Neuroimaging Findings of SARS-CoV-2 Infection

This review article is a pictorial review of the wide variety of brain and spine CT and MR imaging findings related to coronavirus disease 2019 (COVID-19) in patients with neurologic deficits. By classifying CNS manifestations according to their pathogenesis, we provide different examples of vascular, immunologic, infectious, and miscellaneous complications associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We present cases encountered during the pandemic, retrieved from a large health system. Learning Objectives: To review the spectrum of common and uncommon brain and spine neuroimaging findings of COVID-19 and describe the key imaging features for each finding. © 2022, American Society of Neuroradiology. All rights reserved.

The impact of patient demographics on the utilization of video vs telephonic care in a telemedicine clinic during the COVID-19 pandemic

Background: In response to the COVID-19 pandemic, stroke outpatient care was transformed to telemedicine (TM) through video (VTM) and telephonic (TPH) visits. While TM offers potential benefits over in-person visits for stroke patients, accessibility of VTM may be limited for patients at highest risk for poor outcomes. We recommended VTM for all patients, but offered TPH visits if patients did not have adequate equipment or declined VTM. We examined whether demographic variables influenced the TM visit type completed (VTM vs TPH) for patients seen during the pandemic. Methods: We conducted a retrospective review of charts for patients seen in our stroke clinic between 3/16/20 (fully operational TM) and 5/31/20. We determined visit type: VTM vs in-person vs TPH and abstracted demographic and clinical data. We focused on TM visits and used t-tests, Fisher's exact tests, and chi-squared as appropriate for univariate analyses and logistic regression for multivariate analyses. Results: Among 463 visits, 47 in-person visits were excluded, leaving 416 (328 VTM and 88 TPH). Mean age was 61.5 and by race/ethnicity: 42.9% non-Hispanic white (NHW), 36.9% non-Hispanic Black (NHB), 11.6% Hispanic, 4.3% Asian, and 4.3% other (Table 1). In univariate analyses, visit type was significantly associated with race (p = 0.024), insurance type (p=0.001), and visit type (new vs established). In adjusted analysis, NHB race was associated with 1.90 times higher odds (95% CI 1.09-3.32) of TPH vs VTM compared to NHW. Medicaid insurance was associated with 3.90 times higher odds (95% CI 1.54-9.88) of TPH vs VTM visit compared to private insurance. Conclusions: We found that NHB patients and patients with Medicaid were less likely to complete VTM visits compared to TPH. This suggests barriers to VTM based on race and insurance type and deserves further study. If video visits are superior to TPH visits for clinical care, these barriers may widen disparities in secondary stroke prevention during the pandemic.(Figure Presented).

Impact of the COVID-19 pandemic in houston on stroke care in a health system of 10 stroke centers

Introduction: We assessed the impact of COVID-19 pandemic on stroke admissions and care metrics within a health system of 10 stroke centers, with 4 comprehensive stroke centers (CSC) in the greater Houston region. Methods: Between January-June 2019 and January-June 2020, we compared the proportion of ischemic strokes (total & direct CSC presentations) & intracerebral hemorrhage (ICH) relative to total admissions using logistic regression, and among the direct CSC presentations, we compared door to tPA and thrombectomy times using Wilcoxon Rank Sum. Results: A total of 4808 cases were assessed (Table 1). There was an initial drop of ∼30% in cases at the pandemic onset (Fig.1). Numerically fewer patients in the 2020 period were seen at primary and CSCs (Table 1). Compared to 2019, there was a significant reduction in transferred patients [N(%), 829 (36) vs. 637 (34), p=0.02], in hospital strokes [N(%), 111 (5) vs. 69 (4), p=0.04], and mild strokes (NIHSS 1-5) [N (%), 891 (43) vs. 635 (40),p=0.02], and no significant differences in the proportions of total ischemic strokes [OR (95% CI)=0.92 (0.79, 1.06), p=0.23], direct CSC presentations [OR (95% CI) =0.96 (0.86, 1.08), p=0.48] and ICH [OR (95% CI) =1.14 (0.98, 1.33), p=0.08] in 2020 (Fig. 1). Among the direct ischemic strokes at CSCs, there were similar mean (SD) (mins) door to tPA [44 (17) vs. 42 (17), p=0.14] but significantly prolonged door to thrombectomy times [94 (15) vs. 85 (20), p=0.005] in 2020. Conclusion: COVID-19 pandemic led to reduced mild stroke admissions, transfers and in hospital stroke alerts, & prolonged door to thrombectomy times. Identifying reasons to mitigate this discrepancy is crucial for next pandemic preparedness. (Figure Presented).

Population-based drug repurposing to treat thrombosis in COVID-19 patients

Introduction: Patients with coronavirus disease 2019 (COVID-19) have an increased risk of thrombosis. Our objective is to obtain population-level treatment effects of drugs on treating thrombosis in COVID-19. Methods: We conducted a retrospective analysis of Optum electronic health records (EHRs) with 34,043 hospitalized COVID-19 patients. We identified case-patient with thrombosis (stroke, deep vein thrombosis, pulmonary embolism, and myocardial infarction) using PheWas codes. The propensity score matching was used to select comparable control patients who survived without any thrombosis based on demographics and admission status (temperature and SpO2 level). We computed the average treatment effect (ATT) for medication using advanced inverse propensity score weighting based on pre-treatment conditions (i.e., comorbidities in the last 6 months and medications in the last 2 months before hospitalization). Results: We identified 2,446 case-patients with thrombosis and 5,020 comparable control patients. There were a total of 540 drugs that were administered in at least 80 patients. We calculated the 540 drugs' ATT coefficient. As a result, 23 drugs had a positive ATT coefficient with a p-value of less than 0.05. After filtering out commonly prescribed symptomatic drugs (e.g., Acetaminophen, Guaifenesin, and Ondansetron), we highlight the following drugs with statistically significant treatment effects: Atorvastatin (ATT=0.34), Ceftriaxone (ATT=0.26), Levothyroxine (ATT=0.26), Albuterol (ATT=0.25), Azithromycin (ATT=0.23), Enoxaparin (ATT=0.20), and Metformin (ATT=0.20). Conclusions: In this preliminary work, we identified anti-thrombotic drugs (Enoxaparin) but also anti-inflammatory drugs (Atorvastatin, Metformin) and possibly antibiotics that have a significant treatment effect in COVID-19 patients that could reduce risk of thrombosis. We also observed that several anti-thrombotic drugs (Apixaban and Ticagrelor) had negative treatment effects, which was partly due to an imbalance in pre-treatment conditions. Our future work is to incorporate more extensive data (such as lab tests and vital signs) into the propensity scores to better capture the severity of admission status.

Delaying admission to inpatient rehabilitation worsens outcome for stroke patients: Detrimental impact of COVID-19 on stroke survivors

Introduction: Inpatient rehabilitation (IPR) is crucial to recovery after stroke. COVID-19, however, has led to delays in post-stroke admission to IPR due to transmission concerns. Objective: We evaluated the effect of time from stroke onset to IPR admission on post-stroke recovery Design: A retrospective analysis of 680 patients with acute stroke or intracerebral hemorrhage (ICH), admitted to IPR between APR-2017 and AUG-2019. Association between time from stroke onset to IPR and discharge FIM-Motor Total and FIM-Motor Total with transfers scores was studied, after adjusting for sex, age at onset, stroke severity and type. Multiple linear regression models were conducted for outcomes discharge: (FIM-Motor Total) and (FIM-Motor Total with transfers) (Table 1). Square transformations were used to satisfy model assumptions. Ordinal logistic regression models were run for outcomes discharge FIM subset scores categorized as independent (6-7), needs supervision (5), and needs assistance (1-4, reference). The primary variable of interest was days onset to IPR, adjusted for stroke severity (admit FIM subset scores), sex, stroke type and age. (Table 2). The proportional odds assumption was verified using Brant test. Results: An inverse relationship was observed between days from onset to IPR and discharge FIMMotor with and without transfers. Time from stroke onset to IPR admission was associated with decreased discharge FIM-Motor and FIM-Motor with transfers, after adjusting for other covariates. Among FIM subset discharges, an additional day also resulted in a 2-5% decrease in the odds of being more independent. Conclusion: Delays to IPR admission result in decreased motor function gains and lower chance of independence. In addition to current community education practices, acute care hospitals and IPR facilities must review their processes to remove delays. These processes include requirements for COVID disease testing and IPR acceptance policies.