Early Impact of the COVID-19 Pandemic on Acute Stroke Treatment Delays.

This is an observational cohort study comparing 156 patients evaluated for acute stroke between March 30 and May 31, 2020 at a comprehensive stroke center with 138 patients evaluated during the corresponding time period in 2019. During the pandemic, the proportion of COVID-19 positive patients was low (3%), the time from symptom onset to hospital presentation was significantly longer, and a smaller proportion of patients underwent reperfusion therapy. Among patients directly evaluated at our institution, door-to-needle and door-to-recanalization metrics were significantly longer. Our findings support concerns that the current pandemic may have a negative impact on the management of acute stroke.

Impact of the SARS-COV-2 Pandemic on the Endovascular Treatment of Acute Stroke - an Italian Single-Center Experience.

OBJECTIVES: The SARS-CoV-2 pandemic greatly influenced the overall quality of healthcare. The purpose of this study was to compare the time variables for acute stroke treatment and evaluate differences in the pre-hospital and in-hospital care before and during the SARS-CoV-2 pandemic, as well as between the first and second waves. MATERIALS AND METHODS: Observational and retrospective study from an Italian hospital, including patients who underwent thrombectomy between January 1st 2019 and December 31st 2020. RESULTS: Out of a total of 594 patients, 301 were treated in 2019 and 293 in 2020. The majority observed in 2019 came from spoke centers (67,1%), while in 2020 more than half (52%, p < 0.01) were evaluated at the hospital's emergency room directly (ER-NCGH). When compared to 2019, time metrics were globally increased in 2020, particularly in the ER-NCGH groups during the period of the first wave (N = 24 and N = 56, respectively): "Onset-to-door":50,5 vs 88,5, p < 0,01; "Arrival in Neuroradiology - groin":13 vs 25, p < 0,01; "Door-to-groin":118 vs 143,5, p = 0,02; "Onset-to-groin":180 vs 244,5, p < 0,01; "Groin-to-recanalization": 41 vs 49,5, p = 0,03. When comparing ER-NCGH groups between the first (N = 56) and second (N = 49) waves, there was an overall improvement in times, namely in the "Door-to-CT" (47,5 vs 37, p < 0,01), "Arrival in Neuroradiology - groin" (25 vs 20, p = 0,03) and "Onset-to-groin" (244,5 vs 227,5, p = 0,02). CONCLUSIONS: During the SARS-CoV-2 pandemic, treatment for stroke patients was delayed, particularly during the first wave. Reallocation of resources and the shutting down of spoke centers may have played a determinant role.

Changes in Stroke Hospital Care During the COVID-19 Pandemic: A Systematic Review and Meta-Analysis.

[Figure: see text].

COVID-19 Lockdown Effects on Acute Stroke Care in Latin America.

OBJECTIVES: COVID-19 pandemic has forced important changes in health care worldwide. Stroke care networks have been affected, especially during peak periods. We assessed the impact of the pandemic and lockdowns in stroke admissions and care in Latin America. MATERIALS AND METHODS: A multinational study (7 countries, 18 centers) of patients admitted during the pandemic outbreak (March-June 2020). Comparisons were made with the same period in 2019. Numbers of cases, stroke etiology and severity, acute care and hospitalization outcomes were assessed. RESULTS: Most countries reported mild decreases in stroke admissions compared to the same period of 2019 (1187 vs. 1166, p = 0.03). Among stroke subtypes, there was a reduction in ischemic strokes (IS) admissions (78.3% vs. 73.9%, p = 0.01) compared with 2019, especially in IS with NIHSS 0-5 (50.1% vs. 44.9%, p = 0.03). A substantial increase in the proportion of stroke admissions beyond 48 h from symptoms onset was observed (13.8% vs. 20.5%, p < 0.001). Nevertheless, no differences in total reperfusion treatment rates were observed, with similar door-to-needle, door-to-CT, and door-to-groin times in both periods. Other stroke outcomes, as all-type mortality during hospitalization (4.9% vs. 9.7%, p < 0.001), length of stay (IQR 1-5 days vs. 0-9 days, p < 0.001), and likelihood to be discharged home (91.6% vs. 83.0%, p < 0.001), were compromised during COVID-19 lockdown period. CONCLUSIONS: In this Latin America survey, there was a mild decrease in admissions of IS during the COVID-19 lockdown period, with a significant delay in time to consultations and worse hospitalization outcomes.

The challenge of maintaining necessary vascular and endovascular services at a referral center in Northern Italy during the COVID-19 outbreak.

OBJECTIVES: The Padova Hospital Vascular Surgery Division is located in Veneto, one of the area of the Northern Italy most hit by the Coronavirus disease 2019 outbreak. The aim of this paper is to describe the protocols adopted and to evaluate their impact during the acute phase of Coronavirus spread, focusing on the management of elective and urgent/emergent surgery, outpatients activity, and also health staff preservation from intra-hospital Coronavirus disease 2019 infection. METHODS: Several measures were progressively adopted in the Padova University Hospital to front the Coronavirus disease 2019 outbreak, with a clear strong asset established by 9 March 2020, after the Northern Italy lockdown. Since this date, the Vascular Surgery Unit started a "scaled-down" activity, both for elective surgical procedures and for the outpatient Clinical activities; different protocols were developed for health preservation of staff and patients. We compared a two months period, 30 days before and 30 days after this time point. In particular, emergent vascular surgery was regularly guaranteed as well as urgent surgery (to be performed within 24 h). Elective cases were scheduled for "non-deferrable" pathology. A swab test protocol for COVID-19 was applied to health-care professionals and hospitalized patients. RESULTS: The number of urgent or emergent aortic cases remained stable during the two months period, while the number of Hospital admissions via Emergency Room related to critical limb ischemia decreased after national lockdown by about 20%. Elective vascular surgery was scaled down by 50% starting from 9 March; 35% of scheduled elective cases refused hospitalization during the lockdown period and 20% of those contacted for hospitalization where postponed due to fever, respiratory symptoms, or close contacts with Coronavirus disease 2019 suspected cases. Elective surgery reduction did not negatively influence overall carotid or aortic outcomes, while we reported a higher major limb amputation rate for critical limb ischemia (about 10%, compared to 4% for the standard practice period). We found that 4 out of 98 (4%) health-care providers on the floor had an asymptomatic positive swab test. Among 22 vascular doctors, 3 had a confirmed Coronavirus disease 2019 infection (asymptomatic); a total of 72 swab were performed (mean = 3.4 swab/person/month) during this period; no cases of severe Coronavirus disease 2019 (deaths or requiring intensive care treatment) infection were reported within this period for the staff or hospitalized patients. CONCLUSIONS: Elective vascular surgery needs to be guaranteed as possible during Coronavirus disease 2019 outbreak. The number of truly emergent cases did not reduce, on the other side, Emergency Room accesses for non-emergent cases decreased. Our preliminary results seem to describe a scenario where, if the curve of the outbreak in the regional population is flattened, in association with appropriate hospitals containment rules, it may be possible to continue the activity of the Vascular Surgery Units and guarantee the minimal standard of care.

Stroke Systems of Care During the COVID-19 Epidemic in Kobe City.

BACKGROUND: The novel coronavirus disease 2019 (COVID-19) outbreak raised concerns over healthcare systems' ability to provide suitable care to stroke patients. In the present study, we examined the provision of stroke care in Kobe City during the COVID-19 epidemic, where some major stroke centers ceased to provide emergency care. METHODS: This was a cross-sectional study. The Kobe Stroke Network surveyed the number of stroke patients admitted to all primary stroke centers (PSCs) in the city between March 1 and May 23, 2020, and between March 3 and May 25, 2019. In addition, online meetings between all PSC directors were held regularly to share information. The survey items included emergency response system characteristics, number of patients with stroke hospitalized within 7 days of onset, administered treatment types (IV rt-PA, mechanical thrombectomy, surgery, and endovascular therapy), and stroke patients with confirmed COVID-19. RESULTS: During the period of interest in 2020, the number of stroke patients hospitalized across 13 PSCs was 813, which was 15.5% lower than that during the same period of 2019 (p = 0.285). The number of patients admitted with cerebral infarction, intracerebral hemorrhage, and subarachnoid hemorrhage decreased by 15.4% (p = 0.245), 16.1% (p = 0.659), and 14.0% (p = 0.715), respectively. However, the rates of mechanical thrombectomy and surgery for intracerebral hemorrhage were slightly increased by 12.1% (p = 0.754) and 5.0% (p = 0.538), respectively. PSCs that ceased to provide emergency care reported a decrease in the number of stroke cases of 65.7% compared with the same period in 2019, while other PSCs reported an increase of 0.8%. No case of a patient with stroke and confirmed COVID-19 was reported during the study period. CONCLUSION: Kobe City was able to maintain operation of its stroke care systems thanks to close cooperation among all city PSCs and a temporal decrease in the total number of stroke cases.

Decreased Stroke Presentation Rates at a Comprehensive Stroke Center during COVID-19.

We reviewed stroke care delivery during the COVID-19 pandemic at our stroke center and provincial telestroke system. We counted referrals to our prevention clinic, code strokes, thrombolysis, endovascular thrombectomies, and activations of a provincial telestroke system from February to April of 2017-2020. In April 2020, there was 28% reduction in prevention clinic referrals, 32% reduction in code strokes, and 26% reduction in telestroke activations compared to prior years. Thrombolysis and endovascular thrombectomy rates remained constant. Fewer patients received stroke services across the spectrum from prevention, acute care to telestroke care in Ontario, Canada, during the COVID-19 pandemic.

Tracking the Volume of Neurosurgical Care During the Coronavirus Disease 2019 Pandemic.

OBJECTIVE: In the present study, we quantified the effect of the coronavirus disease 2019 (COVID-19) on the volume of adult and pediatric neurosurgical procedures, inpatient consultations, and clinic visits at an academic medical center. METHODS: Neurosurgical procedures, inpatient consultations, and outpatient appointments at Vanderbilt University Medical Center were identified from March 23, 2020 through May 8, 2020 (during COVID-19) and March 25, 2019 through May 10, 2019 (before COVID-19). The neurosurgical volume was compared between the 2 periods. RESULTS: A 40% reduction in weekly procedural volume was demonstrated during COVID-19 (median before, 75; interquartile range [IQR], 72-80; median during, 45; IQR, 43-47; P < 0.001). A 42% reduction occurred in weekly adult procedures (median before, 62; IQR, 54-70; median during, 36; IQR, 34-39; P < 0.001), and a 31% reduction occurred in weekly pediatric procedures (median before, 13; IQR, 12-14; median during, 9; IQR, 8-10; P = 0.004). Among adult procedures, the most significant decreases were seen for spine (P < 0.001) and endovascular (P < 0.001) procedures and cranioplasty (P < 0.001). A significant change was not found in the adult open vascular (P = 0.291), functional (P = 0.263), cranial tumor (P = 0.143), or hydrocephalus (P = 0.173) procedural volume. Weekly inpatient consultations to neurosurgery decreased by 24% (median before, 99; IQR, 94-114; median during, 75; IQR, 68-84; P = 0.008) for adults. Weekly in-person adult and pediatric outpatient clinic visits witnessed a 91% decrease (median before, 329; IQR, 326-374; median during, 29; IQR, 26-39; P < 0.001). In contrast, weekly telehealth encounters increased from a median of 0 (IQR, 0-0) before to a median of 151 (IQR, 126-156) during COVID-19 (P < 0.001). CONCLUSIONS: Significant reductions occurred in neurosurgical operations, clinic visits, and inpatient consultations during COVID-19. Telehealth was increasingly used for assessments. The long-term effects of the reduced neurosurgical volume and increased telehealth usage on patient outcomes should be explored.

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.

Impact of the COVID-19 pandemic on the process and outcome of thrombectomy for acute ischemic stroke.

BACKGROUND: The novel coronavirus disease 2019 (COVID-19) pandemic is still spreading across the world. Although the pandemic has an all-round impact on medical work, the degree of its impact on endovascular thrombectomy (EVT) for patients with acute ischemic stroke (AIS) is unclear. METHODS: We continuously included AIS patients with large artery occlusion who underwent EVT in a comprehensive stroke center before and during the Wuhan shutdown. The protected code stroke (PCS) for screening and treating AIS patients was established during the pandemic. The efficacy and safety outcomes including the rate of successful reperfusion (defined as modified Thrombolysis In Cerebral Infarction (mTICI) graded 2b or 3) and time intervals for reperfusion were compared between two groups: pre-pandemic and pandemic. RESULTS: A total of 55 AIS patients who received EVT were included. The baseline characteristics were comparable between the two groups. The time from hospital arrival to puncture (174 vs 125.5 min; p=0.002) and time from hospital arrival to reperfusion (213 vs 172 min; p=0.047) were significantly prolonged in the pandemic group compared with the pre-pandemic group. The rate of successful reperfusion was not significantly different between the two groups (85.7% (n=18) vs 88.2% (n=30); OR 0.971, 95% CI 0.785 to 1.203; p=1.000). CONCLUSION: The results of this study suggest a proper PCS algorithm which combines the COVID-19 screening and protection measures could decrease the impact of the disease on the clinical outcomes of EVT for AIS patients to the lowest extent possible during the pandemic.