Stroke Care During the COVID-19 Pandemic: Asian Stroke Advisory Panel Consensus Statement

The COVID-19 pandemic has impacted the health system worldwide. Stroke is one of the leading causes of death and disability in the world. Asia has a diverse health system and more than two-thirds of strokes occur in this region. The Asian Stroke Advisory Panel (ASAP) conducted a survey among the member countries to explore the impact of COVID-19 on stroke care. The stroke admission numbers have fallen, as have the number of patients who received thrombolysis and mechanical thrombectomy. The stroke unit and rehabilitation beds have been reallocated for COVID-19 care. ASAP recommends emergency department screening of stroke patients for COVID-19 and protected stroke code to be activated for COVID-19 suspect stroke patients. Noncontrast computed tomography (CT), CT angiography, and CT chest are the imaging modalities of choice. All health care professionals involved in triaging, imaging, and stroke care should wear appropriate personal protective equipment. All eligible stroke patients (COVID suspect/positive/non-COVID) should receive intravenous thrombolysis/mechanical thrombectomy. Mobile stroke units and robots can be used wherever available for evaluation and triaging. All stroke patients should receive standard stroke unit care. Limited rehabilitation should be offered to patients and training of caregivers if needed. Telemedicine/telestroke should be used for rehabilitation and follow-up. The ASAP consensus statement can be adapted to suit local and national health care systems.

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Consequences of COVID-19 pandemic lockdown on emergency and stroke care in a German tertiary stroke center

Neurological Research and Practice ◽

10.1186/s42466-021-00118-z ◽

2021 ◽

Vol 3 (1) ◽

Author(s):

Robin Jansen ◽

John-Ih Lee ◽

Bernd Turowski ◽

Marius Kaschner ◽

Julian Caspers ◽

...

Keyword(s):

Stroke Unit ◽

Hot Spot ◽

Stroke Care ◽

Single Center ◽

Stroke Patients ◽

Number Of Patients ◽

Single Center Study ◽

The Mean ◽

Stroke Center ◽

Center Study

Abstract Background COVID-19 pandemic caused a decline in stroke care in several countries. The objective was to describe lockdown stroke care in a tertiary stroke center in Düsseldorf, Germany near Heinsberg, a German hot spot for COVID-19 in spring 2020. Methods In a retrospective, observational, single-center study, we compared all patients treated in our emergency department (ED), patients seen by a neurologist in the ED, ED patients suffering from ischemic and hemorrhagic strokes and transient ischemic attacks (TIAs) as well as stroke patients admitted to our stroke unit during lockdown in spring 2020 (16 March 2020–12 April 2020) to those cared for during the same period in 2019 and lockdown light in fall 2020 (2 November – 29 November 2020). Results In spring 2020 lockdown the mean number of patients admitted to our ED dropped by 37.4%, seen by a neurologist by 35.6%, ED stroke patients by 19.2% and number of patients admitted to our stroke unit by 10% compared to the same period in 2019. In fall lockdown light 2020 effects were comparable but less pronounced. Thrombolysis rate was stable during spring and fall lockdown, however, endovascular treatment (EVT) rate declined by 58% in spring lockdown and by 51% in fall lockdown compared to the period in 2019. Conclusions Our study indicates a profound reduction of overall ED patients, neurological ED patients and EVT during COVID-19 pandemic caused lockdowns. Planning for pandemic scenarios should include access to effective emergency therapies.

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COVID-19 and stroke—A global World Stroke Organization perspective

International Journal of Stroke ◽

10.1177/1747493020923472 ◽

2020 ◽

Vol 15 (4) ◽

pp. 361-364 ◽

Cited By ~ 92

Author(s):

Hugh S Markus ◽

Michael Brainin

Keyword(s):

Health Care ◽

Risk Factor ◽

Health Care Professionals ◽

Severe Infection ◽

Stroke Care ◽

Stroke Patients ◽

The World ◽

Stroke Services ◽

Global World ◽

The Impact

The COVID-19 pandemic affecting all parts of the world is having huge implications for stroke care. Not only do stroke patients appear to be more susceptible to severe infection, but the pandemic is having major implications on how we deliver stroke care, while ensuing safety of both our patients and health care professionals. COVID-19 infection itself has also been described as a risk factor for stroke. The World Stroke Organization has been monitoring the impact of the pandemic globally, and has identified an initial marked fall in stroke presentations as well as a widespread impact on stroke services. The pandemic is changing the way we deliver care, and has highlighted the enormous potential of telemedicine in stroke care.

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The impact of tele-neurologists on acute stroke care at an advanced primary stroke centre

Journal of Telemedicine and Telecare ◽

10.1177/1357633x20921039 ◽

2020 ◽

pp. 1357633X2092103

Author(s):

Scott Gutovitz ◽

Jonathan Leggett ◽

Leslie Hart ◽

Samuel M Leaman ◽

Heather James ◽

...

Keyword(s):

Acute Stroke ◽

Mechanical Thrombectomy ◽

Stroke Care ◽

Final Diagnosis ◽

Stroke Patients ◽

Acute Stroke Care ◽

Care Guidelines ◽

Stroke Center ◽

The Impact ◽

Stroke Centre

Introduction We evaluated the impact of tele-neurologists on the time to initiating acute stroke care versus traditional bedside neurologists at an advanced stroke center. Methods This observational study evaluated time to treatment for acute stroke patients at a single hospital, certified as an advanced primary stroke centre, with thrombectomy capabilities. Consecutive stroke alert patients between 1 March, 2016 and 31 March, 2018 were divided into two groups based on their neurology consultation service (bedside neurology: 1 March, 2016–28 February, 2017; tele-neurology: 1 April, 2017–31 March, 2018). Door-to-tPA time and door-to-IR time for mechanical thrombectomy were compared between the two groups. Results Nine hundred and fifty-nine stroke patients met the inclusion criteria (436 bedside neurology, 523 tele-neurology patients). There were no significant differences in sex, age, or stroke final diagnosis between groups ( p > 0.05). 85 bedside neurology patients received tPA and 35 had mechanical thrombectomy, 84 and 44 for the tele-neurology group respectively. Door-to-tPA time (median (IQR)) was significantly higher among tele-neurology (64 min (51.5–83.5)) than bedside neurology patients (45 min (34–69); p < 0.0001). There was no difference in door-to-IR times (mean ± SD) between bedside neurology (87.2 ± 33.3 min) and tele-neurology (90.4 ± 33.4 min; p = 0.67). Discussion At this facility, our tele-neurology services vendor was associated with a statistically significant delay in tPA administration compared with bedside neurologists. There was no difference in door-to-IR times. Delays in tPA administration make it harder to meet acute stroke care guidelines and could worsen patient outcomes.

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Abstract 42: Epidemiological Surveillance of the Impact of the Covid-19 Pandemic on Stroke Care Using Artificial Intelligence

Stroke ◽

10.1161/str.52.suppl_1.42 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Raul Nogueira ◽

Jason Davies ◽

Rishi Gupta ◽

Ameer E Hassan ◽

Thomas G Devlin ◽

...

Keyword(s):

Artificial Intelligence ◽

Acute Stroke ◽

Real Time ◽

Systems Of Care ◽

Stroke Care ◽

Epidemiological Surveillance ◽

Day Hospital ◽

Stroke Patients ◽

Number Of Patients ◽

The Impact

Background: The degree to which the COVID-19 pandemic has affected systems of care, in particular those for time-sensitive conditions such as stroke, remains poorly quantified. We sought to evaluate the impact of COVID-19 in the overall screening for acute stroke utilizing a commercial clinical artificial intelligence (AI) platform. Methods: Data were derived from the Viz Platform, an AI application designed to optimize the workflow of acute stroke patients. Neuroimaging data on suspected stroke patients across 97 hospitals in 20 US states were collected in real-time and retrospectively analyzed with the number of patients undergoing imaging screening serving as a surrogate for the amount of stroke care. The main outcome measures were the number of CTA, CTP, Large vessel occlusions (LVOs) (defined according to the automated software detection), and severe strokes on CTP (defined as those with hypoperfusion volumes>70mL) normalized as number of patients per day per hospital. Data from the pre-pandemic (November 4, 2019 to February 29, 2020) and pandemic (March 1 to May 10, 2020) periods were compared at national and state levels. Correlations were made between the inter-period changes in imaging screening, stroke hospitalizations, and thrombectomy procedures using state-specific sampling. Results: A total of 23,223 patients were included. The incidence of LVO on CTA and severe strokes on CTP were 11.2%(n=2,602) and 14.7%(n=1,229/8,328), respectively. There were significant declines in the overall number of CTAs (-22.8%;1.39 to 1.07 patients/day/hospital,p<0.001) and CTPs (-26.1%;0.50 to 0.37 patients/day/hospital,p<0.001) as well as in the incidence of LVO (-17.1%;0.15 to 0.13 patients/day/hospital,p<0.001) and severe strokes on CTP (-16.7%;0.12 to 0.10 patients/day/hospital, p<0.005). The sampled cohort showed similar declines in the rates of LVOs versus thrombectomy (18.8%vs.19.5%, p=0.9) and CSC hospitalizations (18.8%vs.11.0%, p=0.4). Conclusions: A significant decline in stroke imaging screening has occurred during the COVID-19 pandemic. This underscores the broader application of AI neuroimaging platforms for the real-time monitoring of stroke systems of care.

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Alarming downtrend in mechanical thrombectomy rates in African American patients during the COVID-19 pandemic-Insights from STAR

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2020-016946 ◽

2021 ◽

pp. neurintsurg-2020-016946

Author(s):

Sami Al Kasab ◽

Eyad Almallouhi ◽

Ali Alawieh ◽

Pascal Jabbour ◽

Ahmad Sweid ◽

...

Keyword(s):

African American ◽

Mechanical Thrombectomy ◽

Stroke Care ◽

Care Process ◽

Vascular Risk ◽

Stroke Patients ◽

Discharge Outcomes ◽

The Us ◽

The Impact ◽

Length Of Hospitalization

BackgroundThe coronavirus disease (COVID-19) pandemic has affected stroke care globally. In this study, we aim to evaluate the impact of the current pandemic on racial disparities among stroke patients receiving mechanical thrombectomy (MT).MethodsWe used the prospectively collected data in the Stroke Thrombectomy and Aneurysm Registry from 12 thrombectomy-capable stroke centers in the US and Europe. We included acute stroke patients who underwent MT between January 2017 and May 2020. We compared baseline features, vascular risk factors, location of occlusion, procedural metrics, complications, and discharge outcomes between patients presenting before (before February 2020) and those who presented during the pandemic (February to May 2020).ResultsWe identified 2083 stroke patients: of those 235 (11.3%) underwent MT during the COVID-19 pandemic. Compared with pre-pandemic, stroke patients who received MT during the pandemic had longer procedure duration (44 vs 38 min, P=0.006), longer length of hospitalization (6 vs 4 days, P<0.001), and higher in-hospital mortality (18.7% vs 11%, P<0.001). Importantly, there was a lower number of African American patients undergoing MT during the COVID-19 pandemic (609 (32.9%) vs 56 (23.8%); P=0.004).ConclusionThe COVID-19 pandemic has affected the care process for stroke patients receiving MT globally. There is a significant decline in the number of African American patients receiving MT, which mandates further investigation.

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Paradigm Shift in Clinical Practice of Sexual Health in Men During COVID-19 Pandemic

Journal of Psychosexual Health ◽

10.1177/26318318211032386 ◽

2021 ◽

pp. 263183182110323

Author(s):

Aditya Prakash Sharma ◽

Japleen Kaur ◽

Ravimohan S. Mavuduru ◽

Shrawan K. Singh

Keyword(s):

Health Care ◽

Sexual Health ◽

Surgical Procedures ◽

Care Center ◽

Tertiary Care ◽

Health Care Seeking ◽

Care Seeking ◽

Health Seeking ◽

Number Of Patients ◽

The Impact

Sexual health-care seeking behavior and practices have been affected during COVID-19 pandemic. The impact of COVID-19 on this subspecialty is far reaching. This study aimed to assess the impact of COVID-19 on health-care seeking practice pertaining to sexual health in men in our tertiary care center and review the relevant literature regarding impact of COVID-19 on sexual health seeking practice and challenges faced. Outpatient data was analyzed from January 2019 to April 2021. Patients awaiting surgical procedures due to COVID were documented. A narrative synthesis of literature based on systematic search using the keywords sexual health, sexual health seeking, sexual health practice, andrology, and COVID with operators “AND” and “OR” was carried out in three search engines PubMed, Scopus, and Embase. The study outcomes were obtained by comparing data of outpatient attendance and compiling the reviewed literature. The mean attendance fell significantly from 95.11±11.17 to 17.25±13.70 persons (P <.0001) per outpatient clinic, March 2020 being the reference point. Teleconsultation has taken over physical consultation. In 98/949 cases, teleconsult could not be provided despite registration. Over 25 patients were waiting for surgical procedures pertaining to andrology due to shut down of elective services. Similar trends have been reported from other countries. Number of patients seeking consultation for sexual health problems has dramatically decreased during COVID-19 era. Establishment of data safe teleconsultation facility and its widespread advertisement is needed to encourage patients to seek consult.

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Development of the Madrid Stroke Programme: Milestones and Changes in Stroke Trends and Mortality from 1997 to 2017

Neuroepidemiology ◽

10.1159/000514077 ◽

2021 ◽

pp. 1-6

Author(s):

Silvia Pastor ◽

Elena de Celis ◽

Itsaso Losantos García ◽

María Alonso de Leciñana ◽

Blanca Fuentes ◽

...

Keyword(s):

Hospital Mortality ◽

Hospital Admissions ◽

Temporal Trends ◽

Intravenous Thrombolysis ◽

Stroke Care ◽

Care Organization ◽

Stroke Units ◽

Health Region ◽

Number Of Patients ◽

The Impact

Introduction: Stroke is a serious health problem, given it is the second leading cause of death and a major cause of disability in the European Union. Our study aimed to assess the impact of stroke care organization measures (such as the development of stroke units, implementation of a regional stroke code, and treatment with intravenous thrombolysis and mechanical thrombectomy) implemented from 1997 to 2017 on hospital admissions due to stroke and mortality attributed to stroke in the Madrid health region. Methods: Epidemiological data were obtained from the National Statistics Institute public website. We collected data on the number of patients discharged with a diagnosis of stroke, in-hospital mortality due to stroke and the number of inhabitants in the Madrid health region each year. We calculated rates of discharges and mortality due to stroke and the number of inhabitants per SU bed, and we analysed temporal trends in in-hospital mortality due to stroke using the Daniels test in 2 separate time periods (before and after 2011). Figures representing annual changes in these data from 1997 to 2017 were elaborated, marking stroke care organizational measures in the year they were implemented to visualize their temporal relation with changes in stroke statistics. Results: Hospital discharges with a diagnosis of stroke have increased from 170.3/100,000 inhabitants in 1997 to 230.23/100,000 inhabitants in 2017. However, the in-hospital mortality rate due to stroke has decreased (from 33.3 to 15.2%). A statistically significant temporal trend towards a decrease in the mortality percentage and rate was found from 1997 to 2011. Conclusions: Our study illustrates how measures such as the development of stroke units, implementation of a regional stroke code and treatment with intravenous thrombolysis coincide in time with a reduction in in-hospital mortality due to stroke.

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Abstract P141: Global Impact of Covid-19 Pandemic on Acute Stroke and Mechanical Thrombectomy - An International Survey

Stroke ◽

10.1161/str.52.suppl_1.p141 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Dileep R Yavagal ◽

Vasu Saini ◽

Violiza Inoa ◽

Hannah E Gardener ◽

Sheila O Martins ◽

...

Keyword(s):

Acute Stroke ◽

Mechanical Thrombectomy ◽

High Volume ◽

Stroke Care ◽

Acute Stroke Care ◽

Treatment Practices ◽

Global Impact ◽

Significant Difference ◽

The World ◽

The Impact

Introduction: The COVID-19 pandemic has strained the healthcare systems across the world but its impact on acute stroke care is just being elucidated. We hypothesized a major global impact of COVID-19 not only on stroke volumes but also on thrombectomy practice. Methods: A 19-item questionnaire survey aimed to identify the changes in stroke volumes and treatment practices seen during COVID-19 pandemic was designed using Qualtrics software. It was sent to stroke and neuro-interventional physicians around the world who are part of the executive committee of a global coalition, Mission Thrombectomy 2020 (MT2020) between April 5 th to May 15 th , 2020. Results: There were 113 responses across 25 countries. Globally there was a median 33% decrease in stroke admissions and a 25% decrease in mechanical thrombectomy (MT) procedures during COVID-19 pandemic compared to immediately preceding months (Figure 1A-B). This overall median decrease was despite a median increase in stroke volume in 4 European countries which diverted all stroke patients to only a few selected centers during the pandemic. The intubation policy during the pandemic for patients undergoing MT was highly variable across participating centers: 44% preferred intubating all patients, including 25% centers that changed their policy to preferred-intubation (PI) vs 27% centers that switched to preferred-conscious-sedation (PCS). There was no significant difference in rate of COVID-19 infection between PI vs PCS (p=0.6) or if intubation policy was changed in either direction (p=1). Low-volume (<10 stroke/month) compared with high-volume stroke centers (>20 strokes/month) are less likely to have neurointerventional suite specific written personal protective equipment protocols (74% vs 88%) and if present, these centers are more likely to report them to be inadequate (58% vs 92%). Conclusion: Our data provides a comprehensive snapshot of the impact on acute stroke care observed worldwide during the pandemic.

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Abstract 1122‐000242: Effect of Covid‐19 on Stroke Treatment in Australia and New Zealand

Stroke: Vascular and Interventional Neurology ◽

10.1161/svin.01.suppl_1.000242 ◽

2021 ◽

Vol 1 (S1) ◽

Author(s):

Ela Machiroutu

Keyword(s):

New Zealand ◽

Stroke Care ◽

Small Subset ◽

Stroke Patients ◽

Secondary Research ◽

Stroke Treatment ◽

Survey Tool ◽

Early Adoption ◽

Survey Responses ◽

The Impact

Introduction : In general, compared to the rest of the world, the impact of Covid‐19 in the Australia and New Zealand regions has been minimal and this may be attributed to their early adoption of social distancing, stable governments, national wealth and geographic isolation. However, this research was designed to validate this perception amongst the stakeholders. Methods : This research included: primary and secondary research. First, secondary research about Covid‐19 and stroke treatment and Australia and New Zealand in particular was conducted and compiled in a Google spreadsheet. Research sources include Stroke Foundation, Brain Foundation, and World Meters. Data collected included the number of stroke and Covid‐19 cases in Australia and New Zealand as well as a list of stakeholders with their contact information. The stakeholders included neurosurgeons, hospitals, neurologists, interventionists, and vascular surgeons. A survey tool and an interview questions were prepared next. The survey request was emailed to stakeholders, requesting the stakeholders for an interview and survey response. Over the following weeks, survey results came in and interviews were conducted. Since only a small subset of stakeholders responded to the survey (6 survey responses and 4 interviews), this study must be considered to be primarily qualitative in nature. The interviews were conducted online using Zoom. After the interviews, I replayed the interviews and took notes of important details. Results : The survey showed that 83% of the doctors worked in a hospital that had a separate stroke unit and that they perform mechanical thrombectomies most often as a treatment for stroke. Most of the doctors suggested that the stroke numbers have not changed significantly since Covid‐19. Yet, 50% of the doctors said that there had been delays in admitting stroke patients. One third believed Covid‐19 may have made an impact on mortality of stroke patients. One of the interviewees revealed that the main barriers to access to stroke care are the time it takes to treat the patient, fewer locations that treat strokes or perform mechanical thrombectomy, and patients’ reluctance to go to the hospital during the pandemic. Another confirmed that she did think there had been delays due to Covid‐19. Conclusions : Counter to widespread perception, Covid‐19 pandemic DID worsen many barriers for stroke treatment in Australia and New Zealand. These regions have insufficient stroke centers and these are not spread out widely enough for accessibility. Stroke deaths have increased during the Covid‐19 pandemic. Barriers such as time, accessibility, and the patient’s fear of hospitals have affected stroke treatment during the pandemic. Several measures can alleviate the impact: stroke awareness is critical. Every hospital needs to have the ability to assess and treat stroke. Hospitals must run simulations to practice and prepare for different scenarios that they could encounter when dealing with stroke patients. In conclusion, stroke treatment has been affected by the Covid‐19 pandemic and it is critical to minimize and overcome these barriers as stroke is one of the leading causes of death in Australia and New Zealand.

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Evaluation of Health Care Services Provided in Political Public Meetings in Turkey: A Forgotten Detail in Politics

Prehospital and Disaster Medicine ◽

10.1017/s1049023x18001048 ◽

2018 ◽

Vol 33 (6) ◽

pp. 607-613

Author(s):

Mehmet Ali Ceyhan ◽

Gültekin Günhan Demir ◽

Gamze Babur Güler

Keyword(s):

Health Care ◽

Political Parties ◽

Health Care Services ◽

Heat Index ◽

Election Campaign ◽

Medical Conditions ◽

Public Meetings ◽

Care Services ◽

Number Of Patients ◽

The Impact

AbstractBackgroundPolitical parties in Turkey execute political public meetings (PPMs) during their election campaign for members of the parliament (MoP). A great number of people attend these meetings. No guidelines exist regarding preparation and organization of health care services provided during these meetings. Furthermore, there is no study evaluating health care problems encountered in previous PPMs.ObjectivePolitical parties arranged PPMs in 2015 during the election campaign for general election of MoP. The present study aimed to investigate the context of health care services, the distribution of assigned health staff, as well as the number and the symptoms of patients admitted in health care tents in these PPMs.MethodsTwo general elections for MoP were done in Turkey on June 7, 2015 and November 1, 2015. Health care services were provided by the City Emergency Medical Services Department (CEMSD) in the cities. Demographic characteristics, symptoms, comorbid conditions, treatment, discharge, and hospital transfer of the patients were obtained from patient medical registration records. Information about the distribution and the number of the assigned staff was received from local CEMSDs. The impact of variables such as the number of attendees, heat index, humidity, and the day of the week on the number of patients and the patient presentation rate (PPR) were analyzed.ResultsA total of 97 PPMs were analyzed. The number of total attendees was 5,265,450 people. The number of patients seeking medical help was 1,991. The PPR was 0.5 (0.23-0.91) patients per 1,000 attendees. Mean age of the patients was 40 (SD=19) years old while 1,174 (58.9%) of the patients were female. A total of 1,579 patients were treated in the tents and returned to the PPM following treatment. Two-hundred and three patients were transferred to a hospital by ambulance. Transfer-to-hospital ratio (TTHR) was 0.05 (0.0-0.13) patients per 1,000 attendees. None of the patients suffered sudden cardiac death (SCD) or cardiac arrest. Medical conditions were the main cause for admission. The most common symptoms were dizziness, low blood pressure, fatigue, and hypertension, respectively. The most commonly used medical agents included pain killers and myorelaxants. The number of attendees, heat index, and weekend days were positively correlated with the number of the patients.Conclusion: The majority of medical conditions encountered in PPMs are easily treatable in health care tents settled in the meeting area. The number of attendees, heat index, and weekend days are factors associated with the number of patients.CeyhanMA, DemirGG, GülerGB. Evaluation of health care services provided in political public meetings in Turkey: a forgotten detail in politics. Prehosp Disaster Med. 2018;33(6):607–613.

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