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Background and Purpose: Stroke is a serious complication of COVID-19. However, the risk factors for this complication are poorly understood. We hypothesize that genetic predisposition to cardioand cerebrovascular disease (CVD) leads to an increased risk of stroke in patients with COVID-19 infection. Methods: We evaluated data from a nested cohort study conducted within the UK Biobank focused on persons with documented COVID-19. Incident strokes (ischemic and hemorrhagic) were identified by combining inpatient data (including critical care and discharge diagnostic codes) and primary care data, the latter entered by providers within 30 days of a positive COVID-19 test. Genetic predisposition to CVD was evaluated through a polygenic risk score that integrated genomic information on 2,176 independent genetic risk variants for stroke, coronary artery disease and cardiometabolic risk factors. This score was divided into low (0-20th percentile), intermediate (20th- 80th percentile), and high (80 -100 percentile) genetic risk. Results: A total of 11,882 study participants (mean age 65.8, SD [8.6], female sex 6,306 [53.1%]) with documented COVID-19 infection were included in this study, including 99 (0.8%) persons that ustained a stroke during the infection. Compared to persons with low genetic predisposition to CVD, those with intermediate and high genetic risk had 35% (OR 1.35, 95%CI 1.14-1.55) and 2.4- fold (OR 2.38, 95% CI 1.71-3.05) higher risk of stroke (test for trend p=0.004). Sub-scoring analyses evaluating one polygenic risk score per CVD trait of interest indicated that genetic predisposition to hypertension (p=0.017) and smoking (p=0.03) were the most important genetic risk factors. Conclusions: Genetic predisposition to CVD is associated with a higher risk of stroke in persons with acute COVID-19 infection. Genetic risk factors for hypertension and smoking appear to mediate a significant portion of this association. Genetic information should be considered in the multiple ongoing efforts to create risk-stratification strategies to identify COVID-19 patients at high risk of stroke.
ABSTRACT
Background: Although hospital admissions for stroke declined in 2020 during the COVID-19 pandemic, patients with comorbid COVID-19 and stroke had increased mortality. We explored stroke mortality in 2020 and its association with COVID-19 prevalence and state-level hospital capacities. Methods: We analyzed CDC National Vital Statistics System and COVID Data Tracker data from 2017-2020. The primary outcome was age-adjusted stroke (ischemic and hemorrhagic) mortality rate per 100,000. The secondary outcome was % change in state-level stroke mortality rates in 2020 (vs. 2017-19);we report its correlation with state-level 1) prevalence of confirmed COVID-19 infections by 12/31/2021, 2) total COVID mortality by 12/31/20, and the 2020 average state-level % of 3) hospital and 4) ICU beds occupied by COVID-19 patients. Results: Figure 1A shows the typical seasonal decline in stroke mortality in quarters 2/3 was attenuated in 2020. The % change in state-level stroke mortality in 2020 (Figure 1B) was not correlated with prevalence of COVID-19 infection (rho=0.05, p=0.74), mortality (rho=0.10, p=0.49), or the % of ICU beds occupied by COVID-19 patients (rho=0.24, p=0.09). There was a correlation with % of hospital beds occupied by COVID-19 patients (rho=0.35, p=0.01) (Figure 2) Conclusion: Overall stroke mortality increased in 2020, particularly in Q2/3, the early-to-mid phase of the COVID-19 pandemic. At the state level, the average % of all hospital beds occupied by COVID-19 patients in 2020 was the only COVID-19 metric associated with change in stroke mortality. Future work should determine if this association was due to decreased hospital capacity to deliver standard stroke care.
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Objective: To obtain neuroimaging on patients with COVID-19 using a low-field, portable magnetic resonance imaging (MRI) device. Background: Neuroimaging is a key step in the clinical evaluation of brain injury. Conventional MRI systems operate at high-strength magnetic fields (1.5-3T) that require patient transportation to access-controlled environments. During the COVID-19 pandemic, critically ill patients have had limited neuroimaging due to infection control and safety concerns. We report neuroimaging in patients with severe COVID-19 using a portable MRI device. Design/Methods: A 64mT point-of-care (POC) MRI was used to acquire neuroimaging in Yale New Haven Hospital ICUs from April 2020 through August 2020. COVID-19 patients with neurological symptoms and no MRI contraindications were scanned. Exams were acquired using a standard 110V/15A power outlet. Hospital rooms included vital signs monitors, ventilators, dialysis machines, and intravenous infusion pumps. Images were acquired by trained research staff, without the need for an MRI technician. POC MRI exams were interpreted by two boardcertified physicians (one neuroradiologist and one neurologist). Results: POC MRI exams were obtained on 22 ICU COVID-19 patients (19% female, ages 42-74 years, 86% mechanically ventilated). Glasgow Coma Scale and Richmond Agitation-Sedation Scale at time of scan were 7±3 and-3±2, respectively. T1-weighted (T1W), T2-weighted (T2W), fluid-attenuated inversion recovery (FLAIR), and diffusion-weighted imaging (DWI) sequences were obtained for all patients. Axial scan times were 4:54 minutes, 7:03 minutes, 9:31 minutes, and 9:04 minutes, respectively. Examination time was 35:40 minutes. Abnormal neuroimaging findings were observed in 10 patients: Intracranial hemorrhage (n=2), cerebral infarction (n=4), diffuse cerebral edema (n=1), and leukoencephalopathy (n=3). The device did not interfere with ICU equipment, and no significant adverse events occurred. Conclusions: We report the acquisition of neuroimaging using a low-field, portable MRI at the bedside of patients with severe COVID-19. This approach may hold promise for bedside assessment of neurological injury in settings with imaging access constraints.
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Introduction: The magnitude and drivers of excess cerebrovascular-specific mortality during the coronavirus-19 (COVID-19) pandemic are unknown. We aim to quantify excess stroke-related death and characterize its association with psychosocial factors and emerging COVID-19 related mortality. Methods: U.S. and state-level excess cerebrovascular deaths from January-May 2020 were quantified by Poisson regression models built using National Center for Health Statistic (NCHS) data. Weekly excess cerebrovascular deaths in the U.S. were analyzed as functions of time-varying, weekly stroke-related EMS calls and weekly COVID-19 deaths by univariable linear regression. A state-level negative binomial regression analysis was performed to determine the association between excess cerebrovascular deaths and social distancing (degree of change in mobility per Google COVID-19 Community Mobility Reports) during the height of the pandemic after the first COVID-19 death (February 29, 2020), adjusting for cumulative COVID-19 related deaths and completeness of deaths attributable to COVID-19 in NCHS. Findings: There were 918 more cerebrovascular deaths than expected from January 1-May 16 , 2020 in the U.S. Excess cerebrovascular mortality occurred during every week between March 28- May 2 , 2020, up to 7.8% during the week of April 18 . Decreased stroke-related EMS calls were associated with excess stroke deaths one (β -0.06, 95% CI -0.11, -0.02) and two weeks (β -0.08, 95% CI -0.12, -0.04) later. There was no significant association between weekly excess stroke death and COVID-19 death. Twenty-three states and NYC experienced excess cerebrovascular mortality during the pandemic height. At the state level, a 10% increase in social distancing was associated with a 4.3% increase in stroke deaths (IRR 1.043, 95% CI 1.001-1.085) after adjusting for COVID- 19 mortality. Conclusions: Excess U.S. cerebrovascular deaths during the COVID-19 pandemic were observedwith decreases in stroke-related EMS calls nationally and less mobility at the state level. Publichealth measures are needed to identify and counter the reticence to seeking medical care for acutestroke during the COVID-19 pandemic.
ABSTRACT
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.