Patient Management in Neurology Intensive Care During COVID-19 Pandemic Period

Objective: This study aims to evaluate data from coronavirus disease-2019 (COVID-19) patients with neurological manifestations hospitalized in the intensive care unit (ICU). Materials and Methods: The study included data from COVID-19 patients with neurological manifestations hospitalized in ICU. Patients' demographic characteristics, risk factors, laboratory results, treatment methods, mechanical ventilation methods, use of non-invasive techniques to meet O2 requirements, clinical outcome at discharge and after three months, and mortality rates were evaluated. Results: The study included 25 patients. Mean age of the patients was 66.76±12.93. Fifty two percent of the patients were male. Of the patients 96% had a positive polymerase chain reaction test, and 92% had lung involvement. The comorbidities of the patients were hypertension (48%), diabetes mellitus (28%), coronary artery disease (28%), cerebrovascular disease (20%), cancer (20%), and chronic obstructive pulmonary disease (12%). Seventy two percent of the patients presented with stroke. Of the patients %12 presented with encephalopathy, whereas patients with epilepsy and myasthenia gravis accounted for 8%. Patients' average length of stay in ICU was 13.16±12.44 days. Pressure-synchronized intermittent mandatory ventilation mode was used in 56% of patients. Number of intubation days was 9.5±12.26. All patients were treated with favipiravir and antiaggregant, 92% with steroids and antibacterial therapy, 52% with antiaggregant, 20% with plasma therapy, 8% with cytokine filter and immunoglobulin therapy, and 4% with monoclonal antibody therapy. During hospitalization, mortality rate was 48%, good clinical outcome rate was 36%. Conclusion: The rates of poor clinical outcomes are seen to be high during in-hospital treatment and follow-up of COVID-19 patients presenting with neurological symptoms, as well as at discharge. (English) [ FROM AUTHOR] Amaç: Bu çalışmada yoğun bakım ünitesine (YBÜ) yatan nörolojik manifestasyonları olan koronavirüs hastalığı-2019 (COVID-19) hastalarının verilerini değerlendirmeyi amaçladık. Gereç ve Yöntem: Çalışmaya nöroloji YBÜ'de nörolojik manifestasyonlar ile yatan COVID-19 hastalarının verileri dahil edildi. Hastaların demografik özellikleri, risk faktörleri, laboratuvar sonuçları, tedavi yöntemleri, mekanik ventilasyon süreçleri, O2 ihtiyacını karşılayan non-invazif yöntemlerin kullanımı, taburculuk ve 3. ayda klinik sonlanım oranları, ölüm oranları değerlendirildi. Bulgular: Çalışmaya nörolojik prezentasyonu olan toplam 25 COVID-19 hastası dahil edildi. Hastaların yaş ortalaması 66,76±12,93 (36-83) idi. Yüzde 52 oranını erkek cinsiyet oluşturuyordu. Hastaların %96'sında polimeraz zincir reaksiyonu testi pozitif, %92 oranında akciğer tutulumu vardı. Hastaların komorbitesini %48 hipertansiyon, %28 diabetes mellitus ve koroner arter hastalığı, %20 serebrovasküler hastalık, %20 kanser, %12 kronik obstriktif akciğer hastalığı oluşturdu. Hastaların %72'si inme ile prezente olan COVID-19 grubundan oluşuyordu. Yüzde 12 ensefalopati tablosunda gelen COVID-19 hastalarından, %8 epilepsi ve miyastenia gravis semptomları ile gelen hastalardan oluşuyordu. Hastaların ortalama YBÜ yatış süresi 13,16±12,44 gündü. Hastaların %56'sı yüksek mekanik ventilatör ayarlarında, senkronize intermittent mekanik ventilasyon modunda takip edildi. Entübasyon gün sayısı 9,5±12,26 idi. Hastaların tümüne favipravir ve antiagregan, %92'sine steroid ve antibakterial tedavi, %52'sine antiagregan, %20'sine plazma tedavisi, %8'ine sitokin filtiresi ve immünoglobulin tedavisi, %4'üne monoklonal antikor tedavisi uygulandı. Hastaların yatışı sürecinde ölümle sonuçlanma oranı %48, iyi klinik sonlanım oranı %36, saptandı. Sonuç: Nörolojik belirtilerle gelen COVID-19 hastalarının hastane içi tedavi ve takip sürecinde, aynı zamanda taburculuklarında kötü klinik sonlanım oranları yüksek görülmektedir. (Turkish) [ FROM AUTHOR] Copyright of Turkish Journal of Neurology / Turk Noroloji Dergisi is the property of Galenos Yayinevi Tic. LTD. STI and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

COVID-19 ile Myastenia Gravis Birlikteliğindeki Bir Olguda Tedavi Stratejileri Nelerdir?

Amaç: Otoimmün nöromüsküler bir hastalık olan Myastenia gravis (MG), şiddetli COVID-19 için bir risk faktörü olabilir. Şu anda, COVID-19’un MG hastalarını nasıl etkilediği net bilinmemektedir. MG’de COVID-19’un yönetimine yönelik mevcut kılavuzlar, uzmanların teorik olarak fikir birliğine dayanmaktadır. Amacımız, eşlik eden COVID-19 enfeksyonu eşlik eden MG hastalarında plazmaferez tedavisinin prognoz üzerine etkinliğini vurgulamaktır. Olgu: Elli beş yaş erkek hasta -24 yıldır MG tanısı ile takipli- acil servise 2 gündür devam eden nefes darlığı ve 4 gün önce yapılan COVID PZR testi pozitifliği ile başvurdu. Favipiravir kullanmıyordu. Nörolojik muayede solunum sıkıntısı ve bilateral parsiyel oftalmoparezi mevcuttu. HRCT’de bilateral yaygın opasiteler ve buzlu cam görünümü mevcuttu. COVID-19 pnomonisi ve miyatenik kriz ön tanısı ile nöroloji yoğun bakım ünitesine yatırıldı. Yatış esnasında nazal kanul ile 6 l/dk O2 tedavisi başlandı. Ancak SO2 ’de progesif düşüş nedeni (Şekil 1) ile HFNC ile O2 desteğine geçildi. Favipiravire ek olarak antibiyoterapi (seftriakson) başlandı (Tablo 1) ve 2 doz konvelan plazma tedavisi uygulandı. Ancak solunum sıkıntısında progresyon nedeni ile 3. gün 1000 mg/gün puls steroid tedavisine geçildi. Beşinci gün progresif hipoksemisi nedeni ile entübe edildi (Şekil 2). Altıncı gün bir kür sitokin filtesi uygulandı. Sekizinci gün miyastenik kriz nedeni ile 5 gün günlük plamaferez yapıldı. Herhangi bir kompliaksyon oluşmadı. On üçüncü günde hasta ekstube oldu. Yatışının 20. günü azothıpurin 25 mg/gün, oral prendnizlon 32 mg/gün ve pridostigmin 5/gün ile tam iyilik hali ile taburcu edildi. Sonuç: COVID-19’un bir krizi tetiklediği bu hastada, plazmaferez uygulamasının, hastanın miyastenik krizinin tetikleyicilerinden biri olabilecek COVID-19 enfeksiyonuna bağlı enflamatuvar sitokinleri ortadan kaldırarak iyileşmeyi hızlandırdığına inanıyoruz. COVID-19 tedavisi olarak plazma değişiminin etkinliğini değerlendirmek için çalışmalar devam etmektedir. Hali hazırda mevcut olan intravenöz immünoglobulin (ÍVÍG), COVID-19’a karşı koruyucu antikorlara sahip olmayabilir, bu nedenle, bu olguda plazmaferez tercih edildi. Biz bu özel durumda plazmaferezin, IVIG’ye göre daha güvenle tercih edilebilir olduğunu ve prognoz üzerine olumlu etkisini vurgulamak istedik. (Turkish) [ FROM AUTHOR] Copyright of Turkish Journal of Intensive Care is the property of Galenos Yayinevi Tic. LTD. STI and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Lessons learned in stroke care during COVID-19 pandemic and preparing for future pandemics in the MENA+ region: A consensus statement from the MENA+-SINO.

BACKGROUND: COVID-19 pandemic has negatively impacted stroke care services at multiple levels. There was a decline in acute stroke admissions. Fewer interventions have been performed. Increased "door-to-needle times and "door-to-groin puncture" during this pandemic. These factors combined have led to declining in the favoured outcomes of stroke patients' globally. Yet this pandemic permits an opportunity for higher preparedness for future pandemics. OBJECTIVES AND METHODS: This paper aims to shed light on the main lessons learned in the field of stroke care during the first wave of COVID-19 pandemic. Here we are presenting proposals and initiatives for better preparedness in future similar emergencies. These proposals are based primarily on literature review of COVID-19 publications, as well as the first-hand experience gained during the first wave at the regional level. In addition to the consensus and collective ride of stroke experts in the Middle East North Africa Stroke and Interventional Neurotherapies Organization (MENA+-SINO) and interaction and collaboration with international stroke specialists from the Stroke World Organization (WSO), European Stroke Organization (ESO) and stroke and COVID-19 papers authors. CONCLUSION: Stroke care is very complex, particularly in the initial hours after onset of symptoms. A successful outcome requires very close collaboration between clinical personnel from multiple specialties. Preparedness for future pandemics requires the improvement of care plans that allow for rapid assessment of stroke patients and ensuring that regular 'mock exercises' familiarize quintessential services that care for the stroke patients.

Decline in subarachnoid haemorrhage volumes associated with the first wave of the COVID-19 pandemic.

BACKGROUND: During the COVID-19 pandemic, decreased volumes of stroke admissions and mechanical thrombectomy were reported. The study's objective was to examine whether subarachnoid haemorrhage (SAH) hospitalisations and ruptured aneurysm coiling interventions demonstrated similar declines. METHODS: We conducted a cross-sectional, retrospective, observational study across 6 continents, 37 countries and 140 comprehensive stroke centres. Patients with the diagnosis of SAH, aneurysmal SAH, ruptured aneurysm coiling interventions and COVID-19 were identified by prospective aneurysm databases or by International Classification of Diseases, 10th Revision, codes. The 3-month cumulative volume, monthly volumes for SAH hospitalisations and ruptured aneurysm coiling procedures were compared for the period before (1 year and immediately before) and during the pandemic, defined as 1 March-31 May 2020. The prior 1-year control period (1 March-31 May 2019) was obtained to account for seasonal variation. FINDINGS: There was a significant decline in SAH hospitalisations, with 2044 admissions in the 3 months immediately before and 1585 admissions during the pandemic, representing a relative decline of 22.5% (95% CI -24.3% to -20.7%, p<0.0001). Embolisation of ruptured aneurysms declined with 1170-1035 procedures, respectively, representing an 11.5% (95%CI -13.5% to -9.8%, p=0.002) relative drop. Subgroup analysis was noted for aneurysmal SAH hospitalisation decline from 834 to 626 hospitalisations, a 24.9% relative decline (95% CI -28.0% to -22.1%, p<0.0001). A relative increase in ruptured aneurysm coiling was noted in low coiling volume hospitals of 41.1% (95% CI 32.3% to 50.6%, p=0.008) despite a decrease in SAH admissions in this tertile. INTERPRETATION: There was a relative decrease in the volume of SAH hospitalisations, aneurysmal SAH hospitalisations and ruptured aneurysm embolisations during the COVID-19 pandemic. These findings in SAH are consistent with a decrease in other emergencies, such as stroke and myocardial infarction.

MENA-SINO Consensus Statement on Implementing Care Pathways for Acute Neurovascular Emergencies During the COVID-19 Pandemic.

In the unprecedented current era of the COVID-19 pandemic, challenges have arisen in the management and interventional care of patients with acute stroke and large vessel occlusion, aneurysmal subarachnoid hemorrhage, and ruptured vascular malformations. There are several challenges facing endovascular therapy for stroke, including shortages of medical staff who may be deployed for COVID-19 coverage or who may have contracted the infection and are thus quarantined, patients avoiding early medical care, a lack of personal protective equipment, delays in door-to-puncture time, anesthesia challenges, and a lack of high-intensity intensive care unit and stroke ward beds. As a leading regional neurovascular organization, the Middle East North Africa Stroke and Interventional Neurotherapies Organization (MENA-SINO) has established a task force composed of medical staff and physicians from different disciplines to establish guiding recommendations for the implementation of acute care pathways for various neurovascular emergencies during the current COVID-19 pandemic. This consensus recommendation was achieved through a series of meetings to finalize the recommendation.

Current Recommendations for the Management of Stroke Patients in the Middle East in the Era of COVID-19 Pandemic; Statement from the MENA SINO.

COVID-19 pandemic has led to a change in the way we manage acute medical illnesses. This pandemic had a negative impact on stroke care worldwide. The World Stroke Organization (WSO) has raised concerns due to the lack of available care and compromised acute stroke services globally. The numbers of thrombolysis and thrombectomy therapies are declining. As well as, the rates and door-to treatment times for thrombolysis and thrombectomy therapies are increasing. The stroke units are being reallocated to serve COVID-19 patients, and stroke teams are being redeployed to COVID-19 centers. Covid 19 confirmed cases and deaths are rising day by day. This pandemic clearly threatened and threatening all stroke care achievements regionally. Managing stroke patients during this pandemic is even more challenging at our region. The Middle East and North Africa Stroke and Interventional Neurotherapies Organization (MENA-SINO) is the main stroke organization regionally. MENA-SINO urges the need to developing new strategies and recommendations for stroke care during this pandemic. This will require multiple channels of interventions and create a protective code stroke with fast triaging path. Developing and expanding the tele-stroke programs are urgently required. There is an urgent need for enhancing collaboration and cooperation between stroke expertise regionally and internationally. Integrating such measures will inevitably lead to an improvement and upgrading of the services to a satisfactory level.

Call to Action: SARS-CoV-2 and CerebrovAscular DisordErs (CASCADE).

BACKGROUND AND PURPOSE: The novel severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2), now named coronavirus disease 2019 (COVID-19), may change the risk of stroke through an enhanced systemic inflammatory response, hypercoagulable state, and endothelial damage in the cerebrovascular system. Moreover, due to the current pandemic, some countries have prioritized health resources towards COVID-19 management, making it more challenging to appropriately care for other potentially disabling and fatal diseases such as stroke. The aim of this study is to identify and describe changes in stroke epidemiological trends before, during, and after the COVID-19 pandemic. METHODS: This is an international, multicenter, hospital-based study on stroke incidence and outcomes during the COVID-19 pandemic. We will describe patterns in stroke management, stroke hospitalization rate, and stroke severity, subtype (ischemic/hemorrhagic), and outcomes (including in-hospital mortality) in 2020 during COVID-19 pandemic, comparing them with the corresponding data from 2018 and 2019, and subsequently 2021. We will also use an interrupted time series (ITS) analysis to assess the change in stroke hospitalization rates before, during, and after COVID-19, in each participating center. CONCLUSION: The proposed study will potentially enable us to better understand the changes in stroke care protocols, differential hospitalization rate, and severity of stroke, as it pertains to the COVID-19 pandemic. Ultimately, this will help guide clinical-based policies surrounding COVID-19 and other similar global pandemics to ensure that management of cerebrovascular comorbidity is appropriately prioritized during the global crisis. It will also guide public health guidelines for at-risk populations to reduce risks of complications from such comorbidities.