concept of a protected code stroke during a pandemic, as in the case of COVID-19, and provide a framework for key considerations including screening, personal protective equipment, and crisis resource management. These considerations and suggested algorithms can be utilized and adapted for local practice.