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1.
J Stroke Cerebrovasc Dis ; 30(12): 106152, 2021 Dec.
Article in English | MEDLINE | ID: covidwho-1506161

ABSTRACT

Cerebrovascular diseases attributed to coronavirus disease 2019 (COVID-19) are uncommon but can result in devastating outcomes. Pediatric acute ischemic strokes are themselves rare and with very few large vessel occlusion related acute ischemic strokes attributed to COVID-19 described in the literature as of date. COVID-19 pandemic has contributed to acute stroke care delays across the world and with pediatric endovascular therapy still in its infancy, it poses a great challenge in facilitating good outcomes in children presenting with acute ischemic strokes in the setting of COVID-19. We present a pediatric patient who underwent endovascular therapy for an internal carotid artery occlusion related acute ischemic stroke in the setting of active COVID-19 and had an excellent outcome thanks to a streamlined stroke pathway involving the vascular neurology, neuro-interventional, neurocritical care, and anesthesiology teams.


Subject(s)
COVID-19/complications , Carotid Artery Thrombosis/therapy , Carotid Artery, Internal , Carotid Stenosis/therapy , Endovascular Procedures , Ischemic Stroke/therapy , Thrombectomy , COVID-19/diagnosis , Carotid Artery Thrombosis/diagnosis , Carotid Artery Thrombosis/etiology , Carotid Artery, Internal/diagnostic imaging , Carotid Stenosis/diagnosis , Carotid Stenosis/etiology , Child , Endovascular Procedures/instrumentation , Humans , Ischemic Stroke/diagnosis , Ischemic Stroke/etiology , Male , Stents , Treatment Outcome
2.
J Am Heart Assoc ; 10(14): e021046, 2021 07 20.
Article in English | MEDLINE | ID: covidwho-1463078

ABSTRACT

Background Acute ischemic stroke (AIS) in the context of COVID-19 has received considerable attention for its propensity to affect patients of all ages. We aimed to evaluate the effect of age on functional outcome and mortality following an acute ischemic event. Methods and Results A prospectively maintained database from comprehensive stroke centers in Canada and the United States was analyzed for patients with AIS from March 14 to September 30, 2020 who tested positive for SARS-CoV-2. The primary outcome was Modified Rankin Scale score at discharge, and the secondary outcome was mortality. Baseline characteristics, laboratory values, imaging, and thrombectomy workflow process times were assessed. Among all 126 patients with COVID-19 who were diagnosed with AIS, the median age was 63 years (range, 27-94). There were 35 (27.8%) patients with AIS in the aged ≤55 years group, 47 (37.3%) in the aged 56 to 70 group, and 44 (34.9%) in the aged >70 group. Intravenous tissue plasminogen activator and thrombectomy rates were comparable across these groups, (P=0.331 and 0.212, respectively). There was a significantly lower rate of mortality between each group favoring younger age (21.9% versus 45.0% versus 48.8%, P=0.047). After multivariable adjustment for possible confounders, a 1-year increase in age was significantly associated with fewer instances of a favorable outcome of Modified Rankin Scale 0 to 2 (odds ratio [OR], 0.95; 95 CI%, 0.90-0.99; P=0.048) and higher mortality (OR, 1.06; 95 CI%, 1.02-1.10; P=0.007). Conclusions AIS in the context of COVID-19 affects young patients at much greater rates than pre-pandemic controls. Nevertheless, instances of poor functional outcome and mortality are closely tied to increasing age.


Subject(s)
COVID-19/complications , Ischemic Stroke/etiology , Adult , Age Factors , Aged , Aged, 80 and over , Canada , Female , Humans , Ischemic Stroke/mortality , Ischemic Stroke/therapy , Male , Middle Aged , Prospective Studies , United States
3.
J Stroke Cerebrovasc Dis ; 30(11): 106072, 2021 Nov.
Article in English | MEDLINE | ID: covidwho-1377775

ABSTRACT

Recently cases of vaccine-induced immune thrombotic thrombocytopenia (VITT) and thrombosis following the adenoviral vector vaccine against the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) were reported. A mechanism similar to heparin-induced thrombocytopenia was proposed with antibodies to platelet factor 4 (PF4). Vaccine related arterial thrombosis in the brain is rare but life-threatening and optimal treatment is not established. We report clinical, laboratory, imaging findings and treatment in a 51-year-old female presenting with acute left middle cerebral artery (MCA) occlusion 7 days after the first dose of ChAdOx1 nCoV-19 vaccine. Due to low platelet count and suspicion of VITT she was not eligible for intravenous thrombolysis (IVT) and proceeded to mechanical thrombectomy (MER) with successful recanalization four hours after onset of symptoms. Treatment with intravenous immunoglobulin (IVIG) and heparin pentasaccharide fondaparinux was initiated. Presence of anti-PF4 antibodies was confirmed. The patient improved clinically with normalization of platelet count. Clinicians should be alert of VITT in patients with acute ischemic stroke after ChAdOx1 nCov-19 vaccination and low platelet counts. MER showed to be feasible and effective. We propose considering MER in patients with VITT and large vessel occlusion despite thrombocytopenia. High-dose IVIG should be started immediately. Alternative anticoagulation to heparin should be started 24 hours after stroke onset unless significant hemorrhagic transformation occurred. Platelet transfusion is contraindicated and should be considered only in severe hemorrhagic complications. Restenosis or reocclusion of the revascularized artery is possible due to the hypercoagulable state in VITT and angiographic surveillance after the procedure is reasonable.


Subject(s)
COVID-19 Vaccines/adverse effects , COVID-19/prevention & control , Infarction, Middle Cerebral Artery/chemically induced , Ischemic Stroke/chemically induced , Purpura, Thrombocytopenic, Idiopathic/chemically induced , Anticoagulants/therapeutic use , COVID-19/immunology , COVID-19/virology , Female , Humans , Immunoglobulins, Intravenous/therapeutic use , Infarction, Middle Cerebral Artery/diagnostic imaging , Infarction, Middle Cerebral Artery/immunology , Infarction, Middle Cerebral Artery/therapy , Ischemic Stroke/diagnostic imaging , Ischemic Stroke/immunology , Ischemic Stroke/therapy , Middle Aged , Purpura, Thrombocytopenic, Idiopathic/diagnosis , Purpura, Thrombocytopenic, Idiopathic/immunology , Purpura, Thrombocytopenic, Idiopathic/therapy , Thrombectomy , Treatment Outcome
4.
Cerebrovasc Dis ; 50(2): 185-199, 2021.
Article in English | MEDLINE | ID: covidwho-1348201

ABSTRACT

BACKGROUND: Posterior circulation stroke is characterized by poor prognosis because its optimal thrombolysis "time window" is always missed. After mechanical thrombectomy (MT), the recanalization rate of posterior circulation obstruction is significantly increased, but prognosis remains poor. To best manage patients, prognostic factors are needed to inform MT triaging after posterior circulation stroke. METHODS: A systematic literature search was done for the period through April 2020. Studies included those with posterior circulation stroke cases that underwent MT. The primary outcome measure in this study was the modified Rankin Scale on day 90. RESULTS: No outcome differences were found in gender, atrial fibrillation, smoking, and coronary artery disease (OR = 1.07, 95% CI: 0.90-1.28; OR = 1.02, 95% CI: 0.82-1.26; OR = 1.26, 95% CI: 0.94-1.68; and OR = 0.84, 95% CI: 0.58-1.22, respectively). Hypertension, diabetes mellitus, and previous stroke correlated with poorer prognosis (OR = 0.61, 95% CI: 0.48-0.77; OR = 0.60, 95% CI: 0.50-0.73; and OR = 0.74, 95% CI: 0.55-0.99, respectively). However, hyperlipidemia correlated with better prognosis (OR = 1.28, 95% CI: 1.04-1.58). CONCLUSION: Our analysis indicates that hypertension, diabetes mellitus, or previous stroke correlate with poorer outcomes. Intriguingly, hyperlipidemia correlates with better prognosis. These factors may help inform triage decisions when considering MT for posterior circulation stroke patients. However, large, multicenter, randomized controlled trials are needed to validate these observations.


Subject(s)
COVID-19 , Ischemic Stroke/therapy , Outcome and Process Assessment, Health Care/trends , Patient Admission/trends , Practice Patterns, Physicians'/trends , Thrombectomy/trends , Aged , Aged, 80 and over , Female , Hospital Mortality/trends , Humans , Ischemic Stroke/diagnosis , Ischemic Stroke/mortality , Male , Middle Aged , Quality Indicators, Health Care/trends , Recovery of Function , Referral and Consultation/trends , Retrospective Studies , Risk Assessment , Risk Factors , Thrombectomy/adverse effects , Thrombectomy/mortality , Time Factors , Time-to-Treatment/trends , Treatment Outcome
6.
J Neurosurg Anesthesiol ; 33(3): 268-272, 2021 Jul 01.
Article in English | MEDLINE | ID: covidwho-1322669

ABSTRACT

BACKGROUND: The coronavirus disease (COVID-19) pandemic is currently a major challenge for health care systems around the world. For a time-sensitive emergency such as acute ischemic stroke (AIS), streamlined workflow times are essential to ensure good clinical outcomes. METHODS: The aim of this single-center, retrospective, observational study was to describe changes in stroke workflow patterns and clinical care during the COVID-19 pandemic. Data from AIS patients undergoing emergent endovascular treatment (EVT) between 23 January and 8 April 2020 were retrospectively collected and compared with data from patients admitted during a similar period in 2019. The primary outcome was difference in time from symptom onset to recanalization. Secondary outcomes included workflow times, clinical management, discharge outcomes, and health-economic data. RESULTS: In all, 21 AIS patients were admitted for emergent EVT during the 77-day study period, compared with 42 cases in 2019. Median time from symptom onset to recanalization was 132 minutes longer during the pandemic compared with the previous year (672 vs. 540 min, P=0.049). Patients admitted during the pandemic had a higher likelihood of endotracheal intubation (84.6% vs. 42.4%, P<0.05) and a higher incidence of delayed extubation after EVT (69.2% vs. 45.5%, P<0.05). National Institutes of Health Stroke Scale at hospital discharge was similar in the 2 cohorts, whereas neurointensive care unit stay was longer in patients admitted during the pandemic (10 vs. 7 days, P=0.013) and hospitalization costs were higher (123.9 vs. 95.2 thousand Chinese Yuan, P=0.052). CONCLUSION: Disruptions to medical services during the COVID-19 pandemic has particularly impacted AIS patients undergoing emergent EVT, resulting in increased workflow times. A structured and multidisciplinary protocol should be implemented to minimize treatment delays and maximize patient outcomes.


Subject(s)
COVID-19/prevention & control , Endovascular Procedures/methods , Ischemic Stroke/therapy , Time-to-Treatment/statistics & numerical data , Acute Disease , Aged , Beijing , Female , Humans , Male , Middle Aged , Pandemics , Retrospective Studies , SARS-CoV-2 , Treatment Outcome
8.
BMC Neurol ; 21(1): 238, 2021 Jun 24.
Article in English | MEDLINE | ID: covidwho-1282244

ABSTRACT

BACKGROUND AND PURPOSE: The purpose of our study was to analyse endovascular treatment (EVT) in patients presenting acute anterior circulation ischemic stroke with large-vessel occlusion (AIS-LVO) during the pandemic and post-epidemic periods. METHODS: Patients with AIS-LVO of the anterior circulation who underwent EVT were enrolled. According to the times of Wuhan closure and reopening, patients were divided into a pre-pandemic group (from November 8, 2019, to January 22, 2020), pandemic group (from January 23, 2020, to April 8, 2020) and post-epidemic group (from April 9, 2020, to June 24, 2020). The primary endpoints were the time delay among symptom onset to arriving hospital door, to groining puncture and to vascular reperfusion. Secondary endpoints were the functional outcomes evaluated by 90-day modified Rankin scale (mRS) score. RESULTS: In total, the times from onset to reperfusion (OTR, median 356 min vs. 310 min, p = 0.041) and onset to door (OTD, median 238 min vs. 167 min, p = 0.017) were prolonged in the pandemic group compared to the pre-pandemic group, and the delay continue in the post-epidemic period. In the subgroup analysis, the time from door to imaging (DTI) was significantly prolonged during the pandemic period. Interestingly, the prolonged DTI was corrected in the directly admitted subgroup during post-epidemic period. In addition, the functional outcomes showed no significant differences across the three periods. CONCLUSIONS: Total time and prehospital time were prolonged during the pandemic and post-epidemic periods. Urgent public education and improved in-hospital screening processes are necessary to decrease time delays.


Subject(s)
COVID-19 , Endovascular Procedures/methods , Ischemic Stroke/therapy , Aged , Aged, 80 and over , Brain Ischemia/therapy , Female , Humans , Male , Middle Aged , Reperfusion/methods , Retrospective Studies , Treatment Outcome
9.
J Stroke Cerebrovasc Dis ; 30(9): 105942, 2021 Sep.
Article in English | MEDLINE | ID: covidwho-1281474

ABSTRACT

Vaccine-induced immune thrombotic thrombocytopenia is a rare syndrome following the ChAdOx1 nCov-19 or Ad26.COV2.S vaccine. Reported patients developed mainly venous thrombosis. We describe a case of a young healthy women suffering from acute ischemic stroke due to large vessel occlusion without cerebral venous thrombosis 8 days after vaccination and its consequences on recanalization strategy. Considering the thrombocytopenia, intravenous thrombolysis was contraindicated. She underwent mechanical thrombectomy with complete recanalization and dramatically improved clinically. Positive detection of anti-PF4-heparin-antibodies confirmed vaccine-induced immune thrombotic thrombocytopenia diagnosis. In case of acute ischemic stroke after recent ChAdOx1 nCov-19 or Ad26.COV2.S vaccine, platelet count should be systematically checked before giving thrombolysis, and direct mechanical thrombectomy should be proposed in patients with large vessel occlusion.


Subject(s)
COVID-19 Vaccines/adverse effects , Ischemic Stroke/therapy , Purpura, Thrombotic Thrombocytopenic/therapy , Thrombectomy , Vaccination/adverse effects , Adult , Antibodies/blood , Blood Platelets/immunology , COVID-19 Vaccines/administration & dosage , Female , Heparin/immunology , Humans , Ischemic Stroke/blood , Ischemic Stroke/chemically induced , Ischemic Stroke/diagnosis , Platelet Factor 4/immunology , Purpura, Thrombotic Thrombocytopenic/blood , Purpura, Thrombotic Thrombocytopenic/chemically induced , Purpura, Thrombotic Thrombocytopenic/diagnosis , Treatment Outcome
10.
J Stroke Cerebrovasc Dis ; 30(8): 105919, 2021 Aug.
Article in English | MEDLINE | ID: covidwho-1253283

ABSTRACT

BACKGROUND: The characteristics and pathophysiological mechanisms involved in acute ischemic stroke in patients with COVID-19 infection have not been fully clarified. We prospectively studied the phenotypic and etiological features of acute stroke occurring in COVID-19 infection. PATIENTS & METHODS: Within nine months starting from April-2020, the presence of COVID-19 infection was determined by thoracic CT and SARS-CoV-2 PCR in all acute stroke cases managed in a single tertiary center. Consecutive and prospective data on vascular risk factors/comorbidities, in-hospital quality metrics, discharge outcomes, etiological subclassification and blood markers of thrombosis / inflammation were compared in 44 COVID-19 positive cases (37 acute ischemic stroke, 5 TIA, 2 intracerebral hematoma) and 509 COVID-19 negative patients (355 ischemic, 105 TIA, 44 hematoma and 5 stroke mimic). RESULTS: COVID-19 positive patients had more severe strokes, delayed hospital admission, longer hospital stay, higher mortality rates, but had similar vascular risk factors/comorbidities frequency, thrombolysis/thrombectomy utilization rates, metrics, and stroke etiological subtype. They had significantly higher CRP, fibrinogen, ferritin, leukocyte count and lower lymphocyte count. No difference was detected in aPTT, INR, D-dimer, platelet, hemoglobin, homocysteine levels and ANA, anti-dsDNA antibody and ENA panel positivity rates. Anti-phospholipid antibodies have been studied in 70% of COVID-19 positive and all cryptogenic patients, but were never found positive. Tests for coagulation factor levels and hereditary thrombophilia did not show major thrombophilia in any of the stroke patients with COVID-19. CONCLUSION: We documented that there is no significant difference in etiological spectrum in acute stroke patients with COVID-19 infection. In addition, cryptogenic stroke and antiphospholipid antibody positivity rates did not increase.


Subject(s)
COVID-19/complications , Hemorrhagic Stroke/etiology , Ischemic Attack, Transient/etiology , Ischemic Stroke/etiology , Aged , Aged, 80 and over , Biomarkers/blood , Blood Coagulation , COVID-19/diagnosis , COVID-19/therapy , COVID-19/virology , Case-Control Studies , Female , Hemorrhagic Stroke/diagnosis , Hemorrhagic Stroke/therapy , Humans , Inflammation Mediators/blood , Ischemic Attack, Transient/diagnosis , Ischemic Attack, Transient/therapy , Ischemic Stroke/diagnosis , Ischemic Stroke/therapy , Male , Middle Aged , Prognosis , Prospective Studies , Risk Assessment , Risk Factors
11.
Clin Appl Thromb Hemost ; 27: 10760296211002274, 2021.
Article in English | MEDLINE | ID: covidwho-1191430

ABSTRACT

The purpose of this article is to address several challenging questions in the management of young patients (those age 60 and under) who present with ischemic stroke. Do genetic thrombophilic states, strongly associated with venous thrombosis, independently cause arterial events in adults? Should cases of patent foramen ovale be closed with mechanical devices in patients with cryptogenic stroke? What are the optimal treatments for cerebral vein thrombosis, carotid artery dissection, and antiphospholipid syndrome and are DOACs acceptable treatment for these indications? What is the mechanism underlying large vessel stroke in patients with COVID-19? This is a narrative review. We searched PubMed and Embase and American College of physicians Journal club database for English language articles since 2000 looking mainly at randomized clinical trials, Meta analyses, Cochran reviews as well as some research articles viewed to be cutting edge regarding anticoagulation and cerebrovascular disease. Searches were done entering cerebral vein thrombosis, carotid dissection, anticoagulation therapy and stroke, antiphospholipid antibody and stroke, stroke in young adults, cryptogenic stroke and anticoagulation, patent foramen ovale and cryptogenic stroke, COVID-19 and stroke.


Subject(s)
COVID-19/complications , Ischemic Stroke/etiology , Ischemic Stroke/therapy , SARS-CoV-2 , Adult , Aneurysm, Dissecting/complications , Anticoagulants/adverse effects , Anticoagulants/therapeutic use , Antiphospholipid Syndrome/complications , Cervical Vertebrae/blood supply , Female , Foramen Ovale, Patent/complications , Foramen Ovale, Patent/surgery , Humans , Intracranial Thrombosis/etiology , Intracranial Thrombosis/therapy , Ischemic Stroke/prevention & control , Male , Middle Aged , Pandemics , Prognosis , Risk Factors , Thrombophilia/complications
12.
J Stroke Cerebrovasc Dis ; 30(7): 105802, 2021 Jul.
Article in English | MEDLINE | ID: covidwho-1188832

ABSTRACT

While use of telemedicine to guide emergent treatment of ischemic stroke is well established, the COVID-19 pandemic motivated the rapid expansion of care via telemedicine to provide consistent care while reducing patient and provider exposure and preserving personal protective equipment. Temporary changes in re-imbursement, inclusion of home office and patient home environments, and increased access to telehealth technologies by patients, health care staff and health care facilities were key to provide an environment for creative and consistent high-quality stroke care. The continuum of care via telestroke has broadened to include prehospital, inter-facility and intra-facility hospital-based services, stroke telerehabilitation, and ambulatory telestroke. However, disparities in technology access remain a challenge. Preservation of reimbursement and the reduction of regulatory burden that was initiated during the public health emergency will be necessary to maintain expanded patient access to the full complement of telestroke services. Here we outline many of these initiatives and discuss potential opportunities for optimal use of technology in stroke care through and beyond the pandemic.


Subject(s)
COVID-19 , Continuity of Patient Care , Delivery of Health Care, Integrated , Ischemic Stroke/therapy , Outcome and Process Assessment, Health Care , Telemedicine , Continuity of Patient Care/economics , Delivery of Health Care, Integrated/economics , Fee-for-Service Plans , Health Care Costs , Healthcare Disparities , Humans , Insurance, Health, Reimbursement , Ischemic Stroke/diagnosis , Ischemic Stroke/economics , Occupational Health , Outcome and Process Assessment, Health Care/economics , Patient Safety , Telemedicine/economics
13.
J Stroke Cerebrovasc Dis ; 30(7): 105805, 2021 Jul.
Article in English | MEDLINE | ID: covidwho-1171128

ABSTRACT

INTRODUCTION: There is limited literature on coronavirus disease 2019 (COVID -19) complications such as thromboembolism, cardiac complications etc. as possible trigger for stroke. Hence, we aim to evaluate the prevalence and outcomes of COVID-19 related cardiovascular complications and secondary infection and their possibility as potential triggers for the stroke. METHODS: Data from observational studies describing the complications [acute cardiac injury (ACI), cardiac arrhythmias (CA), disseminated intravascular coagulation (DIC), septic shock, secondary infection] and outcomes of COVID-19 hospitalized patients from December 1, 2019 to June 30, 2020, were extracted following PRISMA guidelines. Adverse outcomes defined as intensive care units, oxygen saturation less than 90%, invasive mechanical ventilation, severe disease, and in-hospital mortality. The odds ratio and 95% confidence interval were obtained, and forest plots were created using random-effects models. A short review of these complications as triggers of stroke was conducted. RESULTS: 16 studies with 3480 confirmed COVID-19 patients, prevalence of ACI [38%vs5.9%], CA [26%vs5.3%], DIC [4%vs0.74%], septic shock [18%vs0.36%], and infection [30%vs12.5%] was higher among patients with poor outcomes. In meta-analysis, ACI [aOR:9.93(95%CI:3.95-25.00], CA [7.52(3.29-17.18)], DIC [7.36(1.24-43.73)], septic shock [30.12(7.56-120.10)], and infection [10.41(4.47-24.27)] had higher odds of adverse outcomes. Patients hospitalized with acute ischemic stroke and intracerebral hemorrhage, had complications like pulmonary embolism, venous thromboembolism, DIC, etc. and had poor outcomes CONCLUSION: The complications like acute cardiac injury, cardiac arrhythmias, DIC, septic shock, and secondary infection had poor outcomes. Patients with stroke were having history of these complications. Long term monitoring is required in such patients to prevent stroke and mitigate adverse outcomes.


Subject(s)
Arrhythmias, Cardiac/epidemiology , COVID-19/epidemiology , Disseminated Intravascular Coagulation/epidemiology , Ischemic Stroke/epidemiology , Venous Thromboembolism/epidemiology , Adult , Aged , Arrhythmias, Cardiac/diagnosis , Arrhythmias, Cardiac/mortality , Arrhythmias, Cardiac/therapy , COVID-19/diagnosis , COVID-19/mortality , COVID-19/therapy , Disseminated Intravascular Coagulation/diagnosis , Disseminated Intravascular Coagulation/mortality , Disseminated Intravascular Coagulation/therapy , Female , Hospital Mortality , Hospitalization , Humans , Ischemic Stroke/diagnosis , Ischemic Stroke/mortality , Ischemic Stroke/therapy , Male , Middle Aged , Observational Studies as Topic , Prevalence , Prognosis , Risk Assessment , Risk Factors , Time Factors , Venous Thromboembolism/diagnosis , Venous Thromboembolism/mortality , Venous Thromboembolism/therapy
14.
Neurosciences (Riyadh) ; 26(2): 158-162, 2021 Apr.
Article in English | MEDLINE | ID: covidwho-1170592

ABSTRACT

OBJECTIVES: To assess and quantify the impact COVID-19 has had thus far on ischemic stroke admission rate and severity (National Institutes of Health Stroke Scale (NIHSS) score) at a single tertiary center in Makkah, Saudi Arabia. METHODS: This is a retrospective analysis performed on admitted cases with definitive final diagnoses of transient ischemic attack (TIA) and ischemic stroke at King Abdullah Medical City in Makkah between January 1, 2020 and July 2020. RESULTS: Sixty-nine patients were included in our study, 41 of whom presented at our facility before the pandemic and 29 during the pandemic. No statistical significance was observed between rate of admission, stroke severity, and rate of thrombolysis before the COVID-19 pandemic and after the outbreak. We observed a reduction of mean arrival time after the pandemic began, as well as a reduction of hospital stay days. CONCLUSION: A 29% reduction of admission secondary to acute ischemic stroke was noted during the pandemic. However, COVID-19 did not affect acute stroke care at our institute. The study is limited because of its small sample size, as we assessed just one medical center.


Subject(s)
COVID-19 , Ischemic Attack, Transient/epidemiology , Ischemic Stroke/epidemiology , Adult , Aged , Aged, 80 and over , Female , Hospitalization/statistics & numerical data , Humans , Intensive Care Units/statistics & numerical data , Ischemic Attack, Transient/therapy , Ischemic Stroke/therapy , Length of Stay/statistics & numerical data , Male , Middle Aged , Retrospective Studies , SARS-CoV-2 , Saudi Arabia/epidemiology , Severity of Illness Index , Sex Distribution , Stroke/epidemiology , Stroke/therapy , Tertiary Care Centers , Thrombolytic Therapy/statistics & numerical data , Time-to-Treatment/statistics & numerical data , Young Adult
15.
Neurosurgery ; 89(1): E35-E41, 2021 06 15.
Article in English | MEDLINE | ID: covidwho-1139998

ABSTRACT

BACKGROUND: While there are reports of acute ischemic stroke (AIS) in coronavirus disease 2019 (COVID-19) patients, the overall incidence of AIS and clinical characteristics of large vessel occlusion (LVO) remain unclear. OBJECTIVE: To attempt to establish incidence of AIS in COVID-19 patients in an international cohort. METHODS: A cross-sectional retrospective, multicenter study of consecutive patients admitted with AIS and COVID-19 was undertaken from March 1 to May 1, 2020 at 12 stroke centers from 4 countries. Out of those 12 centers, 9 centers admitted all types of strokes and data from those were used to calculate the incidence rate of AIS. Three centers exclusively transferred LVO stroke (LVOs) patients and were excluded only for the purposes of calculating the incidence of AIS. Detailed data were collected on consecutive LVOs in hospitalized patients who underwent mechanical thrombectomy (MT) across all 12 centers. RESULTS: Out of 6698 COVID-19 patients admitted to 9 stroke centers, the incidence of stroke was found to be 1.3% (interquartile range [IQR] 0.75%-1.7%). The median age of LVOs patients was 51 yr (IQR 50-75 yr), and in the US centers, African Americans comprised 28% of patients. Out of 66 LVOs, 10 patients (16%) were less than 50 yr of age. Among the LVOs eligible for MT, the average time from symptom onset to presentation was 558 min (IQR 82-695 min). A total of 21 (50%) patients were either discharged to home or discharged to acute rehabilitation facilities. CONCLUSION: LVO was predominant in patients with AIS and COVID-19 across 2 continents, occurring at a significantly younger age and affecting African Americans disproportionately in the USA.


Subject(s)
Brain Ischemia/diagnostic imaging , Brain Ischemia/epidemiology , COVID-19/diagnostic imaging , COVID-19/epidemiology , Ischemic Stroke/diagnostic imaging , Ischemic Stroke/epidemiology , Adult , Aged , Aged, 80 and over , Brain Ischemia/therapy , COVID-19/therapy , Cerebrovascular Disorders/diagnostic imaging , Cerebrovascular Disorders/epidemiology , Cerebrovascular Disorders/therapy , Cohort Studies , Cross-Sectional Studies , Female , Humans , Incidence , Internationality , Ischemic Stroke/therapy , Male , Middle Aged , Retrospective Studies , Thrombectomy/adverse effects , Treatment Outcome
17.
BMJ Case Rep ; 14(3)2021 Mar 02.
Article in English | MEDLINE | ID: covidwho-1115107

ABSTRACT

The COVID-19 pandemic has dealt a devastating blow to healthcare systems globally. Approximately 3.2% of patients infected with COVID-19 require invasive ventilation during the course of the illness. Within this population, 25% of patients are affected with neurological manifestations. Among those who are affected by severe neurological manifestations, some may have acute cerebrovascular complications (5%), impaired consciousness (15%) or exhibit skeletal muscle hypokinesis (20%). The cause of the severe cognitive impairment and hypokinesis is unknown at this time. Potential causes include COVID-19 viral encephalopathy, toxic metabolic encephalopathy, post-intensive care unit syndrome and cerebrovascular pathology. We present a case of a 60 year old patient who sustained a prolonged hospitalization with COVID-19, had a cerebrovascular event and developed a persistent unexplained encephalopathy along with a hypokinetic state. He was treated successfully with modafinil and carbidopa/levodopa showing clinical improvement within 3-7 days and ultimately was able to successfully discharge home.


Subject(s)
Brain Diseases , COVID-19 , Carbidopa/administration & dosage , Hypokinesia , Ischemic Stroke , Levodopa/administration & dosage , Modafinil/administration & dosage , Rehabilitation/methods , SARS-CoV-2/isolation & purification , Blood Coagulation , Brain Diseases/physiopathology , Brain Diseases/virology , COVID-19/blood , COVID-19/complications , COVID-19/physiopathology , COVID-19/therapy , Central Nervous System Stimulants/administration & dosage , Cognitive Dysfunction/diagnosis , Cognitive Dysfunction/etiology , Critical Care/methods , Drug Combinations , Humans , Hypokinesia/diagnosis , Hypokinesia/etiology , Hypokinesia/therapy , Ischemic Stroke/diagnostic imaging , Ischemic Stroke/etiology , Ischemic Stroke/physiopathology , Ischemic Stroke/therapy , Magnetic Resonance Imaging/methods , Male , Middle Aged , Respiration, Artificial/methods , Severity of Illness Index , Treatment Outcome , Ventilator Weaning/methods
18.
Neurol Sci ; 42(4): 1237-1245, 2021 Apr.
Article in English | MEDLINE | ID: covidwho-1064523

ABSTRACT

INTRODUCTION: The COVID-19 outbreak highly impacted the acute ischemic stroke care management. The primary end point of the study was to evaluate the impact of the COVID-19 outbreak and the following lockdown measures on our hub-and-spoke network; the secondary end point was to evaluate if the impact of the COVID-19 outbreak was different in hub-and-spoke centers. METHODS: This was a retrospective multicenter observational study conducted at the Stroke Units of Policlinico Gemelli, Ospedale San Filippo Neri, Ospedale di Belcolle, and Ospedale San Camillo de Lellis. We collected clinical reports of all consecutive patients admitted with diagnosis of acute ischemic stroke or transient ischemic attack (TIA) during the phase 1 of the lockdown period (11 March 2020-4 May 2020). As controls, we used all consecutive patients admitted for acute ischemic stroke or TIA in the same period of the previous year. RESULTS: A total of 156 and 142 clinical reports were collected in 2019 and 2020, respectively. During the COVID-19 outbreak, we observed a reduction of number of thrombolysis, a reduction of the length of hospitalization, and an increase of pneumonia. Regarding performance indicators, we observed an increase in onset-to-door time and in door-to-groin time. We did not observe any statistically significant interaction between year (2019 vs 2020) and facility of admission (hub vs spoke) on all variables analyzed. DISCUSSION: Our observational study, involving hub-and-spoke stroke network of a wide regional area, indicates that the COVID-19 outbreak impacted on the acute stroke management. This impact was equally observed in hub as well as in spoke centers.


Subject(s)
COVID-19 , Pandemics , Quarantine , Stroke/therapy , Aged , Aged, 80 and over , Female , Hospitalization/statistics & numerical data , Humans , Ischemic Attack, Transient/epidemiology , Ischemic Attack, Transient/therapy , Ischemic Stroke/epidemiology , Ischemic Stroke/therapy , Italy/epidemiology , Length of Stay , Male , Middle Aged , Pneumonia/epidemiology , Retrospective Studies , Thrombolytic Therapy/statistics & numerical data
19.
Stroke ; 52(1): 40-47, 2021 01.
Article in English | MEDLINE | ID: covidwho-1050420

ABSTRACT

BACKGROUND AND PURPOSE: The pandemic caused by the novel coronavirus disease 2019 (COVID-19) has led to an unprecedented paradigm shift in medical care. We sought to evaluate whether the COVID-19 pandemic may have contributed to delays in acute stroke management at comprehensive stroke centers. METHODS: Pooled clinical data of consecutive adult stroke patients from 14 US comprehensive stroke centers (January 1, 2019, to July 31, 2020) were queried. The rate of thrombolysis for nontransferred patients within the Target: Stroke goal of 60 minutes was compared between patients admitted from March 1, 2019, and July 31, 2019 (pre-COVID-19), and March 1, 2020, to July 31, 2020 (COVID-19). The time from arrival to imaging and treatment with thrombolysis or thrombectomy, as continuous variables, were also assessed. RESULTS: Of the 2955 patients who met inclusion criteria, 1491 were admitted during the pre-COVID-19 period and 1464 were admitted during COVID-19, 15% of whom underwent intravenous thrombolysis. Patients treated during COVID-19 were at lower odds of receiving thrombolysis within 60 minutes of arrival (odds ratio, 0.61 [95% CI, 0.38-0.98]; P=0.04), with a median delay in door-to-needle time of 4 minutes (P=0.03). The lower odds of achieving treatment in the Target: Stroke goal persisted after adjustment for all variables associated with earlier treatment (adjusted odds ratio, 0.55 [95% CI, 0.35-0.85]; P<0.01). The delay in thrombolysis appeared driven by the longer delay from imaging to bolus (median, 29 [interquartile range, 18-41] versus 22 [interquartile range, 13-37] minutes; P=0.02). There was no significant delay in door-to-groin puncture for patients who underwent thrombectomy (median, 83 [interquartile range, 63-133] versus 90 [interquartile range, 73-129] minutes; P=0.30). Delays in thrombolysis were observed in the months of June and July. CONCLUSIONS: Evaluation for acute ischemic stroke during the COVID-19 period was associated with a small but significant delay in intravenous thrombolysis but no significant delay in thrombectomy time metrics. Taking steps to reduce delays from imaging to bolus time has the potential to attenuate this collateral effect of the pandemic.


Subject(s)
COVID-19 , Ischemic Stroke/therapy , Time-to-Treatment/statistics & numerical data , Adult , Aged , Aged, 80 and over , Female , Humans , Male , Middle Aged , SARS-CoV-2 , Thrombectomy/statistics & numerical data , Thrombolytic Therapy/statistics & numerical data
20.
Stroke ; 51(12): 3746-3750, 2020 12.
Article in English | MEDLINE | ID: covidwho-1021185

ABSTRACT

BACKGROUND AND PURPOSE: We aimed to investigate the rate of hospital admissions for cerebrovascular events and of revascularization treatments for acute ischemic stroke in Italy during the coronavirus disease 2019 (COVID-19) outbreak. METHODS: The Italian Stroke Organization performed a multicenter study involving 93 Italian Stroke Units. We collected information on hospital admissions for cerebrovascular events from March 1 to March 31, 2020 (study period), and from March 1 to March 31, 2019 (control period). RESULTS: Ischemic strokes decreased from 2399 in 2019 to 1810 in 2020, with a corresponding hospitalization rate ratio (RR) of 0.75 ([95% CI, 0.71-0.80] P<0.001); intracerebral hemorrhages decreased from 400 to 322 (hospitalization RR, 0.81 [95% CI, 0.69-0.93]; P=0.004), and transient ischemic attacks decreased from 322 to 196 (hospitalization RR, 0.61 [95% CI, 0.51-0.73]; P<0.001). Hospitalizations decreased in Northern, Central, and Southern Italy. Intravenous thrombolyses decreased from 531 (22.1%) in 2019 to 345 in 2020 (19.1%; RR, 0.86 [95% CI, 0.75-0.99]; P=0.032), while primary endovascular procedures increased in Northern Italy (RR, 1.61 [95% CI, 1.13-2.32]; P=0.008). We found no correlation (P=0.517) between the hospitalization RRs for all strokes or transient ischemic attack and COVID-19 incidence in the different areas. CONCLUSIONS: Hospitalizations for stroke or transient ischemic attacks across Italy were reduced during the worst period of the COVID-19 outbreak. Intravenous thrombolytic treatments also decreased, while endovascular treatments remained unchanged and even increased in the area of maximum expression of the outbreak. Limited hospitalization of the less severe patients and delays in hospital admission, due to overcharge of the emergency system by COVID-19 patients, may explain these data.


Subject(s)
COVID-19/epidemiology , Cerebral Hemorrhage/epidemiology , Hospitalization/statistics & numerical data , Ischemic Attack, Transient/epidemiology , Ischemic Stroke/epidemiology , Thrombectomy/statistics & numerical data , Thrombolytic Therapy/statistics & numerical data , Aged , Aged, 80 and over , Endovascular Procedures/statistics & numerical data , Female , Humans , Ischemic Stroke/therapy , Italy/epidemiology , Male , Middle Aged
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