In a study, researchers have reported key demographic and clinical characteristics of patients who developed ischaemic stroke associated with the COVID-19 infection and received care within one hospital system serving all 5 boroughs of New York City. During the study period of 15 March through 19 April, 2020, out of 3,556 hospitalised patients with diagnosis of COVID-19 infection, 32 patients (0.9%) had imaging-proven ischemic stroke.
They compared those 32 patients admitted with stroke and COVID-19 to those admitted only with stroke (46 patients) and found that the patients with COVID-19: tended to be younger, average age of 63 years vs. 70 years for non-COVID stroke patients; had more severe strokes, average score of 19 vs. 8 on the National Institutes of Health Stroke Scale; had higher D-dimer levels, 10,000 vs. 525, which can indicate significant blood clotting; were more likely to be treated with blood thinners, 75% vs. 23.9%; were more likely to have a cryptogenic stroke in which the cause is unknown, 65.6% vs. 30.4%; and were more likely to be dead at hospital discharge, 63.6% vs. 9.3%.
Conversely, COVID-19 stroke patients were less likely than those stroke patients without the novel coronavirus to have high blood pressure (56.3% vs. 76.1%) or to have a prior history of stroke (3.1% vs. 13%).
The researchers observed that the rate of imaging-confirmed acute ischemic stroke in hospitalised patients with COVID-19 in their New York City hospital system was lower compared to prior reports in COVID-19 studies from China. One reason for the difference might be related to variations in race/ethnicity between the two study populations. In addition, the low rate of ischemic stroke with COVID-19 infection may be an underestimate because "the diagnosis of ischemic stroke can be challenging in those critically ill with COVID-19 infection who are intubated and sedated," said lead study author Dr Shadi Yaghi, of the department of neurology at NYU Grossman School of Medicine in Manhattan.
Yaghi said, "It was difficult to determine the exact cause of the strokes of the COVID-19 patients, however, most patients appeared to experience abnormal blood clotting. Additional research is needed to determine if therapeutic anticoagulation for stroke is useful in patients with COVID-19." The researchers noted that at least one clinical trial is already underway to investigate the safety and efficacy of treatment for active clotting vs. preventive treatment in certain patients with COVID-19 infection presenting with possible clotting indicators.
Yaghi and his co-authors also noted the number of stroke cases with COVID-19 seems to have peaked and is now decreasing. This finding may be related to the overall reduction in COVID-19 hospital admissions, which may be due to social distancing and guidance for people to stay at home. In addition, the number of stroke patients hospitalised during the study period was significantly lower than the same time frame in 2019.
Similar trends are reported in several other studies, reflecting a global disruption of emergency health care services including delayed care and a lower-than-usual volume of stroke emergencies during the COVID-19 pandemic crisis.
In a Hong Kong study, by lead author Dr Kay Cheong Teo, researchers compared the stroke onset time to hospital arrival time for stroke and transient ischemic attack (TIA) patients from 23 January to 24 March, 2020 (the first 60 days from the first diagnosed COVID-19 case in Hong Kong) to the same time period in 2019.
In 2020, 73 stroke patients presented to Queen Mary Hospital compared to 83 in 2019. However, the time from stroke onset-to-arrival time was about an hour longer in 2020 compared with last year (154 minutes vs 95 minutes). In addition, the number of patients arriving within the critical 4.5-hour treatment window dropped from 72% in 2019 to 55% in 2020.
Also from China, a study led by Dr Jing Zhao, detailed survey results from more than 200 stroke centres through the Big Data Observatory Platform for Stroke of China, which consists of 280 hospitals across China. They found that in February 2020, hospital admissions related to stroke dropped nearly 40%, while clot-busting treatment and mechanical clot-removal cases also decreased by 25%, compared to the same time period in 2019. The researchers cited several factors likely contributed to the reduced admissions and pre-hospital delays during the COVID-19 pandemic, such as lack of stroke knowledge and proper transportation. They also noted that another key factor was patients not coming to the hospital for fear of virus infection.
In a fourth study, led by Dr Basile Kerleroux, researchers in France compared patient data from stroke centres across the country from 15 February through 30 March, 2020 to data of patients treated during the same time period in 2019. They found a 21% decrease (844 in 2019 vs 668 in 2020) in overall volume of ischemic patients receiving mechanical thrombectomy during the pandemic compared to the previous year.
Additionally, there was a significant increase in the amount of time from imaging to treatment overall – 145 minutes in 2020 compared to 126 minutes in 2019, and that delay increased by nearly 30 minutes in patients transferred to other facilities for treatment after imaging.
The researchers said delays may have been due to unprecedented stress on emergency medical system services, as well as primary care stroke centres lacking transfer resources needed to send eligible patients to thrombectomy capable stroke centres within the therapeutic window. They noted stricter applications of guidelines during the pandemic period could also have meant some patients may have not been referred or accepted for mechanical thrombectomy treatment during that time.
Abstract 1
Background and Purpose: With the spread of coronavirus disease 2019 (COVID-19) during the current worldwide pandemic, there is mounting evidence that patients affected by the illness may develop clinically significant coagulopathy with thromboembolic complications including ischemic stroke. However, there is limited data on the clinical characteristics, stroke mechanism, and outcomes of patients who have a stroke and COVID-19.
Methods: We conducted a retrospective cohort study of consecutive patients with ischemic stroke who were hospitalized between March 15, 2020, and April 19, 2020, within a major health system in New York, the current global epicenter of the pandemic. We compared the clinical characteristics of stroke patients with a concurrent diagnosis of COVID-19 to stroke patients without COVID-19 (contemporary controls). In addition, we compared patients to a historical cohort of patients with ischemic stroke discharged from our hospital system between March 15, 2019, and April 15, 2019 (historical controls).
Results: During the study period in 2020, out of 3556 hospitalized patients with diagnosis of COVID-19 infection, 32 patients (0.9%) had imaging proven ischemic stroke. Cryptogenic stroke was more common in patients with COVID-19 (65.6%) as compared to contemporary controls (30.4%, P=0.003) and historical controls (25.0%, P<0.001). When compared with contemporary controls, COVID-19 positive patients had higher admission National Institutes of Health Stroke Scale score and higher peak D-dimer levels. When compared with historical controls, COVID-19 positive patients were more likely to be younger men with elevated troponin, higher admission National Institutes of Health Stroke Scale score, and higher erythrocyte sedimentation rate. Patients with COVID-19 and stroke had significantly higher mortality than historical and contemporary controls.
Conclusions: We observed a low rate of imaging-confirmed ischemic stroke in hospitalized patients with COVID-19. Most strokes were cryptogenic, possibly related to an acquired hypercoagulability, and mortality was increased. Studies are needed to determine the utility of therapeutic anticoagulation for stroke and other thrombotic event prevention in patients with COVID-19.
Authors
Shadi Yaghi, Koto Ishida, Jose Torres, Brian Mac Grory, Eytan Raz, Kelley Humbert, Nils Henninger, Tushar Trivedi, Kaitlyn Lillemoe, Shazia Alam, Matthew Sanger, Sun Kim, Erica Scher, Seena Dehkharghani, Michael Wachs, Omar Tanweer, Frank Volpicelli, Brian Bosworth, Aaron Lord, Jennifer Frontera
Abstract 2
Background and Purpose: When the coronavirus disease 2019 (COVID-19) outbreak became paramount, medical care for other devastating diseases was negatively impacted. In this study, we investigated the impact of the COVID-19 outbreak on stroke care across China.
Methods: Data from the Big Data Observatory Platform for Stroke of China consisting of 280 hospitals across China demonstrated a significant drop in the number of cases of thrombolysis and thrombectomy. We designed a survey to investigate the major changes during the COVID-19 outbreak and potential causes of these changes. The survey was distributed to the leaders of stroke centers in these 280 hospitals.
Results: From the data of Big Data Observatory Platform for Stroke of China, the total number of thrombolysis and thrombectomy cases dropped 26.7% (P<0.0001) and 25.3% (P<0.0001), respectively, in February 2020 as compared with February 2019. We retrieved 227 valid complete datasets from the 280 stroke centers. Nearly 50% of these hospitals were designated hospitals for COVID-19. The capacity for stroke care was reduced in the majority of the hospitals. Most of the stroke centers stopped or reduced their efforts in stroke education for the public. Hospital admissions related to stroke dropped ≈40%; thrombolysis and thrombectomy cases dropped ≈25%, which is similar to the results from the Big Data Observatory Platform for Stroke of China as compared with the same period in 2019. Many factors contributed to the reduced admissions and prehospital delays; lack of stroke knowledge and proper transportation were significant limiting factors. Patients not coming to the hospital for fear of virus infection was also a likely key factor.
Conclusions: The COVID-19 outbreak impacted stroke care significantly in China, including prehospital and in-hospital care, resulting in a significant drop in admissions, thrombolysis, and thrombectomy. Although many factors contributed, patients not coming to the hospital was probably the major limiting factor. Recommendations based on the data are provided.
Authors
Kay-Cheong Teo, William CY Leung, Yuen-Kwun Wong, Roxanna KC Liu, Anna HY Chan, Olivia MY Choi, Wing-Man Kwok, Kung-Ki Leung, Man-Yu Tse, Raymond TF Cheung, Anderson Chun-On Tsang, Kui Kai Lau.
Abstract 3
Background and Purpose: When the coronavirus disease 2019 (COVID-19) outbreak became paramount, medical care for other devastating diseases was negatively impacted. In this study, we investigated the impact of the COVID-19 outbreak on stroke care across China.
Methods: Data from the Big Data Observatory Platform for Stroke of China consisting of 280 hospitals across China demonstrated a significant drop in the number of cases of thrombolysis and thrombectomy. We designed a survey to investigate the major changes during the COVID-19 outbreak and potential causes of these changes. The survey was distributed to the leaders of stroke centers in these 280 hospitals.
Results: From the data of Big Data Observatory Platform for Stroke of China, the total number of thrombolysis and thrombectomy cases dropped 26.7% (P<0.0001) and 25.3% (P<0.0001), respectively, in February 2020 as compared with February 2019. We retrieved 227 valid complete datasets from the 280 stroke centers. Nearly 50% of these hospitals were designated hospitals for COVID-19. The capacity for stroke care was reduced in the majority of the hospitals. Most of the stroke centers stopped or reduced their efforts in stroke education for the public. Hospital admissions related to stroke dropped ≈40%; thrombolysis and thrombectomy cases dropped ≈25%, which is similar to the results from the Big Data Observatory Platform for Stroke of China as compared with the same period in 2019. Many factors contributed to the reduced admissions and prehospital delays; lack of stroke knowledge and proper transportation were significant limiting factors. Patients not coming to the hospital for fear of virus infection was also a likely key factor.
Conclusions: The COVID-19 outbreak impacted stroke care significantly in China, including prehospital and in-hospital care, resulting in a significant drop in admissions, thrombolysis, and thrombectomy. Although many factors contributed, patients not coming to the hospital was probably the major limiting factor. Recommendations based on the data are provided.
Authors
Jing Zhao, Hang Li, David Kung, Marc Fisher, Ying Shen, Renyu Liu
Abstract 4
Background and Purpose: The efficiency of prehospital care chain response and the adequacy of hospital resources are challenged amid the coronavirus disease 2019 (COVID-19) outbreak, with suspected consequences for patients with ischemic stroke eligible for mechanical thrombectomy (MT).
Methods: We conducted a prospective national-level data collection of patients treated with MT, ranging 45 days across epidemic containment measures instatement, and of patients treated during the same calendar period in 2019. The primary end point was the variation of patients receiving MT during the epidemic period. Secondary end points included care delays between onset, imaging, and groin puncture. To analyze the primary end point, we used a Poisson regression model. We then analyzed the correlation between the number of MTs and the number of COVID-19 cases hospitalizations, using the Pearson correlation coefficient (compared with the null value).
Results: A total of 1513 patients were included at 32 centers, in all French administrative regions. There was a 21% significant decrease (0.79; [95%CI, 0.76–0.82]; P<0.001) in MT case volumes during the epidemic period, and a significant increase in delays between imaging and groin puncture, overall (mean 144.9±SD 86.8 minutes versus 126.2±70.9; P<0.001 in 2019) and in transferred patients (mean 182.6±SD 82.0 minutes versus 153.25±67; P<0.001). After the instatement of strict epidemic mitigation measures, there was a significant negative correlation between the number of hospitalizations for COVID and the number of MT cases (R2 −0.51; P=0.04). Patients treated during the COVID outbreak were less likely to receive intravenous thrombolysis and to have unwitnessed strokes (both P<0.05).
Conclusions: Our study showed a significant decrease in patients treated with MTs during the first stages of the COVID epidemic in France and alarming indicators of lengthened care delays. These findings prompt immediate consideration of local and regional stroke networks preparedness in the varying contexts of COVID-19 pandemic evolution.
Authors
Basile Kerleroux, Thibaut Fabacher, Nicolas Bricout, Martin Moïse, Benoit Testud, Sivadji Vingadassalom, Héloïse Ifergan, Kévin Janot, Arturo Consoli, Wagih Ben Hassen, Eimad Shotar, Julien Ognard, Guillaume Charbonnier, Vincent L’Allinec, Alexis Guédon, Federico Bolognini, Gaultier Marnat, Géraud Forestier, Aymeric Rouchaud, Raoul Pop, Nicolas Raynaud, François Zhu, Jonathan Cortese, Vanessa Chalumeau, Jérome Berge, Simon Escalard, Grégoire Boulouis
[link url="https://www.sciencedaily.com/releases/2020/05/200521124648.htm"]American Heart Association material[/link]
[link url="https://www.ahajournals.org/doi/10.1161/STROKEAHA.120.030335"]Stroke abstract[/link]
[link url="https://www.ahajournals.org/doi/10.1161/STROKEAHA.120.030225"]Stroke abstract 2[/link]
[link url="https://www.ahajournals.org/doi/10.1161/STROKEAHA.120.030225"]Stroke abstract 3[/link]
[link url="https://www.ahajournals.org/doi/10.1161/STROKEAHA.120.030373"]Stroke abstract 4[/link]