Stroke metrics during the first year of the COVID-19 pandemic, a tale of two comprehensive stroke centers.

Although a decrease in stroke admissions during the SARS-CoV-2 pandemic has been observed, detailed analyses of the evolution of stroke metrics during the pandemic are lacking. We analyzed changes in stroke presentation, in-hospital systems-of-care, and treatment time metrics at two representative Comprehensive Stroke Centers (CSCs) during the first year of Coronavirus disease 2019 pandemic. From January 2018 to May 2021, data from stroke presentations to two CSCs were obtained. The study duration was split into: period 0 (prepandemic), period 1 (Wave 1), period 2 (Lull), and period 3 (Wave 2). Acute stroke therapies rates and workflow times were compared among pandemic and prepandemic periods. Analyses were adjusted for age, sex, comorbidities, and pre-morbid care needs. There was a significant decrease in monthly hospital presentations of stroke during Wave 1. Both centers reported declines in reperfusion therapies during Wave 1, slowly catching up but never to pre pandemic numbers, and dropping again in Wave 2. Both CSCs experienced in-hospital workflow delays during Waves 1 and 2, and even during the Lull period. Our results highlight the need for proactive strategies to reduce barriers to workflow and hospital avoidance for stroke patients during crisis periods.

Thrombolysis in Stroke Mimics: Comprehensive Stroke Centers vs Telestroke Sites.

BACKGROUND: Hyperacute treatment of acute stroke may lead to thrombolysis in stroke mimics (SM). Our aim was to determine the frequency of thrombolysis in SM in primary stroke centers (PSC) dependent on telestroke versus comprehensive stroke centers (CSC). METHOD: Retrospective review of prospectively collected data from the Quality improvement and Clinical Research (QuICR) registry, the Discharge Abstract Database (DAD), and The National Ambulatory Care Reporting System (NACRS) of consecutive patients treated with intravenous thrombolysis for acute ischemic stroke in Alberta (Canada) from April 2016 to March 2021. RESULT: A total of 2471 patients who received thrombolysis were included. Linking the QuICR registry to DAD 169 (6.83%) patients were identified as SM; however, on our review of the records, only 112 (4.53%) were actual SM. SMs were younger with a mean age of 61.66 (±16.15) vs 71.08 (±14.55) in stroke. National Institute of Health Stroke Scale was higher in stroke with a median (IQR) of 10 (5-17) vs 7 (5-10) in SM. Only one patient (0.89 %) in SM groups had a small parenchymal hemorrhage versus 155 (6.57%) stroke patients had a parenchymal hemorrhage. There was no death among patients of thrombolysed SM during hospitalization versus 276 (11.69%) in stroke. There was no significant difference in the rate of SM among thrombolysed patients between PSC 27 (5.36%) versus CSC 85 (4.3%) (P = 0.312). The most responsible diagnosis of SM was migraine/migraine equivalent, functional disorder, seizure, and delirium. CONCLUSION: The diagnosis of SM may not always be correct when the information is extracted from databases. The rate of thrombolysis in SM via telestroke is similar to treatment in person at CSC.

Changes in ischemic stroke presentations, management and outcomes during the first year of the COVID-19 pandemic in Alberta: a population study.

BACKGROUND: Pandemics may promote hospital avoidance, and added precautions may exacerbate treatment delays for medical emergencies such as stroke. We sought to evaluate ischemic stroke presentations, management and outcomes during the first year of the COVID-19 pandemic. METHODS: We conducted a population-based study, using linked administrative and stroke registry data from Alberta to identify all patients presenting with stroke before the pandemic (Jan. 1, 2016 to Feb. 27, 2020) and in 5 periods over the first pandemic year (Feb. 28, 2020 to Mar. 31, 2021), reflecting changes in case numbers and restrictions. We evaluated changes in hospital admissions, emergency department presentations, thrombolysis, endovascular therapy, workflow times and outcomes. RESULTS: The study included 19 531 patients in the prepandemic period and 4900 patients across the 5 pandemic periods. Presentations for ischemic stroke dropped in the first pandemic wave (weekly adjusted incidence rate ratio [IRR] 0.54, 95% confidence interval [CI] 0.50 to 0.59). Population-level incidence of thrombolysis (adjusted IRR 0.50, 95% CI 0.41 to 0.62) and endovascular therapy (adjusted IRR 0.63, 95% CI 0.47 to 0.84) also decreased during the first wave, but proportions of patients presenting with stroke who received acute therapies did not decline. Rates of patients presenting with stroke did not return to prepandemic levels, even during a lull in COVID-19 cases between the first 2 waves of the pandemic, and fell further in subsequent waves. In-hospital delays in thrombolysis or endovascular therapy occurred in several pandemic periods. The likelihood of in-hospital death increased in Wave 2 (adjusted odds ratio [OR] 1.48, 95% CI 1.25 to 1.74) and Wave 3 (adjusted OR 1.46, 95% CI 1.07 to 2.00). Out-of-hospital deaths, as a proportion of stroke-related deaths, rose during 4 of 5 pandemic periods. INTERPRETATION: The first year of the COVID-19 pandemic saw persistently reduced rates of patients presenting with ischemic stroke, recurrent treatment delays and higher risk of in-hospital death in later waves. These findings support public health messaging that encourages care-seeking for medical emergencies during pandemic periods, and stroke systems should re-evaluate protocols to mitigate inefficiencies.

Regional Variation in Transient Ischemic Attack and Minor Stroke in Alberta Emergency Departments.

Background and Purpose- Multiple studies have shown the 90-day risk of stroke following an emergency department (ED) diagnosis of transient ischemic attack (TIA) or minor stroke is significant, with the greatest risk of recurrence being within the first 24 to 48 hours following initial symptom onset. This study explored regional differences in ED disposition, neuroimaging, and subsequent 90-day stroke risk of patients diagnosed with TIA or minor stroke in Alberta. Methods- We used administrative databases to identify ED visits, neuroimaging, and 90-day return visits for TIA or minor stroke in Alberta from April 2011 to March 2016 among adults ≥20 years of age and stratified them based on regions of presentation (Edmonton, Calgary, or nonmajor urban). Results- During the 5-year study period, 22 421 patients had index ED visits for TIA or minor stroke. All 3 regions had a similar number of ED visits for TIA/minor stroke; however, on index ED visit, Calgary had a higher proportion of computed tomographic angiography imaging (48.8%; P<0.0001) compared with Edmonton (6.7%) and nonmajor urban region (5.7%) and higher proportion of discharged patients (83%; P<0.0001) compared with Edmonton (77.7%) and nonmajor urban region (73.5%). The risk of admission for stroke within 90 days of discharge after index ED visit for TIA/minor stroke in Calgary (3.4%) was lower than Edmonton (4.5%) and the nonmajor urban region (4.6%; P=0.002). Conclusions- This study demonstrates regional variation in computed tomographic angiography for neurovascular imaging of patients presenting to the ED for TIA/minor stroke and a possible association with frequency of index visit admission and 90-day readmission for the same problem.