Trends in Stroke Presentations before and during the COVID-19 Pandemic: A Meta-Analysis.

BACKGROUND AND PURPOSE: There are reports of decline in the rates of acute emergency presentations during coronavirus disease 2019 (COVID-19) pandemic including stroke. We performed a meta-analysis of the impact of COVID-19 pandemic on rates of stroke presentations and on rates of reperfusion therapy. METHODS: Following the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines, we systematically searched the literature for studies reporting changes in stroke presentations and treatment rates before and during the COVID-19 pandemic. Aggregated data were pooled using meta-analysis with random-effect models. RESULTS: We identified 37 observational studies (n=375,657). Pooled analysis showed decline in rates of all strokes (26.0%; 95% confidence interval [CI], 22.4 to 29.7) and its subtypes; ischemic (25.3%; 95% CI, 21.0 to 30.0), hemorrhagic (27.6%; 95% CI, 20.4 to 35.5), transient ischemic attacks (41.9%; 95% CI, 34.8 to 49.3), and stroke mimics (45.6%; 95% CI, 33.5 to 58.0) during months of pandemic compared with the pre-pandemic period. The decline was most evident for mild symptoms (40% mild vs. 25%-29% moderate/severe). Although rates of intravenous thrombolytic (IVT) and endovascular thrombectomy (EVT) decreased during pandemic, the likelihood of being treated with IVT and EVT did not differ between the two periods, both in primary and in comprehensive stroke centers (odds ratio [OR], 1.08; 95% CI, 0.94 to 1.24 and OR, 0.95; 95% CI, 0.83 to 1.09, respectively). CONCLUSIONS: Rates of all strokes types decreased significantly during pandemic. It is of paramount importance that general population should be educated to seek medical care immediately for stroke-like symptoms during COVID-19 pandemic. Whether delay in initiation of secondary prevention would affect eventual stroke outcomes in the long run needs further study.

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.

The Emerging Role of Telestroke in the Middle East and North Africa Region in the Era of COVID-19.

Stroke is the second most common cause of death worldwide. It is a medical emergency demanding immediate recognition to provide time-sensitive acute management. The coronavirus disease 2019 (COVID-19) pandemic has challenged acute stroke care, and alternate models of treatment are needed. Telestroke is well proven as a valid tool for acute stroke assessment and has been utilized successfully to manage patients remotely in many parts of the world, though it is underutilized in the Middle East and North Africa region. Given the challenges associated with the COVID-19 pandemic, such as risk of physician exposure to infection, implementation of a telestroke system is critical to provide consultant stroke physician coverage. This article provides a proposed model for coordinated telestroke. Implementation of telestroke in the Middle East and North Africa region and other underdeveloped areas will optimize stroke management, especially during the COVID-19 era.

Impact of COVID-19 pandemic on stroke admissions in Qatar.

INTRODUCTION: The COVID-19 pandemic has resulted in a dramatic unexplained decline in hospital admissions due to acute coronary syndromes and stroke. Several theories have emerged aiming to explain this decline, mostly revolving around the fear of contracting the disease and thus avoiding hospital visits. AIMS: In this study, we aim to examine the impact of the COVID-19 pandemic on stroke admissions to a tertiary care centre in Qatar. METHODS: The Hamad General Hospital stroke database was interrogated for stroke admissions between September 2019 and May 2020. The number of stroke admissions, stroke subtypes and short-term outcomes was compared between the 'pre-COVID-19' period (September 2019 to February 2020) and the COVID-19 pandemic period (March to May 2020). RESULTS: We observed a significant decline in monthly admissions in March (157), April (128) and May (135) compared with the pre-COVID-19 6-month average (229) (p=0.024). The reduction in admissions was most evident in functional stroke mimics. The average admissions decreased from 87 to 34 per month (p=0.0001). Although there were no significant differences in admissions due to ischaemic stroke (IS), intracranial haemorrhage or transient ischaemic attacks between the two periods, we noted a relative decrease in IS due to small vessel disease and an increase in those due to large vessel atherosclerosis in March to May 2020. CONCLUSIONS: The decline in overall stroke admissions during the COVID-19 pandemic is most likely related to concerns of contracting the infection, evidenced mainly by a decline in admissions of stroke mimics. However, a relative increase in large vessel occlusions raises suspicion of pathophysiological effects of the virus, and requires further investigation.

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.

Impact of COVID-19 on neurological manifestations: an overview of stroke presentation in pandemic.

Corona virus disease 2019 (COVID-19) pandemic has become a globally challenging issue after its emergence in December 2019 from Wuhan, China. Despite its common presentation as respiratory distress, patients with COVID-19 have also shown neurological manifestation especially stroke. Therefore, the authors sought to determine the etiology, underlying risk factors, and outcomes among patients with COVID-19 presenting with stroke. We conducted a systematic review of the electronic database (PubMed, Google Scholar, Scopus, Medline, EMBASE, and Cochrane library) using different MeSH terms from November 2019 to June 2020. A total of 39 patients with stroke from 6 studies were included. The mean age of our included patients was 61.4 ± 14.2 years. Majority of the patients (n = 36, 92.3%) with COVID-19 had ischemic stroke, 5.1% (n = 2) had hemorrhagic stroke, and 2.6% (n = 1) had cerebral venous thrombosis at the time of initial clinical presentation. Almost all of the patients presented had underlying risk factors predisposing to stroke which included diabetes mellitus, hyperlipidemia, hypertension, and previous history of cerebrovascular disease. 51.2% (n = 20) of the included patients infected with COVID-19 with stroke died, while remaining patients were either discharged home or transferred to a rehabilitation unit. Exploring the neurological manifestation in terms of stroke among patients with COVID-19 is a step towards better understanding of the virus, preventing further spread, and treating the patients affected by this pandemic.

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.