HYPERCOAGULABLE AND GENETICALLY THROMBOPHILIC PATIENTS WITH CEREBRAL VENOUS THROMBOSIS

Introduction Cerebral venous thrombosis (CVT) may occur due to a number of common etiologies such as thromboembolism, atherosclerotic disease, or small vessel disease. When these are ruled out or considered unlikely, a hypercoagulability workup is performed. We describe a series of 30 patients with CVT and medical and/or genetic basis for the underlying hypercoagulable state and thrombophilia. Methods A retrospective review of all CVT cases treated with venous thrombectomy between June 2016 and August 2021 was performed within our institutional, neuroendovascular database. Results Of the 30 patients identified, 18 were associated with a hypercoagulable state and/or thrombophilia. Underlying illness was present in seven (36.8%) patients due to polycythemia vera, systemic lupus erythematosus, a combination of nephrotic syndrome and morbid obesity, a combination of rheumatoid arthritis and diabetes, chronic rejection of a small bowel transplant further complicated by acute renal failure and ARDS, a combination of diabetes, DVT, and a dyslipidemic state, and Covid-19. Hypercoagulable states were identified in seven (36.8%) patients due to elevated Factor VIII (1/ 7), antiphospholipid syndrome (3/7), and Protein S deficiency (3/7). Genetic thrombophilia was identified in four (16.4%) patients in the form of a heterozygous Factor V mutation in R506Q (2/4), a heterozygous Prothrombin Factor II mutation in G20210A (1/4), and a homozygous 4G/4G promoter Plasminogen Activator inhibitor I deletion mutation (1/4). Overall, no subset of hypercoagulability (I.e. mutation, disease, transient state) nor hypercoagulability overall was predictive of outcome as measured by recanalization, discharge disposition, or reocclusion likelihood. Conclusion The most common cause of hypercoagulability was underlying disease or transient antiphospholipid syndrome/elevated pro-coagulation factor. While we are unable to report hypercoagulability as a predictive variable of outcome in our cohort, we outline the presence of various coagulopathies within this medically refractory, CVT cohort. While CVT may occur due to many common pathologies, in cases where the cause is unknown a hypercoagulability workup my shed light on mitigating factors underlying the thrombosis.

Student Survey Results of a Virtual Medical Student Course Developed as a Platform for Neurosurgical Education During the Coronavirus Disease 2019 Pandemic.

BACKGROUND: Before the coronavirus disease 2019 (COVID-19) pandemic, medical students training in neurosurgery relied on external subinternships at institutions nationwide for immersive educational experiences and to increase their odds of matching. However, external rotations for the 2020-2021 cycle were suspended given concerns of spreading COVID-19. Our objective was to provide foundational neurosurgical knowledge expected of interns, bootcamp-style instruction in basic procedures, and preinterview networking opportunities for students in an accessible, virtual format. METHODS: The virtual neurosurgery course consisted of 16 biweekly 1-hour seminars over a 2-month period. Participants completed comprehensive precourse and postcourse surveys assessing their backgrounds, confidence in diverse neurosurgical concepts, and opinions of the qualities of the seminars. Responses from students completing both precourse and postcourse surveys were included. RESULTS: An average of 82 students participated live in each weekly lecture (range, 41-150). Thirty-two participants completed both surveys. On a 1-10 scale self-assessing baseline confidence in neurosurgical concepts, participants were most confident in neuroendocrinology (6.79 ± 0.31) and least confident in spine oncology (4.24 ± 0.44), with an average of 5.05 ± 0.32 across all topics. Quality ratings for all seminars were favorable. The mean postcourse confidence was 7.79 ± 0.19, representing an improvement of 3.13 ± 0.38 (P < 0.0001). CONCLUSIONS: Feedback on seminar quality and improvements in confidence in neurosurgical topics suggest that an interactive virtual course may be an effective means of improving students' foundational neurosurgical knowledge and providing networking opportunities before application cycles. Comparison with in-person rotations when these are reestablished may help define roles for these tools.

Epidemiological surveillance of the impact of the COVID-19 pandemic on stroke care using artificial intelligence

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.

Epidemiological Surveillance of the Impact of the COVID-19 Pandemic on Stroke Care Using Artificial Intelligence.

BACKGROUND AND PURPOSE: The degree to which the coronavirus disease 2019 (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 platform. METHODS: Data were derived from the Viz Platform, an artificial intelligence application designed to optimize the workflow of patients with acute stroke. Neuroimaging data on suspected patients with stroke 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 computed tomography (CT) angiography, CT perfusion, large vessel occlusions (defined according to the automated software detection), and severe strokes on CT perfusion (defined as those with hypoperfusion volumes >70 mL) normalized as number of patients per day per hospital. Data from the prepandemic (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 large vessel occlusion on CT angiography and severe strokes on CT perfusion were 11.2% (n=2602) and 14.7% (n=1229/8328), respectively. There were significant declines in the overall number of CT angiographies (-22.8%; 1.39-1.07 patients/day per hospital, P<0.001) and CT perfusion (-26.1%; 0.50-0.37 patients/day per hospital, P<0.001) as well as in the incidence of large vessel occlusion (-17.1%; 0.15-0.13 patients/day per hospital, P<0.001) and severe strokes on CT perfusion (-16.7%; 0.12-0.10 patients/day per hospital, P<0.005). The sampled cohort showed similar declines in the rates of large vessel occlusions versus thrombectomy (18.8% versus 19.5%, P=0.9) and comprehensive stroke center hospitalizations (18.8% versus 11.0%, P=0.4). CONCLUSIONS: A significant decline in stroke imaging screening has occurred during the COVID-19 pandemic. This analysis underscores the broader application of artificial intelligence neuroimaging platforms for the real-time monitoring of stroke systems of care.

By the Numbers Analysis of Effect of COVID-19 on a Neurosurgical Residency at the Epicenter.

BACKGROUND: The severe acute respiratory syndrome coronavirus 2 pandemic has created challenges to neurosurgical patient care. Despite editorials evaluating neurosurgery responses to 2019 novel coronavirus disease (COVID-19), data reporting effects of COVID-19 on neurosurgical case volume, census, and resident illness are lacking. The aim of this study was to present a real-world analysis of neurosurgical volumes, resident deployment, and unique challenges encountered during the severe acute respiratory syndrome coronavirus 2 outbreak peak in New York City. METHODS: Daily census and case volume data were prospectively collected throughout the severe acute respiratory syndrome coronavirus 2 outbreak in spring 2020. Neurosurgical census was compared against COVID-19 system-wide data. Neurosurgical cases during the crisis were analyzed and compared with 7-week periods from 2019 and early 2020. Resident deployment and illness were reviewed. RESULTS: From March 16, 2020, to May 5, 2020, residents participated in 72 operations and 69 endovascular procedures compared with 448 operations and 253 endovascular procedures from January 2020 to February 2020 and 530 operations and 340 endovascular procedures from March 2019 to May 2019. There was a 59% reduction in neurosurgical census during the outbreak (median 24 patients, 2.75 average total cases daily). COVID-19 neurosurgical admissions peaked in concert with the system-wide pandemic. Three residents demonstrated COVID-19 symptoms (no hospitalizations occurred) for a total 24 workdays lost (median 7 workdays). CONCLUSIONS: These data provide real-world guidance on neurosurgical infrastructure needs during a COVID-19 outbreak. While redeployment to support the COVID-19 response was required, a significant need remained to continue to provide critical neurosurgical service.

Intracranial hemorrhage in a young COVID-19 patient.

COVID-19 patients are increasingly understood to develop multisystem manifestations, including neurologic involvement. We report the case of a 42-year old COVID-19 positive patient with a fatal intracerebral hemorrhage (ICH). The patient presented with fever and dyspnea, requiring intubation due to medical complications. After prolonged sedation and anticoagulation, the patient suddenly developed bilaterally fixed and dilated pupils, caused by a right-sided intracranial hemorrhage with uncal herniation. The course of this case illustrates the delicate balance between hypercoagulability and coagulation factor depletion; especially in the intubated and sedated patient, in whom regular neurological assessments are impeded. As we expand our understanding of the neurological ramifications of COVID-19, clinicians need to be increasingly aware of the precarious coagulation balance.

Emergent Large Vessel Occlusion Stroke During New York City's COVID-19 Outbreak: Clinical Characteristics and Paraclinical Findings.

BACKGROUND AND PURPOSE: The 2019 novel coronavirus outbreak and its associated disease (coronavirus disease 2019 [COVID-19]) have created a worldwide pandemic. Early data suggest higher rate of ischemic stroke in severe COVID-19 infection. We evaluated whether a relationship exists between emergent large vessel occlusion (ELVO) and the ongoing COVID-19 outbreak. METHODS: This is a retrospective, observational case series. Data were collected from all patients who presented with ELVO to the Mount Sinai Health System Hospitals across New York City during the peak 3 weeks of hospitalization and death from COVID-19. Patients' demographic, comorbid conditions, cardiovascular risk factors, COVID-19 disease status, and clinical presentation were extracted from the electronic medical record. Comparison was made between COVID-19 positive and negative cohorts. The incidence of ELVO stroke was compared with the pre-COVID period. RESULTS: Forty-five consecutive ELVO patients presented during the observation period. Fifty-three percent of patients tested positive for COVID-19. Total patients' mean (±SD) age was 66 (±17). Patients with COVID-19 were significantly younger than patients without COVID-19, 59±13 versus 74±17 (odds ratio [95% CI], 0.94 [0.81-0.98]; P=0.004). Seventy-five percent of patients with COVID-19 were male compared with 43% of patients without COVID-19 (odds ratio [95% CI], 3.99 [1.12-14.17]; P=0.032). Patients with COVID-19 were less likely to be White (8% versus 38% [odds ratio (95% CI), 0.15 (0.04-0.81); P=0.027]). In comparison to a similar time duration before the COVID-19 outbreak, a 2-fold increase in the total number of ELVO was observed (estimate: 0.78 [95% CI, 0.47-1.08], P≤0.0001). CONCLUSIONS: More than half of the ELVO stroke patients during the peak time of the New York City's COVID-19 outbreak were COVID-19 positive, and those patients with COVID-19 were younger, more likely to be male, and less likely to be White. Our findings also suggest an increase in the incidence of ELVO stroke during the peak of the COVID-19 outbreak.

Association of Coronavirus Disease (COVID-19) With Large Vessel Occlusion Strokes: A Case-Control Study.

BACKGROUND. An increase in frequency of acute ischemic strokes has been observed among patients presenting with acute neurologic symptoms during the coronavirus disease (COVID-19) pandemic. OBJECTIVE. The purpose of this study was to investigate the association between COVID-19 and stroke subtypes in patients presenting with acute neurologic symptoms. METHODS. This retrospective case-control study included patients for whom a code for stroke was activated from March 16 to April 30, 2020, at any of six New York City hospitals that are part of a single health system. Demographic data (age, sex, and race or ethnicity), COVID-19 status, stroke-related risk factors, and clinical and imaging findings pertaining to stroke were collected. Univariate and multivariate analyses were conducted to evaluate the association between COVID-19 and stroke subtypes. RESULTS. The study sample consisted of 329 patients for whom a code for stroke was activated (175 [53.2%] men, 154 [46.8%] women; mean age, 66.9 ± 14.9 [SD] years). Among the 329 patients, 35.3% (116) had acute ischemic stroke confirmed with imaging; 21.6% (71) had large vessel occlusion (LVO) stroke; and 14.6% (48) had small vessel occlusion (SVO) stroke. Among LVO strokes, the most common location was middle cerebral artery segments M1 and M2 (62.0% [44/71]). Multifocal LVOs were present in 9.9% (7/71) of LVO strokes. COVID-19 was present in 38.3% (126/329) of the patients. The 61.7% (203/329) of patients without COVID-19 formed the negative control group. Among individual stroke-related risk factors, only Hispanic ethnicity was significantly associated with COVID-19 (38.1% of patients with COVID-19 vs 20.7% of patients without COVID-19; p = 0.001). LVO was present in 31.7% of patients with COVID-19 compared with 15.3% of patients without COVID-19 (p = 0.001). SVO was present in 15.9% of patients with COVID-19 and 13.8% of patients without COVID-19 (p = 0.632). In multivariate analysis controlled for race and ethnicity, presence of COVID-19 had a significant independent association with LVO stroke (odds ratio, 2.4) compared with absence of COVID-19 (p = 0.011). CONCLUSION. COVID-19 is associated with LVO strokes but not with SVO strokes. CLINICAL IMPACT. Patients with COVID-19 presenting with acute neurologic symptoms warrant a lower threshold for suspicion of large vessel stroke, and prompt workup for large vessel stroke is recommended.

COVID-19 and Decompressive Hemicraniectomy for Acute Ischemic Stroke.

BACKGROUND AND PURPOSE: Young patients with malignant cerebral edema have been shown to benefit from early decompressive hemicraniectomy. The impact of concomitant infection with coronavirus disease 2019 (COVID-19) and how this should weigh in on the decision for surgery is unclear. METHODS: We retrospectively reviewed all COVID-19-positive patients admitted to the neuroscience intensive care unit for malignant edema monitoring. Patients with >50% of middle cerebral artery involvement on computed tomography imaging were considered at risk for malignant edema. RESULTS: Seven patients were admitted for monitoring of whom 4 died. Cause of death was related to COVID-19 complications, and these were either seen both very early and several days into the intensive care unit course after the typical window of malignant cerebral swelling. Three cases underwent surgery, and 1 patient died postoperatively from cardiac failure. A good outcome was attained in the other 2 cases. CONCLUSIONS: COVID-19-positive patients with large hemispheric stroke can have a good outcome with decompressive hemicraniectomy. A positive test for COVID-19 should not be used in isolation to exclude patients from a potentially lifesaving procedure.

Initial Stroke Thrombectomy Experience in New York City during the COVID-19 Pandemic.

New York City has become the global epicenter of the coronavirus 2019 (COVID-19) pandemic. Despite a massive shift in health care resources, cerebrovascular disease continues to be a substantial burden. We review the first 10 patients undergoing thrombectomy following a series of governmental and institutional policy changes diverting resources to the care of critically ill patients with COVID-19. Ten patients with emergent large-vessel occlusion underwent thrombectomy between March 23 and April 1, 2020. Five patients tested positive for the COVID-19 virus. Successful reperfusion was achieved in 9 of 10 patients, at a median time of 37 minutes from vascular access. The postprocedural NIHSS score improved by an average of 7.7 points. Of the 5 patients positive for COVID-19, none have experienced a critical respiratory illness. We report the early incidence of COVID-19 positivity in patients with emergent large-vessel occlusion and demonstrate that thrombectomy continues to be an efficacious option, as well as safe for health care providers.

Neuroendovascular clinical trials disruptions due to COVID-19. Potential future challenges and opportunities.

To assess the impact of COVID-19 on neurovascular research and deal with the challenges imposed by the pandemic. METHODS: A survey-based study focused on randomized controlled trials (RCTs) and single-arm studies for acute ischemic stroke and cerebral aneurysms was developed by a group of senior neurointerventionalists and sent to sites identified through the clinical trials website (https://clinicaltrials.gov/), study sponsors, and physician investigators. RESULTS: The survey was sent to 101 institutions, with 65 responding (64%). Stroke RCTs were being conducted at 40 (62%) sites, aneurysm RCTs at 22 (34%) sites, stroke single-arm studies at 37 (57%) sites, and aneurysm single-arm studies at 43 (66%) sites. Following COVID-19, enrollment was suspended at 51 (78%) sites-completely at 21 (32%) and partially at 30 (46%) sites. Missed trial-related clinics and imaging follow-ups and protocol deviations were reported by 27 (42%), 24 (37%), and 27 (42%) sites, respectively. Negative reimbursements were reported at 17 (26%) sites. The majority of sites, 49 (75%), had put new trials on hold. Of the coordinators, 41 (63%) worked from home and 20 (31%) reported a personal financial impact. Remote consent was possible for some studies at 34 (52%) sites and for all studies at 5 (8%) sites. At sites with suspended trials (n=51), endovascular treatment without enrollment occurred at 31 (61%) sites for stroke and 23 (45%) sites for aneurysms. A total of 277 patients with acute ischemic stroke and 184 with cerebral aneurysms were treated without consideration for trial enrollment. CONCLUSION: Widespread disruption of neuroendovascular trials occurred because of COVID-19. As sites resume clinical research, steps to mitigate similar challenges in the future should be considered.

COVID-19 Is an Independent Risk Factor for Acute Ischemic Stroke.

BACKGROUND AND PURPOSE: Coronavirus disease 2019 (COVID-19) is an active worldwide pandemic with diverse complications. Stroke as a presentation has not been strongly associated with COVID-19. The authors aimed to retrospectively review a link between COVID-19 and acute stroke. MATERIALS AND METHODS: We conducted a retrospective case-control study of 41 cases and 82 control subjects matched by age, sex, and risk factors. Cases were patients who underwent stroke alert imaging with confirmed acute stroke on imaging between March 16 and April 5, 2020, at 6 hospitals across New York City. Control subjects were those who underwent stroke alertimaging during the same timeframe without imaging evidence of acute infarction. Data pertaining to diagnosis of COVID-19 infection, patient demographics, and risk factors were collected. A univariate analysis was performed to assess the covariate effect of risk factors and COVID-19 status on stroke imaging with positive findings. RESULTS: The mean age for cases and controls was 65.5 ± 15.3 years and 68.8 ± 13.2 years, respectively. Of patients with acute ischemic stroke, 46.3% had COVID-19 infection compared with 18.3% of controls (P = .001). After adjusting for age, sex, and risk factors, COVID-19 infection had a significant independent association with acute ischemic stroke compared with control subjects (OR, 3.9; 95% CI, 1.7-8.9; P = .001). CONCLUSIONS: We demonstrated that COVID-19 infection is significantly associated with imaging confirmation of acute ischemic stroke, and patients with COVID-19 should undergo more aggressive monitoring for stroke.